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CORK Bibliography: Suicide

109 citations. 2011 to present

Prepared: June 2012

Agrawal A; Nurnberger JI; Lynskey MT. Cannabis involvement in individuals with bipolar disorder. Psychiatry Research 185(3): 459-461, 2011. (13 refs.)

In a study of 471 bipolar disorder (BD) cases and 1761 controls, individuals with BD were 6.8 times more likely to report a lifetime history of cannabis use. Rates of DSM-IV cannabis use disorders in those with BD were 29.4% and were independently and significantly associated with increased suicide attempts, greater likelihood of mixed episodes and greater disability attributable to BD.

Ahmad S. Suicide and substance abuse. (Chapter 4). IN: Brizer D; Castandea R, eds. Clinical Addiction Psychiatry. New York: Cambridge University Press, 2011

This book is described as an anthology of essays setting forth the most current and authoritative information on addiction theory, practice and research. Each chapter is authored by a recognized authority in the field. The volume covers diverse material, from the environment, to genetics, culture and spirituality, treatment and pharmacology. The book, with 24 essays, is organized in three parts. This chapter which addresses the matter of suicide and its relationship to substance abuse, is part of the first section which considers the basic constructs of addiction medicine. Other topics in this section include the disease concept, medical complications associated with addiction, abstinence as a treatment goal, psychotherapeutic paradigms, and drug therapies.

Allen J; Levintova M; Mohatt G. Suicide and alcohol-related disorders in the US arctic: Boosting research to address a primary determinant of health disparities. (review). International Journal of Circumpolar Health 70(5): 473-487, 2011. (41 refs.)

Objectives. To review the existing epidemiological literature on suicide and alcohol-related disorders and their social determinants in the U.S. Arctic, as it relates to U.S. government research and evaluation efforts, and to offer recommendations to boost research capacity in the U.S. Arctic and collaborations across the circumpolar Arctic as part of global health initiatives. Study design. Synthetic literature review. Methods. Published literature; federal and state reports on suicide and alcohol-related disorders; and federal databases on research and program evaluation in the U.S Arctic were reviewed, with a focus on epidemiological trends over the past 50 years. Results. Suicide and alcohol-related disorders play a significant role in health disparities in the U.S. Arctic, with evidence of a disturbing prevalence trend over the past 50 years. Important variations exist in suicide rates across different regions of Alaska with different majority populations of Alaska Native cultural groups - and, in selected key instances, within these regions - with immense implications for guiding effective prevention efforts. Consequences of alcohol abuse are severe and particularly significant in their impact upon Alaska Native people. Health-related conditions associated with alcohol abuse are among the leading causes of mortality. Conclusions. Recommendations to boost research capacity in behavioural health in the U.S. Arctic are offered, specifically on strategies and methods of inquiry and analysis; distinctions between populations and communities in rural circumpolar contexts; and future epidemiological and implementation research.

Archie S; Kazemi AZ; Akhtar-Danesh N. Concurrent binge drinking and depression among Canadian youth: Prevalence, patterns, and suicidality. Alcohol 46(2): 165-172, 2012. (51 refs.)

This study compared differences in risk for suicidality among youth living in the community who met criteria for comorbid depression and binge drinking, depression without binge drinking, and binge drinking without depression relative to a reference group with neither condition. Logistic regression analysis was used to analyze data from the Canadian Community Health Survey, Cycle 3.1 (CCHS 3.1, 2005): a cross-sectional survey of respondents from the Canadian population. To restrict the sample to youth, respondents were excluded who were younger than 15 or older than 24 years. Over 17,000 respondents were assessed to determine whether they met criteria for depression, binge drinking, the comorbid condition, or neither condition (reference group). Binge drinking was defined as five drinks or more on an occasion. The 12-month prevalence rates for comorbid binge drinking and depression were 2.7% for male respondents and 2.1% for female respondents. When adjusted for demographic factors and when compared with the reference group, the risk of suicidality was increased for the depressed group (odds ratio [OR] 5.23, 95% confidence interval [CI]: 3.34-8.2) and the comorbid group (OR 6.28, 95% CI: 3.68-10.70), but not for the binge-drinking group. With the exception of increasing age, sociodemographic factors were not correlates of comorbidity. In conclusion, binge drinking was not associated with an increased risk of suicidality among Canadian youth living in the community, although depression and comorbidity were associated with suicidality.

Arias AJ; Chan G; Gelernter J; Farrer L; Kranzler HR. Variation in OPRM1 and risk of suicidal behavior in drug-dependent individuals. American Journal on Addictions 21(1): 5-10, 2012. (41 refs.)

Completed suicide and nonfatal suicide-related outcomes (SROs), such as suicidal ideation and attempts, are heritable. A recent genetic association study in a sample of suicide victims reported a protective effect of the G allele of Asn40Asp (rs1799971) on risk for completed suicide. We examined the association of three OPRM1 single nucleotide polymorphisms (SNPs) (rs1799971, rs609148, and rs648893) with SRO in 426 European Americans, using GEE logistic regression analysis to examine the association of a lifetime history of SRO. There was no allelic association with the SRO phenotypes. A larger sample may be needed to identify risk variants that convey SRO risk. OPRM1 may not be important in the risk of SRO.

Austin AE; van den Heuvel C; Byard RW. Causes of community suicides among indigenous South Australians. Journal of Forensic and Legal Medicine 18(7): 299-301, 2011. (18 refs.)

A retrospective review of suicides occurring among Aboriginal people in the community in South Australia over a 5-year period was undertaken from January 2005 to December 2009. Twenty-eight cases were identified, consisting of 21 males (age range 16-44 years, mean 29.9 years) and 7 females (age range 23-45 years, mean 32.0 years). Deaths in all cases were caused by hanging (100%). Toxicological evaluation of blood revealed alcohol (39.3% of cases), cannabinoids (39.3%), benzodiazepines (10.7%), opiates (7.1%), antidepressants (7.1%), amphetamines (3.6%) and volatiles (3.6%). This study has demonstrated that the method of suicide overwhelmingly preferred by indigenous victims in South Australia is hanging. The precise reasons for this preference are uncertain, however, an indigenous person in South Australia presenting as a suicide where a method other than hanging has been used would be exceedingly uncommon, raising the possibility of alternative manners of death.

Auten JD; Matteucci MJ; Gaspary MJ; Combs DJ; Clark RF. Psychiatric implications of adolescent methamphetamine exposures. Pediatric Emergency Care 28(1): 26-29, 2012. (27 refs.)

Objectives: Methamphetamine abuse has reached epidemic proportions during the last decade. Abuse among adolescents is linked to increased rates of depression and suicidal ideation. Sources suggest that there is an increase rate of suicide attempts in the methamphetamine-abusing adolescent patient population. Our study seeks to examine adolescent methamphetamine exposures reported to the California Poison Control System during the past decade of suicidal ideation and suicide attempts in comparison to rates reported by population-based surveys. Methods: The records of the California Poison Control System were searched for methamphetamine exposures from 2000 to 2009. All charts of patients identified between the ages of 11 and 18 years were reviewed and abstracted. Results: The records of 293 youth between the ages of 11 and 18 years were identified and assigned levels of severity according to parameters set by the National Poison Data System Medical Outcome Criteria of the American Association of Poison Control Centers. Charts were categorized as follows: 11 as major, 52 as moderate, and 75 as minor. The remainder of the charts were not evaluated because of no effect (n = 13) or unable to follow (n = 142). In this cohort, more females were reported than males (57%). The most common presenting symptom in this patient population was agitation (39%). The most common events were suicidal ideation (31%) and suicide attempts (21%). Conclusions: In this data set, adolescent methamphetamine exposures were associated with increased rates of suicidal ideation and suicide attempts that are disproportionate to population-based surveys during the same period.

Backmund M; Meyer K; Schutz C; Reimer J. Factors associated with suicide attempts among injection drug users. Substance Use & Misuse 46(12): 1553-1559, 2011. (28 refs.)

Injection drug users (IDUs) entering an urban low-threshold opiate detoxification unit in Munich, Germany, between 1991 and 1997 were asked for lifetime suicide attempts and administered a questionnaire, including sociodemographic, IDU-related, and drug user treatment related variables. Among 1,049 participants, 20% had ever tried to commit suicide. In the logistic regression, female gender, older age, drug user treatment experience, lack of drug user counseling, and emergency treatment were associated with attempted suicide. Regular screening for suicidal behavior in IDUs should be undertaken with a special focus to mention risk factors. The study's limitations are noted. This study was partially sponsored by the German Ministry of Health.

Berlin I; Covey LS; Donohue MC; Agostiv V. Duration of smoking abstinence and suicide-related outcomes. Nicotine & Tobacco Research 13(10): 887-893, 2011. (37 refs.)

Objective: To investigate the association between suicide-related outcomes (SROs: wish to die, suicidal thoughts, and attempted suicide) and duration of smoking abstinence. Methods: The National Epidemiologic Survey on Alcohol and Related Conditions Wave 1 is a face-to-face survey of a representative sample of the U. S. adult population (N = 43,093). Analyses were done for a subsample of individuals (N = 13,691) who reported ever smoking, at least 2 weeks of lifetime depressed mood and SROs. Duration of abstinence was categorized as 1-24 hr (reference), 1 day to 12 months, and longer than 12 months. Results: Univariate analyses showed significant demographic associations (positive: female gender and being widowed/divorced/separated; negative: age and household income) with SROs. SROs were positively associated with major psychiatric disorders (dysthymia, major depression, generalized anxiety disorders, antisocial personality disorder, nicotine dependence, and alcohol abuse/dependence). Logistic regression showed that nonsmoking for more than a year compared with less than 24 hr (nonabstinence) was significantly associated with reduced risk for wish to die (odds ratio [OR]: 0.56, 95% CI: 0.49-0.65), suicidal thoughts (OR: 0.54, 95% CI: 0.48-0.62), and attempted suicide (OR: 0.32, 95 % CI: 0.26-0.41). With adjustments for lifetime psychiatric disorders, duration of abstinence was no longer significantly associated with the SROs. Conclusions: In the sample of ever-smokers with lifetime depressed mood, an apparent protective effect of increased duration of smoking abstinence on susceptibility to suicidal behavior was neutralized by the presence of psychiatric disorders. The causal direction of these relationships is unclear, and these cross-sectional findings need confirmation in future prospective studies.

Berlin M; Vinnerljung B; Hjern A. School performance in primary school and psychosocial problems in young adulthood among care leavers from long term foster care. Children and Youth Services Review 33(12, special issue): 2489-2497, 2011. (59 refs.)

We used data from Swedish national registers for ten entire birth year cohorts (1972-1981) to examine psychosocial outcomes in young adulthood for youth that left long term foster care after age 17, comparing them with majority population peers, national adoptees and peers who had received in-home interventions before age 13. The population was followed in the registers from age 16 to 2005. Data were analyzed in Cox regression models. Youth who left long term foster care had six-to eleven fold sex and birth year adjusted excess risks for suicide attempts, substance abuse and serious criminality from age 20, and for public welfare dependency at age 25. Overrisks were considerably lower for the in-home intervention group and the national adoptees. Adjusting results for poor school performance in the final year in primary school (ages 15-16) reduced overrisks by 38-52% for care leavers from long term foster care. Irrespective of issues of causality, poor school performance seems to be a major risk factor for future psychosocial problems among youth who age out of long term foster care. The results suggest that promoting foster children's school performance should be given high priority by agencies.

Bohnert ASB; Roeder KM; Ilgen MA. Suicide attempts and overdoses among adults entering addictions treatment: Comparing correlates in a US national study. Drug and Alcohol Dependence 119(1-2): 106-112, 2011. (55 refs.)

Background: Suicide attempts and non-fatal overdoses are both associated with substance use. The aim of the present study was to examine correlates of suicide attempts and non-fatal overdoses simultaneously among individuals seeking addictions treatment. Methods: A large U.S. national sample of individuals entering addictions treatment participated in a cross-sectional survey (n = 5892). Multinomial logistic regression modeling tested the adjusted associations of violence, injection drug use, specific substances, and depressive symptoms with a four-category outcome variable based on prior histories of suicide attempt and non-fatal overdose (neither, suicide attempt only, overdose only, both), adjusting for demographic and treatment characteristics. Results: Sexual and physical victimization was associated with suicide attempts with or without overdoses (ORs 1.25-2.84), while perpetrating violence was associated with having experienced either or both outcomes (ORs 1.25-1.56). Depressive symptoms had a stronger association with suicide attempts (OR = 3.05) than overdoses (OR = 1.29). Injection drug use was associated with overdoses with or without suicide attempts (ORs 2.65-3.22). Individuals seeking treatment for marijuana use were less likely have overdosed or attempted suicide (ORs 0.39-0.67), while individuals seeking treatment for heroin use were more likely to have overdosed (OR = 1.46). Seeking treatment for use of more than one substance was associated with overdose and overdose and suicide attempt (ORs 1.58-2.51), but not suicide attempt alone. Conclusions: The present findings indicate that suicide and overdose are connected yet distinct problems. Individuals who have had a history of both may be a group with particularly poor psychological functioning as well as more severe drug-related problems.

Bornovalova MA; Tull MT; Gratz KL; Levy R; Lejuez CW. Extending models of deliberate self-harm and suicide attempts to substance users: Exploring the roles of childhood abuse, posttraumatic stress, and difficulties controlling impulsive behavior when distressed. Psychological Trauma: Theory, Research, Practice and Policy 3(4): 349-359, 2011. (122 refs.)

The current study examined models of risk for deliberate self-harm (DSH) and suicide attempts (SA) in a sample of 180 inner-city substance users. The factors of childhood physical, sexual, and emotional abuse, posttraumatic stress (PTS) symptoms, and difficulties controlling impulsive behaviors when distressed were examined, with path modeling used to explore the interrelationships between variables. Analyses examined the utility of a model wherein childhood abuse is associated with DSH and SA as a result of its relationship with PTS symptoms. Further, we examined whether difficulties controlling impulsive behaviors when distressed accounted for the relationship between PTS symptoms and DSH and SA. DSH and SA were both related to physical abuse and sexual abuse, PTS symptoms, and difficulties controlling impulsive behavior when distressed; only SA was associated with emotional abuse. Further, results demonstrated that the effect of childhood sexual abuse on DSH and SA was partially explained by PTS symptoms; however, difficulties controlling impulsive behaviors when distressed contributed little to either model. Findings suggest the importance of developing targeted interventions for PTS symptoms in order to reduce risk for SA and DSH.

Bossarte RM; Swahn MH. The associations between early alcohol use and suicide attempts among adolescents with a history of major depression. Addictive Behaviors 36(5): 532-535, 2011. (30 refs.)

Objective: Previous studies have identified significant associations between alcohol initiation before the age of 13 years and risk for suicide attempts. However, these associations have not been extensively tested using data obtained from populations with clinically significant psychopathology. The current study seeks to extend knowledge of the associations between early alcohol initiation and risk for suicide by identifying the associations between age of first alcohol use and suicide attempts among a sample of youth age 13 to 15 years with a history of major depression. Methodology: Data were obtained from the National Study of Drug Use and Health (NSDUH), a household-based survey of U.S. adolescents and adults age 12 years and older. Results: Results from these analyses confirm previous reports of significant associations between age of first alcohol use and suicide attempts and extend previous understanding of risk by using data obtained from a household-based survey and from adolescents with clinically relevant psychopathology. Conclusions: These findings provide further support for the implementation, enforcement, and continued support of both targeted and universal prevention strategies designed to reduce underage drinking.

Branas CC; Richmond TS; Ten Have TR; Wiebe DJ. Acute alcohol consumption, alcohol outlets, and gun suicide. Substance Use & Misuse 46(13): 1592-1603, 2011. (80 refs.)

A case-control study of 149 intentionally self-inflicted gun injury cases (including completed gun suicides) and 302 population-based controls was conducted from 2003 to 2006 in a major US city. Two focal independent variables, acute alcohol consumption and alcohol outlet availability, were measured. Conditional logistic regression was adjusted for confounding variables. Gun suicide risk to individuals in areas of high alcohol outlet availability was less than the gun suicide risk they incurred from acute alcohol consumption, especially to excess. This corroborates prior work but also uncovers new information about the relationships between acute alcohol consumption, alcohol outlets, and gun suicide. Study limitations and implications are discussed.

Britton PC; Bohnert ASM; Wines JD Jr; Conner KR. A procedure that differentiates unintentional from intentional overdose in opioid abusers. Addictive Behaviors 37(1): 127-130, 2012. (37 refs.)

The purpose of this study is to develop a procedure for assessing unintentional overdose (OD) in opiate abusers that differentiates it from intentional OD, and provides reliable information about the incident. A sample of 121 patients in a methadone maintenance program at an urban university hospital completed a baseline assessment. A total of 70 participants completed an identical assessment at least 14days later. The ability of an OD item to differentiate unintentional OD from intentional OD was tested, as was the test-retest reliability of questions assessing symptoms and treatment of OD. The procedure is reliable and differentiated unintentional OD from intentional OD. Questions assessing symptoms of OD were endorsed in almost every unintentional OD incident, although reliability was affected by loss of consciousness. The reliability of questions assessing emergency treatment and Narcan administration was outstanding. Our procedure for assessing OD differentiates unintentional OD from intentional OD. The use of follow-up questions assessing acute treatment for OD is recommended. Items concerning symptoms of OD are not needed to confirm the presence of an OD, but may be used to clarify whether an event was an OD.

Buckner JD; Joiner TE; Schmidt NB; Zvolensky MJ. Daily marijuana use and suicidality: The unique impact of social anxiety. Addictive Behaviors 37(4): 387-392, 2012. (59 refs.)

Despite a clear relationship between marijuana use and suicidality, little is known about psychological vulnerability factors that may interact with marijuana use to increase suicidality among this high-risk group. The present study examined the moderational impact of social anxiety on the relationship between marijuana use status (current users vs abstainers) and suicidality among 343 community adults. We also examined whether social anxiety moderated the relation between more frequent use (daily vs less frequent) among the 134 current marijuana users. Although social anxiety did not moderate the relation between use status and suicidality, it did moderate the relation between daily use status and suicidality after controlling for a wide range of relevant variables (e.g., demographics, depression, negative affect, and other types of anxiety). The overall model accounted for 59% of the variance in suicidality such that daily marijuana users with elevated social anxiety reported the highest suicidality. Findings highlight the importance of considering social anxiety in efforts to understand and prevent suicidality among this high-risk population.

Budisa D; Gavrilov-Jerkovic V; Dickov A; Vuckovic N; Mitrovic D; Svilokos S. Latent suicidality in heroin addicts. Heroin Addiction and Related Clinical Problems 13(4): 13-20, 2011. (30 refs.)

According to the transactional analysis (TA) theory of personality development and the development of psychopathology, any behaviour that indirectly or directly threatens someone's physical integrity could be a manifestation of the 'Don't exist' injunction and the script decision to die young. A 'don't exist' injunction is defined as a parental message that challenges a child's right to live, and that can be sent directly or indirectly, verbally or nonverbally, intentionally or unintentionally. An (early) script decision is defined as a compromise between the various authentic needs and requirements of the environment. The theoretical assumption on which this work is based is that a mentioned injunction and script decision to die young could be present in the population of heroin addicts, considering their continuous and repeated self-destructive behaviours and, typically, short lifetimes. The main objective of this work was to check the assumption that the 'Don't exist' injunction and the script decision to die young are theoretical concepts that are available for measurement through questionnaires and have the potential to discriminate heroin addicts from non-clinical examinees. The general research method that was selected was non-experimental, correlation research; the sample consisted of 50 heroin addicts and 50 non-clinical examinees. Its results confirm the hypothesis that both measured theoretical concepts have the potential to discriminate heroin addicts from non-clinical examinees. Heroin addicts have, to a statistically significant degree, a more strongly marked "Don't exist" injunction, together with the script decision to die young. This finding may be related to the theoretical assumptions of several authors in the TA assumptions which include the concept that psychoactive substances allow a person to implement the script decision to die young.

Capron DW; Blumenthal H; Medley AN; Lewis S; Feldner MT; Zvolensky MJ et al. Anxiety sensitivity cognitive concerns predict suicidality among smokers. Journal of Affective Disorders 138(3): 239-246, 2012. (59 refs.)

Background: Anxiety along with anxiety-related risk factors is receiving increased attention in regard to its role in elevated suicidality. One such risk factor, anxiety sensitivity (AS), refers to a fear of anxiety-related symptoms. Emerging research indicates that components of AS, particularly the AS subfactor focused on cognitive arousal concerns, are significantly associated with elevated suicidality in samples of diverse clinical outpatients, clinical outpatients with PTSD symptoms, and Air Force cadets undergoing a stressful life experience. Cigarette smokers represent another relevant population for this line of research due to recent reports indicating that cigarette smoking and nicotine dependence may be related to elevated suicidality. Methods: Study 1 examined the role of AS and the AS subfactors in a large sample (n = 343) of community adult smokers. Study 2 examined the role of AS and AS subfactors in a sample of "pack-a-day" adult smokers (n = 78) who were seeking outpatient treatment for substance abuse issues. Results: Study 1 results were consistent with our a priori hypothesis that AS cognitive concerns would be significantly associated with suicidality. Additionally, after covarying for relevant substance use variables, Study 2 results were also consistent with our hypothesis that AS cognitive concerns were significantly associated with suicidality. Limitations: Limitations included the use of suicide related outcomes, not death by suicide, and cross-sectional design. Conclusions: These findings suggest that suicide potential in cigarette smokers may be related to AS cognitive concerns and add to the emerging literature suggesting AS cognitive concerns are a risk factor for suicidality.

Cassidy F. Risk factors of attempted suicide in bipolar disorder. Suicide and Life-Threatening Behavior 41(1): 6-11, 2011. (26 refs.)

Suicide rates of bipolar patients are among the highest of any psychiatric disorder, and improved identification of risk factors for attempted and completed suicide translates into improved clinical outcome. Factors that may be predictive of suicidality in an exclusively bipolar population are examined. White race, family suicide history, and history of cocaine abuse were predictive of suicidal histories. Gender, nicotine use, medical comorbidity, and history of alcohol and other drug abuse were not, although a trend was noted for a history of benzodiazepine abuse. Attempts, although less common among African Americans, were equally as violent. Likewise, attempts were as violent among females as males, in distinction to general population studies.

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The DAWN Report: Trends in Emergency Department Visits for Drug-Related Suicide Attempts among Females: 2005 and 2009. (May 12, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011. (4 refs.)

Suicide ranks 7th in the top 10 leading causes of death for females aged 12 to 65, making suicide prevention among women a public health priority. Although men have higher suicide death rates, women are treated for attempted suicide more often than men. More than 215,000 emergency department (ED) visits involving intentional self-harm were made by females in 2009,1 and females were involved in 3 out of 5 ED visits for drug related suicide attempts. Although men have higher suicide death rates, women are treated for attempted suicide more often than men. More than 215,000 emergency department (ED) visits involving intentional self-harm were made by females in 2009, and females were involved in 3 out of 5 ED visits for drug related suicide attempts. Between 2005 and 2009, emergency department (ED) visits for suicide attempts made by females aged 50 or older increased 49 percent (from 11,235 visits in 2005 to 16,754 visits in 2009). ED visits for suicide attempts involving alcohol or illicit drugs remained stable from 2005 to 2009 among females; however, visits involving certain pharmaceutical drugs increased during this time period. Among females, ED visits for suicide attempts involving drugs to treat anxiety and insomnia increased 56 percent from 2005 to 2009 (from 32,426 visits to 50,548 visits). ED visits for suicide attempts involving hydrocodone products and oxycodone products increased (67 and 210 percent, respectively) from 2005 to 2009.

Public Domain

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The DAWN Report: Monthly and Seasonal Variation in Emergency Department Visits for Drug-Related Suicide Attempts: 2004 to 2008. (February 1, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011. (4 refs.)

Many U.S. and international researchers have tried to discern seasonal suicide patterns, but they have reached no clear consensus. Traditional social and family events that occur seasonally, such as holidays and school activities, may influence depression and suicidal behaviors. Media reports have suggested that these episodes occur more frequently during the winter holiday season. Additionally, fluctuations in weather and sunlight caused by the changing seasons can influence depressive symptoms, such as those experienced by people with seasonal affective disorder. Mortality data do not support the existence of a relationship between seasonality and completed suicides. However, suicide attempts that do not result in death are more common than completed suicides and often require emergency medical attention. Data from emergency departments (EDs) can provide information about risks for suicide attempts, including monthly and seasonal trends. From 2004 to 2008, there was an annual average of 178,423 ED visits for drug-related suicide attempts by patients aged 12 or older; the number of these visits ranged from a high of 16,812 visits in September (9.4 percent) to a low of 12,656 visits in February (7.1 percent). Among adolescent males aged 12 to 17, the percentage of drug-related suicide attempt visits ranged from 2.5 percent in February to 18.9 percent in December. Although there was considerable gender variation by month, there were no significant gender differences by season (autumn, winter, spring, or summer) for any age group.

Public Domain

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The DAWN Report: Emergency Department Visits for Drug-Related Suicide Attempts Involving Antidepressants by Adolescents and Young Adults: 2004 to 2008. (March 8, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011. (10 refs.)

in the past decade, concerns about the safety of antidepressants prompted the U.S. Food and Drug Administration to provide a warning label about the increased risk for suicidal thoughts and behavior among patients younger than 25. Because suicide is the third leading cause of death for adolescents and young adults, a high-profile debate on the risks and benefits of antidepressant use in this population soon followed. National statistical studies shed light on suicide attempts in general among this younger population and provide some background about these attempts. Past year suicide attempts were reported by 6.3% of high school students, 0.9% of college undergraduates, and 0.3% of graduate students. Of those who attempted suicide, 30 percent (approximately 300,000) of high school students, 19 percent (approximately 13,990) of college undergraduates, and 28 percent (approximately 1,874) of graduate students reported that they required medical attention for a suicide attempt. Drug overdoses were involved in about half of suicide attempts among college students. In 2008, adolescents made 23,124 visits to the emergency department (ED) for drug-related suicide attempts, and young adults made 38,036 such visits; of these visits, 23% (5,312 visits) among adolescents and 17.6% (6,700 visits) among young adults involved antidepressants. Among ED visits for suicide attempts involving antidepressants, more than two thirds of visits by adolescents (68.4 percent) and more than three fourths of visits by young adults (78.0 percent) involved other substances in addition to antidepressants. One tenth (10.2 percent) of visits by adolescents and nearly one fourth (22.6%) of those made by young adults involved antidepressants in combination with alcohol. One third (32.9%) of visits for drug-related suicide attempts made by adolescents and one half (49.4%) of visits made by young adults resulted in hospitalization. To the extent that antidepressants contribute indirectly to the likelihood that a person attempts suicide (e.g., having depression may increase the chance of suicide) but not directly to the medical emergency at hand, DAWN may understate the role of antidepressants.

Public Domain

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. The DAWN Report: Trends in Emergency Department Visits for Drug-Related Suicide Attempts among Males: 2005 and 2009. (June 16, 2011). Rockville MD: Substance Abuse and Mental Health Administration, 2011. (8 refs.)

In 2008, adolescents made 23,124 visits to the emergency department (ED) for drug-related suicide attempts, and young adults made 38,036 such visits; of these visits, 23.0 percent (5,312 visits) among adolescents and 17.6 percent (6,700 visits) among young adults involved antidepressants. Among ED visits for suicide attempts involving antidepressants, more than two thirds of visits by adolescents (68.4 percent) and more than three fourths of visits by young adults (78.0%) involved other substances in addition to antidepressants. One tenth (10.2%) of visits by adolescents and nearly one fourth (22.6%) of those made by young adults involved antidepressants in combination with alcohol ?? One third (32.9%) of visits for drug-related suicide attempts made by adolescents and one half (49.4 percent) of visits made by young adults resulted in hospitalization

Public Domain

Chan YC; Tse ML; Lau FL. Hong Kong Poison Information Centre: Annual Report 2009. Hong Kong Journal of Emergency Medicine 18(4): 221-231, 2011. (9 refs.)

Objective: To report and analyse the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2009. Methods: In 2009, all poisoning cases received by HKPIC were retrieved from its database (PICMS) for analysis. Results: Totally 4338 poisoned cases were analysed. There were 1955 male patients (45.1%), 2,367 female patients (54.6%) and 16 patients with no gender specified. More than two-third of cases (68.6%) were between 20 and 59 years old. Common causes of exposure were suspected self harm/suicidal attempt, abusive use and unintentional exposure. Paracetamol, ketamine, zopiclone, benzodiazepine and household products were the common poisons exposed. Majority of the patients were managed supportively, with 13.6% and 13.1% treated by decontamination and antidotes respectively. Most cases had uneventful recovery; about 1% of the poison exposure resulted in death and about 5% of the exposure had major outcomes. Conclusions: The 2009 annual report provides updated epidemiological information on poisoning pattern in Hong Kong and emphasized some changes in comparing with our previous reports.

Conner KR; Gunzler D; Tang W; Tu XM; Maisto SA. Test of a clinical model of drinking and suicidal risk. Alcoholism: Clinical and Experimental Research 35(1): 60-68, 2011. (56 refs.)

Background: There are few data on the role of drinking patterns in suicidal thoughts or behavior among alcohol-dependent individuals (ADIs) and meager data on variables that may influence the role of drinking in suicidal thoughts and behavior. This study tested a heuristic model that predicts that drinking promotes suicidal thoughts and behavior, the association is mediated (accounted for) by depressive symptoms, and that anger moderates (increases) the risk associated with intense drinking. Methods: Data from Project MATCH, a multisite alcohol use disorders treatment trial, were analyzed using structural equation modeling. There were 1,726 participants including 24% women and a mean age of 40.2 +/- 11.0 years. Subjects were assessed at baseline and at 3-, 9-, and 15-month follow-up. Two categorical measures (presence/absence) of suicidal ideation (SI) were used that were analyzed in separate models. Predictors of interest were continuous assessments of average drinking intensity (i.e., drinks per drinking day or DDD), drinking frequency (i.e., percent days abstinent or PDA), depression, and anger. Results: Both DDD and PDA were associated with SI at a statistically significant level, with PDA showing an inverse association. Depression scores served as a partial mediator or a full mediator of the drinking-SI relationship depending on the measure of SI used in the analysis. The models testing anger scores as a moderator fit the data poorly and did not support that anger serves as a moderator of the drinking-SI association. Conclusions: Greater drinking intensity and drinking frequency predict SI among ADIs and depression serves as a mediator of these associations, but anger does not appear to serve as a moderator. Further research is required to clarify whether depression serves as a partial or full mediator and to see whether the results herein extend to suicidal behavior (i.e., suicide attempt, suicide).

Crosby AE; Han BG; Ortega LA; Parks SE; Gfroerer J. Suicidal thoughts and behaviors among adults aged >18 years --- United States, 2008-2009. MMWR. Morbidity and Mortality Weekly Report 60(13): 1-22, 2011

Problem/Condition: Suicidal thoughts and behaviors are important public health concerns in the United States. In 2008, a total of 36,035 persons died as a result of suicide, and approximately 666,000 persons visited hospital emergency departments for nonfatal, self-inflicted injuries. State-level data on suicide-related issues are needed to help establish program priorities and to evaluate the effectiveness of suicide prevention strategies. Public health surveillance with timely and consistent exchange of data between data collectors and prevention program implementers allows prevention program practitioners to implement effective prevention and control activities. Reporting Period: January 1, 2008-December 31, 2009. Description of System: The National Survey on Drug Use and Health (NSDUH) is a national- and state-level survey of a representative sample of the civilian, noninstitutionalized U.S. population aged � >12 years. NSDUH collects data on health-risks related to the use of illicit drugs, alcohol, and tobacco; initiation of substance use; substance use disorders and treatment; health care; and mental health. This report summarizes data on responses to questions concerning suicidal thoughts and behaviors contained in the mental health section among sampled persons aged �o18 years in all 50 states and the District of Columbia. This report analyzes data on the prevalence of suicidal thoughts, planning, and attempts by age, sex, race/ethnicity, and state from 92,264 respondents in the 2008 and 2009 NSDUH. Results: Prevalence estimates of suicidal thoughts and behaviors varied by sociodemographic factors, region, and state. During 2008-2009, an estimated 8.3 million (annual average) adults aged �o18 years in the United States (3.7% of the adult U.S. population) reported having suicidal thoughts in the past year. The prevalence of having suicidal thoughts ranged from 2.1% in Georgia to 6.8% in Utah. An estimated 2.2 million (annual average) adults in the United States (1.0% of the adult U.S. population) reported having made suicide plans in the past year. The prevalence of reports of suicide planning ranged from 0.1% in Georgia to 2.8% in Rhode Island. An estimated 1 million (annual average) adults in the United States (0.5% of the U.S. adult population) reported making a suicide attempt in the past year. The prevalence of reports of suicide attempts ranged from 0.1% in Delaware and Georgia to 1.5% in Rhode Island. The prevalence of suicidal thoughts, suicide planning, and suicide attempts was significantly higher among young adults aged 18-29 years than it was among adults aged >30 years. The prevalence of suicidal thoughts was significantly higher among females than it was among males, but there was no statistically significant difference for suicide planning or suicide attempts. Interpretation: The findings in this report indicate that substantial variations exist at the regional and state level in the prevalence of adults who had suicidal thoughts, made plans to attempt suicide, and attempted suicide in the past year. Geographic differences in prevalence might be attributable to selective migration, sociodemographic composition of the population, or the local social environment (e.g., social relationship indicators such as divorce rates or resources for access to health care). These findings emphasize the importance of continued surveillance to collect locally relevant data on which to base prevention and control activities. Public Health Action: A better understanding of the patterns of the precursors to suicide is crucial to planning and evaluating a broad spectrum of suicide prevention efforts. These results can be used by state health departments and federal agencies to measure progress toward achieving national and state health objectives (e.g., those outlined in the National Strategy for Suicide Prevention). Continued surveillance is needed to design, implement, and evaluate public health policies and programs that can lead to a reduction in morbidity and mortality related to suicide-related thoughts and behaviors. Possible strategies to implement could include universal strategies (e.g., public education campaigns that focus on improving recognition of suicide risk) and indicated strategies (e.g., cognitive-behavioral therapy) that address the needs of persons exhibiting certain risk factors (e.g., persons who have made suicide attempts).

Public Domain

De Leo D; Milner A; Sveticic J. Mental disorders and communication of intent to die in indigenous suicide cases, Queensland, Australia. Suicide and Life-Threatening Behavior 42(2): 136-146, 2012. (54 refs.)

In comparing Indigenous to non-Indigenous suicide in Australia, this study focussed on the frequency of the association between some psychiatric conditions, such as depression and alcohol abuse, and some aspect of suicidality, in particular communication of suicide intent. Logistic regression was implemented to analyze cases of Indigenous (n = 471) versus non-Indigenous suicides (n = 6,655), using the Queensland Suicide Register as a data source. Compared to non-Indigenous suicides, Indigenous cases had lower odds of being diagnosed with unipolar depression, seeking treatment for psychiatric conditions or leaving a suicide note. Indigenous suicides had greater odds of verbally communicating suicide intent and having a history of alcohol and substance use. The magnitude of these differences is remarkable, underscoring the need for culturally sensitive suicide prevention efforts.

Dore G; Mills K; Murray R; Teesson M; Farrugia P. Post-traumatic stress disorder, depression and suicidality in inpatients with substance use disorders. Drug and Alcohol Review 31(3): 294-302, 2012. (25 refs.)

Introduction and Aims. The international literature suggests that traumatic events are common for patients with substance use disorders (SUDs), and are often associated with the development of post-traumatic stress disorder (PTSD) and other psychiatric comorbidities. However, limited research has been conducted among Australian SUD patients. The aim of the present study was to examine the prevalence of these disorders in a group of Australian patients admitted for detoxification. Design and Methods. Data were collected from 253 inpatients using a modified version of the Composite International Diagnostic Interview, the 10-item Trauma Screening Questionnaire, the Zung Self-rating Depression Scale and questions from the PsyCheck. Results. Approximately 20% of inpatients experienced moderate to severe depressive symptoms, and 37% had a lifetime history of self-harm or attempted suicide. Approximately 80% of patients had experienced at least one traumatic event, most experiencing multiple traumas. The mean age of first trauma was 14 years. Almost 45% of patients screened positive for current PTSD symptoms. Women were nine times more likely to have been raped and five times more likely to have been sexually molested than men. PTSD symptoms were associated with greater trauma exposure, younger age of first trauma, specific trauma types, moderate to severe depressive symptoms and a history of self-harm or attempted suicide. Despite their difficulties, patients with PTSD symptoms had high rates of retention in treatment. Discussion and Conclusions. Patients entering treatment for SUDs should be assessed for PTSD, depression and suicidality. These conditions impact significantly on treatment outcomes, and require the development of appropriate treatment strategies.

Ellis TE; Goldston DB. Special Series. Working with suicidal clients: Not business as usual (Introduction). Cognitive and Behavioral Practice 19(2): 205-208, 2012. (21 refs.)

In this introduction to a special series of articles on working with suicidal clients, we note that much of the recent growth in theory and research pertaining to suicidal individuals has been contributed by cognitive-behavioral theorists and researchers. This work has established that suicidal people manifest important cognitive vulnerabilities that can be addressed in therapeutic interventions specifically designed for them. Studies to date have produced outcomes that support this framework. We provide brief previews of the collection of articles that follow, which cover safety planning, protocols for evaluating risk, the utility of health behavior theory for informing treatment, mindfulness-based approaches for suicidality, developmental and family considerations, intensive inpatient CBT for individuals in the military, integrated interventions for substance abuse and suicidal behaviors, and coping with the impact of client suicide. We conclude that clinicians are now in a position to begin moving beyond a "therapy as usual" mindset in working with suicidal clients.

Erlangsen A; Eaton WW; Mortensen PB; Conwell Y. Schizophrenia - A predictor of suicide during the second half of life? Schizophrenia Research 134(2-3): 111-117, 2012. (45 refs.)

Background: Little is known about the suicide risk of older adults diagnosed with schizophrenia. The purpose of the study is to examine whether older adults diagnosed with schizophrenia have an elevated risk of dying by suicide, examine trends by age, and identify predictors of death by suicide. Methods: Individual-level register data on all older adults aged 50+ living in Denmark during 1990-2006 (N = 2, 899, 411) were assessed using survival analysis. The impact of predictors was adjusted for a series of socio-demographic and health-related covariates. Results: In all, 248 suicides were identified among older adults diagnosed with schizophrenia. The suicide rate ratios of men and women aged 50-69 years with a diagnosis of schizophrenia was 7.0 [95%CI: 5.8-8.4] and 13.7 [95%CI: 11.3-16.6], respectively, when compared to those with no diagnosis. With increasing age a lower rate ratio was found; for men and women aged 70+ it was 2.1 [95%CI: 1.1-3.9] and 3.4 [95%CI: 2.0-5.8], respectively. Adjusted analyses revealed an elevated risk of suicide for diagnoses of schizophrenia, greater number of hospitalizations, recent admission (for men), recent discharge, previous suicide attempt, recent suicide attempt, comorbidity of mood disorders, personality disorders, and substance abuse (for women). Conclusions: We found an elevated mortality risk of suicide for both men and women aged 50 years and over diagnosed with schizophrenia. Health care staff should be aware of elevated risk, particularly in older women diagnosed with schizophrenia, in relation to chronic disease courses, recent discharge, and suicide attempt.

Esposito-Smythers C; Spirito A; Kahler CW; Hunt J; Monti P. Treatment of co-occurring substance abuse and suicidality among adolescents: A randomized trial. Journal of Consulting and Clinical Psychology 79(6): 728-739, 2011. (41 refs.)

This study tested a cognitive-behavioral treatment protocol for adolescents with a co-occurring alcohol or other drug use disorder (AOD) and suicidality in a randomized clinical trial. Method: Forty adolescents (M(age) = 15 years; 68% female, 89% White) and their families recruited from an inpatient psychiatric hospital were randomly assigned to an integrated outpatient cognitive-behavioral intervention for co-occurring AOD and suicidality (I-CBT) or enhanced treatment as usual (E-TAU). Primary measures include the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Suicide Ideation Questionnaire, Columbia Impairment Scale, Timeline Followback, Rutgers Alcohol Problem Index, and Rutgers Marijuana Problem Index. Assessments were completed at pretreatment as well as 3, 6, 12, and 18 months postenrollment. Results: In intent-to-treat analyses, I-CBT was associated with significantly fewer heavy drinking days and days of marijuana use relative to E-TAU but not with fewer drinking days. Those randomized to I-CBT in comparison to E-TAU also reported significantly less global impairment as well as fewer suicide attempts, inpatient psychiatric hospitalizations, emergency department visits, and arrests. Adolescents across groups showed equivalent reductions in suicidal ideation. Conclusions: I-CBT for adolescents with co-occurring AOD and suicidality is associated with significant improvement in both substance use and suicidal behavior, as well as markedly decreased use of additional health services including inpatient psychiatric hospitalizations and emergency department visits. Further testing of integrated protocols for adolescent AOD and suicidality with larger and more diverse samples is warranted.

Esposito-Smythers C; Walsh A; Spirito A; Rizzo C; Goldston DB; Kaminer Y. Working with the suicidal client who also abuses substances. Cognitive and Behavioral Practice 19(2): 245-255, 2012. (45 refs.)

Substance use disorders and suicidal thoughts and behaviors commonly co-occur in adolescent and adult psychiatric populations and are often functionally interrelated. Although the evidence base for treatment of this population is sparse, integrated cognitive behavioral treatment (CBT) protocols, or those that rely heavily on CBT techniques, hold promise. In this paper we provide an overview of the evidence-based literature for interventions that target suicidal behavior and substance use disorders with adults and adolescents. We then discuss the manner in which these behaviors may be functionally interrelated and offer a conceptual framework (S-O-R-C) to guide case conceptualization and treatment planning for clients with co-occurring suicidality and substance use disorders. Next, we provide a case example of a client with suicidal behavior and an alcohol use disorder and demonstrate how to apply an integrated CBT treatment protocol to this case. This case example is followed by a more general discussion about the potential advantages of integrated CBT protocols for suicidality and substance use disorders, guidelines for prioritizing treatment targets and skill selection for each individual client, and other important treatment considerations. We conclude with recommendations for future research in this area.

Felthous AR. Suicide behind bars: Trends, inconsistencies, and practical implications. Journal of Forensic Sciences 56(6): 1541-1555, 2011. (90 refs.)

The results of two comprehensive approaches are compared: the nationwide surveys of suicides in U.S. jails by Hayes and the international meta-analyses of suicides in jails and prisons by Fazel et al. Factors are classified as demographic, situational, clinical, and methodical. More than 50% of U.S. jail suicide victims were men, white, unmarried, under 28 years of age, charged with minor or drug-related offenses, and intoxicated with drugs or alcohol. Suicides significantly occurred in isolation. Suicide victims in the international study were significantly (p < 0.001) men, white, married, pretrial, and charged with or convicted of violent offenses. Psychiatric diagnosis, alcohol abuse, taking psychotropic medication, and suicidal ideation were also positively correlated in the international study, but suicide victims were distributed more evenly over age-groups. Results of other studies illustrate the near universality of some findings. Three theories of suicide are briefly discussed.

Giraudon I; Vicente J; Matias J; Mounteney J; Griffiths P. Reducing drug related mortality in Europe: A seemingly intractable. public health issue. (editorial). Adicciones 24(1): 3-7, 2012. (20 refs.)

Drawing on an analysis of data from over 30 cohort studies, it can be estimated that between 10.000 and 20.000 opioid users die each year in Europe. Typically, annual mortality rates are between 10-20/1000, representing an excess mortality 10 to 20 times greater than expected. Most deaths occur among males in their mid-thirties. Four broad categories of cause of death can be identified: overdoses, diseases, suicide and trauma. While the long term trend in HIV related mortality among drug users is downwards, other causes of mortality have shown little sign of decreasing in recent years. Of particular concern are overdoses which account for 6300 to 8400 deaths reported annually. The fact that deaths have not decreased is surprising given the scaling up of treatment and other services. Opioid substitution treatment in particular is known to be protective and the numbers of those in substitution treatment in Europe has increased dramatically. A number of interrelated factors may help explain this intractable problem. These include: the possibility of an aging cohort becoming more vulnerable; the use of alcohol and other drugs; high levels of ill-health, risk behaviour, and co-morbidity; and social exclusion and marginalisation. Reducing overall morbidity among heroin users remains a key issue for Europe's public health services. More efforts are required to better understand and target both the direct and indirect factors associated with mortality among problem drugs users, if this major health cost associated with drug consumption is to be reduced.

Graham K; Livingston M. The relationship between alcohol and violence: Population, contextual and individual research approaches. (editorial). Drug and Alcohol Review 30(5, special issue): 453-457, 2011. (48 refs.)

Hakansson A; Bradvik L; Schlyter F; Berglund M. Variables associated with repeated suicide attempt in a criminal justice population. Suicide and Life-Threatening Behavior 41(5): 517-531, 2011. (81 refs.)

The aim of this study was to identify factors associated with repeated suicide attempts among criminal justice clients examined for substance abuse using the Addiction Severity Index. Among suicide attempters (n = 1,404), repeaters (two or more attempts, n = 770) were compared to nonrepeaters. In logistic regression, repetition was associated with younger age, opioid analgesics, somatic medication, overdose, maternal psychiatric problems, delirium tremens, cognitive problems, and violent behavior. As in other settings, factors associated with repetition differed from those associated with suicide attempts in general. In this setting, substance use complications and cognitive problems were connected to repetition and should be addressed in risk assessments.

Harrison-Woolrych M; Ashton J. Psychiatric adverse events associated with varenicline: An intensive postmarketing prospective cohort study in New Zealand. Drug Safety 34(9): 763-772, 2011. (21 refs.)

Background: Psychiatric adverse events, including depression, suicidal ideation and psychotic reactions have been reported in patients taking the smoking cessation medicine varenicline. However, data regarding the frequency of psychiatric adverse reactions in 'real-life' postmarketing use are limited to date. Objective: The aim of the study was to calculate the occurrence rates of psychiatric adverse reactions in a nationwide general population prescribed varenicline in New Zealand. Methods: Observational prospective cohort study using Prescription Event Monitoring methods. All New Zealand patients dispensed a prescription for varenicline from 1 April 2007 to 31 March 2008 were included in this study. Patients were followed up by multiple methods, including linkage to national morbidity and mortality datasets, questionnaires to patients' doctors and assessment of spontaneous reports sent to the Intensive Medicines Monitoring Programme. Main outcome measures were occurrence rates of psychiatric adverse events in the total patient cohort and in the subgroup for whom a follow-up questionnaire was returned (the 'responder population'). Results: The cohort for this study included 3415 patients prescribed varenicline during the first year of monitoring in New Zealand. Follow-up by record linkage was performed for 3353 (98%) patients, and questionnaires were returned for 1394 (42%) of these patients. Of 1394 questionnaires returned, 1310 were valid and defined as the 'responder' population. Sleep disorders, including insomnia, sleep disturbance, dreams and nightmares, were the most frequently reported psychiatric events and were experienced by 56 (4.3%) patients in the responder population. Symptoms of depression were reported by 39 (2.98%) patients in the responder population (24 new-onset depression, 14 worsening of pre-existing depression and 1 report of impaired motivation). Withdrawal reactions after stopping varenicline were reported by 6 (0.46%) patients in the responder population. Serious psychiatric reactions including suicide (one case), suicidal ideation (two cases) and psychotic reactions (three cases) were also identified. Six self-harm events (one fatal, five non-fatal) were identified in the total cohort, giving an occurrence rate of 0.18% (95% CI 0.06, 0.38) in this population. Conclusions: This intensive postmarketing study of 3415 New Zealand patients demonstrates that psychiatric adverse events are commonly reported in patients taking varenicline. Approximately 3% of patients experienced symptoms of depression and the majority of these cases appeared to have a causal association with varenicline. Serious psychiatric reactions including suicide, suicidal ideation and psychotic reactions were also identified, but these were less frequently reported.

Haw CM; Hawton K. Problem drug use, drug misuse and deliberate self-harm: Trends and patient characteristics, with a focus on young people, Oxford, 1993-2006. Social Psychiatry and Psychiatric Epidemiology 46(2): 85-93, 2011. (34 refs.)

Drug misuse is related to self-harm and suicide. However, relatively little is known about deliberate self-harm (DSH) in patients with drug problems and whether drug misuse by DSH patients is increasing. We used data collected by the Oxford Monitoring System for Attempted Suicide to study the characteristics of DSH patients with drug problems who presented to the general hospital in Oxford between 1993 and 2006, and who underwent psychosocial assessment at their first presentation in the study period. We also studied trends in problem drug use and drugs misused over this period. During the 14-year study period, 11,426 patients presented of whom 9,248 underwent psychosocial assessment and it was known whether or not they had a drug problem. Problem drug use was present in 805/9,248 (8.7%) patients. Problem drug use was more common in males (13.6%) than in females (5.3%). Problem drug users were younger, more likely to be socially disadvantaged, to have a personality disorder and comorbid alcohol problems and to have a further episode of DSH within a year. Problem drug use in young females was associated with higher suicidal intent scale (SIS) scores. During the study period, problem drug use and drug misuse increased in females, but not in males. Cannabis and cocaine misuse increased with time. Provision of help for DSH patients with problem drug use is particularly challenging due to their complex social and clinical characteristics and increased risk of further self-harm, suicide and accidental death. It may require extensive liaison between different services. The increasing misuse of drugs by female DSH patients and the higher SIS scores of young females are of concern.

Hysinger EB; Callahan T; Caples TL; Fuchs DC; Shelton R; Cooper WO. Suicidal behavior differs among early and late adolescents treated with antidepressant agents. Pediatrics 128(3): 447-454, 2011. (42 refs.)

OBJECTIVE: To identify circumstances and characteristics of suicidal behavior among early (aged 10-14 years) and late (aged 15-18 years) adolescents from a cohort of youth who were prescribed antidepressant medication. METHODS: In-depth reviews of all available medical records were performed for 250 randomly chosen confirmed episodes of suicidal behavior identified as part of a large retrospective cohort study of antidepressant users and suicidal behavior. Study data were obtained from Tennessee Medicaid records and death certificates from January 1, 1995, to December 31, 2006. Medical records and autopsy reports for cases identified from electronic data were adjudicated by 2 investigators blinded to exposure status and classified by using a validated scale. RESULTS: Of the 250 cases reviewed, 65.6% were female and 26.4% were aged 10 to 14 years. Medication ingestion was the most frequent method of suicidal behavior for both early and late adolescents; however, early adolescents were significantly more likely to use hanging as a method of suicide. Nearly one-half of the adolescents had previously attempted suicide. Early adolescents were significantly more likely to have a history of sexual abuse and significantly less likely to have a history of substance abuse. Early adolescents were also significantly more likely than older adolescents to have a history of a psychotic disorder and to report hallucinations before the suicide attempt. CONCLUSION: Suicidal behavior among early and late adolescents prescribed antidepressant medication differed in terms of methods used, previous psychiatric history, and proximal symptoms.

Innamorati M; De Leo D; Rihmer Z; Serafini G; Brugnoli R; Lester D et al. Tobacco smoking and suicidal ideation in school-aged children 12-15 years old: Impact of cultural differences. Journal of Addictive Diseases 30(4): 359-367, 2011. (40 refs.)

This cross-sectional study examined the association between tobacco smoking and suicidal ideation in school-aged children from 9 countries in Africa, the Americas, and the Western Pacific region. Data were collected through the Global school-based Student Health Survey, a collaborative surveillance project between the World Health Organization, the United Nations, UNICEF, UNESCO, UNAIDS, and the U. S. Centers for Disease Control and Prevention. Suicidal ideation, tobacco smoking, and drug and alcohol use were included in loglinear models to analyze higher order interactions among suicidality and regional and country differences separately for boys and girls. School-aged children who reported suicidal ideation had a higher risk of smoking tobacco even after controlling for drug and alcohol misuse. Furthermore, analyses indicated higher order interactions between suicidal ideation and countries belonging to different regions with different exposure to tobacco smoking among school-aged children. Future studies analyzing the mechanism and sequencing of the relationship among suicidal ideation and tobacco smoking should explore cultural factors.

Jones AW; Kugelberg FC; Holmgren A; Ahlner J. Drug poisoning deaths in Sweden show a predominance of ethanol in mono-intoxications, adverse drug-alcohol interactions and poly-drug use. Forensic Science International 206(1-3): 43-51, 2011. (91 refs.)

Over a 10-year period (1998-2007) all deaths in Sweden classified by forensic pathologists as fatal drug poisonings (N = 6894) were retrieved from a toxicology database (TOXBASE) belonging to the National Board of Forensic Medicine. The deaths were further classified as suicides N = 2288 (33%), undetermined N = 2260 (33%) and accidental N = 2346 (34%). The average age (+/- SD) of all victims was 49.1 +/- 15.9 years and men 47.4 +/- 15.6 years were 5-year younger than women 52.2 +/- 15.8 years (p < 0.01). Most of the deceased (78%) were poly-drug users although a single drug (mono-intoxications) was found in 22% of all poisoning deaths (p < 0.001). The number of drugs in blood samples varied from 1 to 12 with a median of 3-4 per case. Mono-intoxication deaths were mostly ethanol-related (N = 976) and the mean and median blood-alcohol concentration (BAC) was 3.06 g/L and 3.10 g/L, respectively. The BAC decreased as the number of additional drugs in blood increased from 2.15 g/L with one drug to 1.25 g/L with 6 or more drugs. The mean (median) concentrations of non-alcohol drugs in mono-intoxication deaths were morphine (N = 93) 0.5 mg/L (0.2 mg/L), amphetamine (N = 39) 2.0 mg/L (1.2 mg/L), dextropropoxyphene (N = 33) 3.9 mg/L (2.9 mg/L), dihydro-propiomazine (N = 32) 1.6 mg/L (1.0 mg/L) and 7-amino-flunitrazepam (N = 28), 0.4 mg/L (0.3 mg/ L). Elevated blood morphine in these poisoning deaths mostly reflected abuse of heroin as verified by finding 6-monoacetyl morphine (6-MAM) in the blood samples. When investigating drug poisoning deaths a comprehensive toxicological analysis is essential although the results do not reveal the extent of prior exposure to drugs or the development of pharmacological tolerance. The concentrations of drugs determined in post-mortem blood are one element in the case. The autopsy report, the police investigation, the findings at the scene and eye-witness statements should all be carefully considered when the cause and manner of death are determined.

Kaplan MS; McFarland BH; Huguet N; Valenstein M. Suicide risk and precipitating circumstances among young, middle-aged, and older male veterans. American Journal of Public Health 102(Supplement 1): S131-S137, 2012. (65 refs.)

Objectives. The purpose of this study was to evaluate the risk of suicide among veteran men relative to nonveteran men by age and to examine the prevalence of suicide circumstances among male veterans in different age groups (18-34, 35-44, 45-64, and 65 years). Methods. Data from the National Violent Death Reporting System (2003-2008) ere used to calculate age-specific suicide rates for veterans (n = 8440) and nonveterans (n = 21 668) and to calculate the age-stratified mortality ratio for veterans. Multiple logistic regression was used to compare health status, stressful life events preceding suicide, and means of death among young, middle-aged, and older veterans. Results. Veterans were at higher risk for suicide compared with nonveterans in all age groups except the oldest. Mental health, substance abuse, and financial and relationship problems were more common in younger than in older veteran suicide decedents, whereas health problems were more prevalent in the older veterans. Most male veterans used firearms for suicide, and nearly all elderly veterans did so. Conclusions. Our study highlighted heightened risk of suicide in male veterans compared with nonveterans. Within the veteran population, suicide might be influenced by different precipitating factors at various stages of life.

Karch D. Sex differences in suicide incident characteristics and circumstances among older adults: Surveillance Data from the National Violent Death Reporting System-17 US States, 2007-2009. International Journal of Environmental Research and Public Health 8(8): 3479-3495, 2011. (48 refs.)

Each year in the U.S. more than 7,000 adults aged 60 years and older die of suicide and as the population ages, these numbers are expected to increase. While sex is an important predictor of older adult suicide, differences between males and females are often overlooked due to low occurrence, particularly among women. The National Violent Death Reporting System (NVDRS) bridges this gap by providing detailed information on older adult suicide by sex in 17 US states (covering approximately 26% of the U. S. population). NVDRS data for 2007-2009 were used to characterize male (n = 5,004) and female (n = 1,123) suicide decedents aged 60 years and older, including incident characteristics and circumstances precipitating suicide. Stratification of NVDRS data by sex shows significant differences with regard to the presence of antidepressants (19% and 45% respectively), opiates (18%, 37%), and 14 precipitating circumstances concerning mental health, interpersonal problems, life stressors and a history of suicide attempts. No differences were found for alcohol problems, suicide/other death of family or friends, non-criminal legal problems, financial problems, or disclosure of intent to take their own life. The findings of this study demonstrate the value of using comprehensive surveillance data to understand sex-specific suicide circumstances so that opportunities for targeted prevention strategies may be considered.

Kerr WC. More evidence that spirits can be more dangerous: Homicide in Russia and suicide in Japan. (editorial). Drug and Alcohol Review 31(3): 249-250, 2012. (8 refs.)

Kerr WC; Subbaraman M; Ye Y. Per capita alcohol consumption and suicide mortality in a panel of US states from 1950 to 2002. Drug and Alcohol Review 30(5, special issue): 473-480, 2011. (41 refs.)

Introduction and Aims. The relationship between per capita alcohol consumption and suicide rates has been found to vary in significance and magnitude across countries. This study utilises a panel of time-series measures from the US states to estimate the effects of changes in current and lagged alcohol sales on suicide mortality risk. Design and Methods. Generalised least squares estimation utilised 53 years of data from 48 US states or state groups to estimate relationships between total and beverage-specific alcohol consumption measures and age-standardised suicide mortality rates in first-differenced semi-logged models. Results. An additional litre of ethanol from total alcohol sales was estimated to increase suicide rates by 2.3% in models utilising a distributed lag specification while no effect was found in models including only current alcohol consumption. A similar result is found for men, while for women both current and distributed lag measures were found to be significantly related to suicide rates with an effect of approximately 3.2% per litre from current and 5.8% per litre from the lagged measure. Beverage-specific models indicate that spirits is most closely linked with suicide risk for women while beer and wine are for men. Unemployment rates are consistently positively related to suicide rates. Discussion and Conclusions. Results suggest that chronic effects, potentially related to alcohol abuse and dependence, are the main source of alcohol's impact on suicide rates in the USA for men and are responsible for about half of the effect for women.

Keyes KM; Liu XC; Cerda M. The role of race/ethnicity in alcohol-attributable injury in the United States. Epidemiologic Reviews 34(1): 89-102, 2012. (86 refs.)

A substantial proportion of injuries worldwide are attributable to alcohol consumption, and US estimates indicate that the drinking patterns of racial/ethnic groups vary considerably. The authors reviewed evidence from 19 publications regarding racial/ethnic differences in overall alcohol-attributable injury as well as percent blood alcohol content positivity for injury deaths in the United States. They found that Native Americans evidence higher rates of alcohol-attributable motor vehicle crash fatality, suicide, and falls compared with other racial/ethnic groups; conversely, Asians evidence lower rates of alcohol-attributable injury than other racial/ethnic groups. The rate of alcohol positivity and intoxication among Hispanics is disproportionately high relative to estimates of alcohol use. Black subgroups also evidence higher rates of alcohol positivity than would be expected given estimates of alcohol use, including for alcohol positivity among drivers of fatally injured black children and homicide. These findings highlight the continued need for public health focus on Native American populations with respect to alcohol consumption and injury. Further, the disparity in alcohol-attributable injury mortality among black and Hispanic groups relative to their reported rates of alcohol consumption is an overlooked area of research. The authors review potential social determinants of racial/ethnic disparities in alcohol-attributable injuries and identify directions for further research on these patterns.

Kim J; Fan B; Liu XH; Kerner N; Wu P. Ecstasy use and suicidal behavior among adolescents: Findings from a national survey. Suicide and Life-Threatening Behavior 41(4): 435-444, 2011. (49 refs.)

The relationship between ecstasy use and suicidal behavior among adolescents in the United States was examined. Data from the adolescent subsample (ages 12-17, N = 19,301) of the 2000 National Household Survey on Drug Abuse were used in the analyses. Information on adolescent substance use, suicidal behaviors, and related sociodemographic, family, and individual factors was obtained in the survey. The rate of past year suicide attempt among adolescents with lifetime ecstasy use was almost double that of adolescents who had used other drugs only, and nine times that of adolescents with no history of illicit drug use. In multinomial logistic regression analyses controlling for related factors, the effect of ecstasy use remained significant. Adolescent ecstasy users may require enhanced suicide prevention and intervention efforts.

Kizza D; Hjelmeland H; Kinyanda E; Knizek BL. Alcohol and suicide in postconflict northern Uganda: A qualitative psychological autopsy study. Crisis 33(2): 95-105, 2012. (55 refs.)

Background: Alcohol has been noted to be an important factor in nearly 68% of the suicides in Northern Uganda, yet exactly how alcohol contributes to suicide in this region has not been studied. Aims: To determine how alcohol contributes to suicide in this region. Methods: Qualitative psychological autopsy interviews were conducted with bereaved relatives and friends of 20 suicides mainly from Internally Displaced Peoples' camps in Northern Uganda. Data were analyzed using a modified Interpretative Phenomenological analysis (IPA). Results: Alcohol had a direct or an indirect influence on the suicide of 16 out of the 20 decedents. Directly, alcohol facilitated the suicidal process, was a means to suicide, or had an influence on the decedents' lifestyles. Indirectly, alcohol had an influence on the suicidal process of the deceased through the drinking behavior of significant others. Conclusions: This study established that alcohol not only contributes to the suicidal process of the individuals through acute and chronic alcohol consumption, but also through victimization of those lowest in the power hierarchy by alcohol abusers higher up in the power hierarchy. Therefore, future development of suicide prevention programs should address the interrelated public health problem of alcohol abuse.

Klimkiewicz A; Bohnert ASB; Jakubczyk A; Ilgen MA; Wojnar M; Brower K. The association between insomnia and suicidal thoughts in adults treated for alcohol dependence in Poland. Drug and Alcohol Dependence 122(1-2): 160-163, 2012. (49 refs.)

Background: Suicidal ideation is elevated for individuals with alcohol use disorders. Sleep problems are associated with suicide risk and alcohol use, and sleep problems may be associated with suicide risk in those with alcohol use disorders. For the present study, we hypothesized that self-reported sleep problems are associated with suicidal thoughts in a sample of adults seeking treatment for alcohol dependence in Poland. Methods: The sample included 304 patients in addiction treatment programs in Warsaw, Poland who met criteria for alcohol dependence. Measures included demographic characteristics, frequency of alcohol use, psychiatric symptoms, suicidal ideation and two measures of insomnia, which differed by time frame: the Athens Insomnia Scale (AIS, past 1 month) and the Sleep Disorders Questionnaire (SDQ-7, past 6 months). Multivariable logistic regression models tested the association between insomnia and suicidal thoughts. Results: In models that controlled for age, gender, and days of recent drinking, both measures of sleep problems were associated with suicidal ideation: AOR = 2.01 (95% Cl: 1.50-2.70) [AIS] and 1.73 (95% Cl: 1.29-2.31) [SDQ-7]. The association of sleep problems, as measured by the AIS, with suicide remained significant after adjusting for psychiatric symptoms, although the estimated effect size was smaller (AOR = 1.47; 95% CI: 1.05-2.06). Conclusions: Among Polish adults with alcohol dependence, insomnia severity was associated with suicidal ideation. This finding highlights the need to assess for sleep problems, in addition to suicidal thoughts, in alcohol treatment settings and to further examine the potential consequences of poor sleep in this population.

Kokkevi A; Rotsika V; Arapaki A; Richardson C. Adolescents' self-reported suicide attempts, self-harm thoughts and their correlates across 17 European countries. Journal of Child Psychology and Psychiatry 53(4): 381-389, 2012. (46 refs.)

Background: Suicide is a leading cause of death among adolescents in Europe. Self-harm thoughts and behaviours are documented precursors of completed suicide. It is therefore of great importance to investigate the prevalence of suicide thoughts and attempts and their correlates, with the aim of preventing this major life-threatening public health problem. This study provides cross-national European data on self-reported suicidal thoughts and attempts among adolescents. Methods: Data were obtained from 45,806 high school students aged 15-16 years from 17 countries that participated in the European School Survey Project on Alcohol and Other Drugs (ESPAD) 2007 school survey. The standardised methods of the ESPAD survey ensure comparability across countries. Students completed an anonymous questionnaire in their classrooms. The prevalences of suicidal thoughts and attempts are reported as well as their sociodemographic and psychosocial correlates identified in logistic regression. Results: The median prevalence of any lifetime self-reported suicide attempt was 10.5% across the participating countries (range 4.1%-23.5%). The median of frequent self-harm thoughts (at least five times) was 7.4% (range 2.1%-15.3%). Suicidal behaviour and thoughts had significant associations with gender, substance use, family integrity and socioeconomic status. Countries with higher prevalence of substance use tended to have a weaker association between substance use and self-reported suicide attempts. Conclusion: Although self-reported self-harm thoughts and suicide attempts vary in prevalence within Europe, there are common correlates across countries. These have an important impact on understanding the phenomenon of suicide among young people and in guiding prevention.

Kokkevi A; Rotsika V; Arapaki A; Richardson C. Changes in associations between psychosocial factors and suicide attempts by adolescents in Greece from 1984 to 2007. European Journal of Public Health 21(6): 694-698, 2011. (40 refs.)

Background: Suicide is the second commonest cause of death among adolescents and young adults aged 15-35 years in Europe. Suicide attempts are a strong risk indicator for suicide. This article examines psychosocial factors associated with self-reported suicide attempts in adolescents in Greece and whether the reported increase in suicide attempts from 1984 to 2007 was accompanied by changes in the pattern of related psychosocial factors. Methods: Data were taken from nationwide probability sample surveys of Greek high school students aged 14-18 years in 1984 (n = 10,507) and 2007 (n = 9,873). Logistic regression analysis was used to relate any self-reported suicide attempts to basic sociodemographic and psychosocial variables including family and psychological characteristics, and substance use. Results: Female gender, smoking, illicit drug use, low socio-economic status, not living with both parents, dissatisfaction with relationship with parents, visits to a doctor for psychological problems, depression, anti-social behaviour and low self-esteem were risk factors for self-reported attempted suicide by adolescents in both surveys. Significant interaction terms showed that the effects of gender and illicit drug use were smaller in 2007 than in 1984. However, low self-esteem became significantly more important. Conclusions: Several common psychosocial factors seem to be steadily related to self-reported suicide attempts by Greek adolescents in 1984 and 2007. However, the increase in self-reported suicide attempts between 1984 and 2007 has been accompanied by changes in the relative importance of correlates.

Kretschmar JM; Flannery DJ. Displacement and suicide risk for juvenile justice-involved youth with mental health issues. Journal of Clinical Child and Adolescent Psychology 40(6): 797-806, 2011. (52 refs.)

This article examined the relationship between suicide behaviors and displacement, as defined by out-of-home placement, in a sample of juvenile-justice-involved youth with mental health issues. Participants included boys and girls between the ages of 10 and 18 who were enrolled in a juvenile justice diversion program for children with mental or behavioral health problems. Data collected included youth-reported suicide and self-harm ideation, caregiver reports of previous suicide attempts, and whether the youth had been in an out-of-home placement in the year prior to enrollment in the program. Logistic regression analyses indicated that youth who had recently been in an out-of-home placement reported significantly less suicide ideation and marginally less self-harm ideation than youth who had not been in an out-of-home placement. Out-of-home placement status had no impact on caregiver reports of previous youth suicide attempts.

Kuo CJ; Tsai SY; Liao YT; Conwell Y; Lin SK; Chang CL et al. Risk and protective factors for suicide among patients with methamphetamine dependence: A nested case-control study. Journal of Clinical Psychiatry 72(4): 487- 493, 2011. (35 refs.)

Objective: Methamphetamine as a recreational drug has undergone cycles of popularity, with a recent surge worldwide since the 1990s. This study aimed to identify clinical characteristics associated with suicide mortality in patients with methamphetamine dependence by means of a nested case-control design. Method: In a consecutive series of 1,480 inpatients with methamphetamine dependence (diagnosed according to DSM-III-R and DSM-IV criteria) admitted to a psychiatric center in northern Taiwan from January I, 1990, through December 31, 2006, 38 deaths due to suicide were identified as cases via record linkage, and 76 controls were randomly selected using risk-set density sampling in a 2:1 ratio, matched for age, sex, and the year of index admission. A standardized chart review process was adopted to collate sociodemographic and clinical information for each study subject. Multivariate conditional logistic regression analysis was used to identify correlates of suicide among these patients. Results: For the sociodemographic and symptom profiles at the latest admission, financial independence lowered the risk for suicide (adjusted risk ratio [ARR] = 0.33, P<.05), whereas visual hallucinations elevated the risk (ARR = 2.57, P<.05) for suicide. For the profiles during the postdischarge period, financial independence (ARR = 0.11, P<.05) remained associated with reduced risk for suicide, whereas suicide attempt (ARR = 8.78, P<.05) and depressive syndrome (ARR = 3.28, P = .059) were associated with increased risk of suicide. Conclusions: Both protective and risk factors for suicide mortality were found among inpatients with methamphetamine dependence, and the findings have implications for clinical intervention and prevention.

Kuramoto SJ; Chilcoat HD; Ko J; Martins SS. Suicidal ideation and suicide attempt across stages of nonmedical prescription opioid use and presence of prescription opioid disorders among US adults. Journal of Studies on Alcohol and Drugs 73(2): 178-184, 2012. (37 refs.)

Objective: This study compares the likelihood of suicidal ideation and suicide attempt across stages of nonmedical prescription opioid use and by presence of prescription opioid disorders (dependence and/or abuse) among adult respondents. Method: In the 2009 National Survey on Drug Use and Health, 37, 933 adult respondents were asked if they had thought about suicide or had attempted suicide in the past year. The likelihood of ideation and attempt were compared across the following four categories: (a) those who never used prescription opioids, (b) former users, (c) persistent users, and (d) recent-onset users. Weighted multinomial logistic regressions were used to examine if these stages and presence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for prescription opioid disorders were associated with suicidal ideation and suicide attempt. Results: Five percent of respondents (n = 2, 021) reported suicidal ideation; of these, 15% (n = 310) reported attempt. Former and persistent nonmedical prescription opioid users had greater odds of suicidal ideation than those who never used these medications nonmedically. The stages of prescription opioid use were not associated with suicide attempt. Presence of prescription opioid disorders among past-year prescription opioid users was associated with suicidal ideation but not suicide attempt. Conclusions: The risk for suicidal ideation was greater in those who no longer used prescription opioids, in persistent users, and among nonmedical users who had a prescription opioid disorder compared with users without the disorder. The results suggest a need to continue monitoring for suicide risk even among those who have stopped using prescription opioids.

Lamis DA; Malone PS. Alcohol-related problems and risk of suicide among college students: The mediating roles of belongingness and burdensomeness. Suicide and Life-Threatening Behavior 41(5): 543-553, 2011. (58 refs.)

The relationship among alcohol-related problems, perceived burdensomeness, thwarted belongingness, and suicide proneness in undergraduate college students (N = 996) was examined. As hypothesized, alcohol-related problems, perceived burdensomeness, and thwarted belongingness were all significantly and positively correlated with suicide proneness. The relation between experiencing alcohol-related problems and suicide proneness was, in part, accounted for by perceived burdensomeness and thwarted belongingness. Additionally, the mediation via perceived burdensomeness was significantly stronger than the mediation via thwarted belongingness. Results suggest that it would be advisable for clinicians to be aware of students' experiences with alcohol-related problems in conjunction with their levels of burdensomeness and belongingness when assessing for suicide risk.

Lejoyeux M; Gastal D; Bergeret A; Casalino E; Lequen V; Guillermet S. Alcohol use disorders among patients examined in emergency departments after a suicide attempt. European Addiction Research 18(1): 26-33, 2012. (23 refs.)

Aim of the Study: To assess the prevalence of alcohol use disorders (AUD) in a population of patients examined following attempted suicide and compare suicide attempts with and without AUD. Methods: 180 patients examined in an emergency department after a suicide attempt were compared with 180 controls paired for sex and age. All patients answered the CAGE and the Fagerstrom questionnaire. The DSM-IV-R criteria for alcohol, nicotine and cannabis abuse and dependence, as well as for borderline and antisocial personality, were checked. Results: The prevalence of AUD was 43% among suicide attempters. Suicide attempters with AUD were more often men (52 vs. 30%), living alone (64 vs. 31%) and older (35.9 vs. 32.3 years). They were more often dependent on nicotine (87 vs. 43%) and smoked more cannabis joints (1.4 vs. 0.5). They had taken alcohol before committing suicide more often (61 vs. 23%) and had more previous suicide attempts (2.5 vs. 0.9). Additionally, suicide attempters had higher scores of sensation seeking and presented more often with an antisocial or borderline personality. Conclusion: 43% of the patients examined after a suicide attempt presented with AUD. Emergency units may provide an opportunity to identify their dependence disorder and offer information and treatment.

Liang SL; Friedman LS. Analysis of suspected suicides using poison center data. Archives of Suicide Research 15(3): 185-194, 2011. (30 refs.)

Although there has been extensive research into the epidemiology and prevention of suicide, there continues to be a paucity of research on non-fatal suicides, in particular persons not treated in hospitals following a suicide attempt. In this study, we analyzed call data from the Illinois Poison Center from 2002 to 2007, which primarily comprises of non-fatal hospitalized and non-hospitalized attempts. We analyzed 43,057 calls by persons suspected of attempting suicide. The three most common groups of substances used were analgesics, antidepressants, and sedative/hypnotics/antipsychotics. The Poisson regression model showed significant declines in calls for suspected suicides during periods of holidays and vacations, and was more pronounced among youths. This study provides a current and detailed description of substances used primarily in non-fatal suicide attempts.

Logan JE; Crosby AE; Hamburger ME. Suicidal ideation, friendships with delinquents, social and parental connectedness, and differential associations by sex findings among high-risk pre/early adolescent population. Crisis 32(6): 299-309, 2011. (32 refs.)

Background: The association between suicidal ideation, friendships with delinquents, and social/parental connectedness among pre/early adolescents who reside in high-risk communities is poorly understood. Aims: This study examined among high-risk youths: (1) the association between suicidal ideation and having delinquent friends, school connectedness, social support, and different parenting styles (i.e., caring only, supervision only, caring with supervision); and, (2) the differential associations by sex. Methods: The associations were assessed among 2, 598 pre/early adolescents using logistic regression. The analyses were adjusted for demographic, mental distress, illicit substance use, and peer/date violence victimization factors. The interaction terms determined differences by sex. Results: After adjusting for demographic factors and mental distress, suicidal ideation was positively associated with having delinquent friends; however, after factoring in illicit substance use and violence victimization, this association was negative for males. After adjusting for all factors, suicidal ideation was negatively associated with school connectedness and all parenting styles; however, the association between suicidal ideation and having parental caring with supervision was stronger for females. Conclusions: The results suggest the potential benefits of increasing school connectedness and improving parent-child interactions, particularly among females, and the potential benefits of violence and substance-abuse prevention strategies for youths, particularly males, connected with delinquent peers.

Logan J; Hall J; Karch D. Suicide categories by patterns of known risk factors: A latent class analysis. Archives of General Psychiatry 68(9): 935-941, 2011. (42 refs.)

Context: Multiple risk factors contribute to suicides; however, patterns of co-occurrence among these factors have not been fully identified. Objectives: To assess patterns of known suicide-related risk factors, classify suicide decedents by these patterns, track class proportions during a 6-year period, and characterize decedents across the classes to help focus prevention strategies. Design, Setting, and Participants: Latent class analysis was conducted using 2003-2008 data from the National Violent Death Reporting System. The population included 28 703 suicide decedents from 12 US states. Main Outcome Measures: The known risk factors included having the following: mental health conditions; a sad or depressed mood; substance abuse problems; medical problems; recent crises; financial, job, and legal problems; intimate partner and other relationship problems; and perpetrated interpersonal violence. Results: Nine distinct patterns of risk factors emerged. Of these classes, 1 only endorsed mental health-related factors and 1 only endorsed alcohol- and substance abuse-related factors; however, 7 classes of decedents had distinct patterns of factors that spanned multiple domains. For example, 5 of these classes had mental health factors with other risks (eg, substance abuse, financial problems, relationship problems, a recent crisis, and medical problems). Two classes had recent crises with relationship problems; one of these classes also had high probabilities for criminal problems and interpersonal violence. Class proportions differed during the 6 years. Differences across classes by demographic and event characteristics were also found. Conclusions: Most suicide decedents could be classified by patterns of risk factors. Furthermore, most classes revealed a need for more connected services across medical, mental health/substance abuse, and court/social service systems. Reducing fragmentation across these agencies and recruiting family, friend, and community support for individuals experiencing mental health problems and/or other stress might significantly reduce suicides.

Mansfield AJ; Bender RH; Hourani LL; Larson GE. Suicidal or self-harming ideation in military personnel transitioning to civilian life. Suicide and Life-Threatening Behavior 41(4): 392-405, 2011. (71 refs.)

Suicides have markedly increased among military personnel in recent years. We used path analysis to examine factors associated with suicidal/self-harming ideation among male Navy and Marine Corps personnel transitioning to civilian life. Roughly 7% of men (Sailors = 5.3%, Marines = 9.0%) reported ideation during the previous 30 days. Results suggest that combat exposure, substance abuse, and resilience are associated with suicidal ideation/self-harming thoughts through the mediation of posttraumatic stress disorder symptoms and/or depression symptoms. Substance abuse plays a moderating role. Resilience had a direct effect only among the Marines. Implications for improving the transition to civilian life are discussed.

Marshall BDL; Galea S; Wood E; Kerr T. Injection methamphetamine use is associated with an increased risk of attempted suicide: A prospective cohort study. Drug and Alcohol Dependence 119(1-2): 134-137, 2011. (35 refs.)

Background: Methamphetamine (MA) use is a growing public health concern in many settings around the world. While some physical and mental health effects associated with injection MA use have been well described, little is known about the relationship between injecting MA and suicidal behavior. We sought to determine whether MA injection was associated with an increased risk of attempting suicide among a prospective cohort of injection drug users (IDUs) in Vancouver, Canada. Methods: Between 2001 and 2008, eligible participants enrolled in the Vancouver Injection Drug Users Study (VIDUS) completed semi-annual questionnaires that elicited information regarding sociodemographics, drug use patterns, and mental health problems including suicidal behavior. We used Cox proportional hazards models with time-dependent covariates to determine whether self-reported MA injection was an independent predictor of attempting suicide at subsequent time points. Results: of 1873 eligible participants, 149 (8.0%) reported a suicide attempt, resulting in an incidence density of 2.5 per 100 person-years. Participants who attempted suicide were more likely to be younger (median: 35 vs. 40, p < 0.01), female (48.3% vs. 35.1%, p < 0.01), and of Aboriginal ancestry (43.6% vs. 31.3%, p < 0.01). In a Cox proportional hazards model, MA injection was associated with an 80% increase in the risk of attempting suicide (adjusted hazard ratio = 1.80, 95% CI: 1.08-2.99, p = 0.02). Conclusions: These findings suggest that IDUs who inject MA should be monitored for suicidal behavior. Improved integration of mental health and suicide prevention interventions within harm reduction and drug treatment programs may be fruitful.

Mattisson C; Bogren M; Ojehagen A; Nordstrom G; Horstmann V. Mortality in alcohol use disorder in the Lundby Community Cohort: A 50 year follow-up. Drug and Alcohol Dependence 118(2-3): 141-147, 2011. (45 refs.)

Aims: To describe the mortality and causes of death among subjects with alcohol use disorder in comparison with those without alcohol disorder and to study whether mental disorders increase mortality in alcoholics. Design and setting: Data were analysed from the database of the Lundby Study, comprising 3563 subjects followed from 1947 to 1997. Method: A community-based sample was investigated in 1947 with follow-ups in 1957, 1972 and 1997. Best-estimate consensus diagnoses of mental disorders, including alcohol use disorder, were assessed. In the total cohort, 427 cases of alcohol use disorders were identified. Differences in mortality between subjects with alcohol use disorders and non-alcoholics were studied using Cox regression models and causes of death were compared between alcoholic subjects and other participants. Risk factors for mortality among the 348 individuals with alcohol use disorders and known age-of-onset were analysed by means of Cox regression analyses. Results: The hazard ratio for mortality was higher for alcoholics compared to other subjects in the cohort. A substantial proportion of the causes of death among the alcoholics was suicide N = 27(6.3%) (26 males, 1 female). In the multivariate models of risk factors in alcohol use disorders, anxiety disorders, psychotic disorders, alcohol induced psychotic disorders and dementia were risk factors for premature death. Conclusion: The mortality risk for subjects with alcohol use disorder was increased, females were especially vulnerable. The risk for suicide was high among males with alcohol problems. Anxiety disorders and severity of alcohol use disorder turned out as risk factors for premature death.

McLean D; Gladman B; Mowry B. Significant relationship between lifetime alcohol use disorders and suicide attempts in an Australian schizophrenia sample. Australian and New Zealand Journal of Psychiatry 46(2): 132, 2012. (38 refs.)

Objective: Suicide and attempted suicide are common in individuals with schizophrenia, and evidence exists for a link between substance use disorders and suicidality in this disorder. However, alcohol has not been consistently implicated. We examined the relationship between substance use disorders and suicide attempts in schizophrenia. Methods: We recruited a schizophrenia sample in Australia (n = 821) for genetic analyses. We analysed demographic and clinical variables, including substance use disorders, and their relationship to suicide attempts using generalised equation modelling. Results: A significant association was identified between lifetime alcohol abuse/dependence and suicide attempts (OR = 1.66; 95% CI, 1.23 to 2.24; p= 0.001) after adjustment for potential confounders, but not between cannabis abuse/dependence and suicide attempts, nor between other illicit drug abuse/dependence and suicide attempts. Polysubstance abuse/dependence was also not implicated. Conclusions: These results suggest that the presence of alcohol abuse/dependence may be a risk factor for suicide attempts in individuals with schizophrenia, independent of comorbid substance abuse/dependence.

Melle I; Barrett EA. Insight and suicidal behavior in first-episode schizophrenia. (review). Expert Review of Neurotherapeutics 12(3): 353-359, 2012. (101 refs.)

Suicidal behavior and suicide is prevalent in schizophrenia, with an estimated lifetime risk of approximately 5%. The risk is particularly high in the early phases of the disorder, and especially during the years around treatment initiation. Suicide attempts before first treatment contact are also prevalent, with the risk of suicide attempt associated with the length of untreated illness. Several risk factors are in common with the general population, and include previous suicide attempts, impulsive personality traits, substance abuse, depression and feelings of hopelessness. Recent research examines how patients' subjective experiences, including their insight into having a severe mental illness and their beliefs about mental illnesses, may influence suicidal behavior. In this article, we will present a review of studies illustrating the complex background of suicide risk in schizophrenia, with a particular emphasis on the role of insight in the early phases of schizophrenia.

Merrall ELC; Bird SM; Hutchinson SJ. Mortality of those who attended drug services in Scotland 1996-2006: Record-linkage study. International Journal of Drug Policy 23(1): 24-32, 2012. (46 refs.)

Background: We examine major causes of death amongst persons in contact with drug-treatment services across Scotland during April 1996-March 2006, hereafter Scottish Drug Misuse Database (SDMD) cohort. Methods: Drug-treatment records were linked to national registers of deaths and hepatitis C virus (HCV) diagnoses. For eras 1996/97-2000/01 and 2001/02-2005/06, we calculated cause-specific death-rates and standardised mortality ratios (SMRs) using age-, sex- and calendar-rates of the general Scottish population. Major causes of death were identified by high SMRs (>5 across eras) or rates (>50 per 100,000 person-years in either era), and their time-specific influences characterised by proportional hazards analyses. Results: The SDMD cohort comprised 69,456 individuals, 350,315 person-years and 2590 deaths. The overall SMR reduced from 6.4 (95% CI: 6.0-6.9) to 4.8 (95% CI: 4.6-5.0) between eras. We identified five major causes of death: drug-related (1383 deaths), homicide (118) and infectious diseases (90) with high SMRs; suicide (269) and digestive system disease (168) with high rates. HCV diagnosis marked individuals with at least double the risk of cause-specific mortality, including adjusted hazard ratio (HR) for no HCV diagnosis of 0.46(95% CI: 0.41-0.53) for drug-related deaths (DRDs) and 0.15 (95% CI: 0.10-0.22) for death from digestive system disease. Increased DRD risk at older age (>34 years) appeared specific to HCV-diagnosed individuals (interaction: chi(2)(1) = 7.7. p = 0.01). Alcohol misuse increased HRs: for DRD (1.76, 95% CI: 1.50-2.06), suicide (1.88, 95% CI: 1.35-2.60), deaths from digestive system disease (3.19, 95% CI: 2.21-4.60) and non-major causes (1.87, 95% CI: 1.49-2.35). Stimulant misuse increased suicide risk: adjusted HR 1.91 (95% CI: 1.43-2.54). Conclusions: Drug-users in Scotland are exposed to variously increased mortality risks. HCV-diagnosed individuals are particularly vulnerable, and may need additional support.

Miller M; Borges G; Orozco R; Mukamal K; Rimm EB; Benjet C et al. Exposure to alcohol, drugs and tobacco and the risk of subsequent suicidality: Findings from the Mexican Adolescent Mental Health Survey. Drug and Alcohol Dependence 113(2-3): 110-117, 2011. (59 refs.)

Aims: To examine whether the association between prevalence measures of suicidality and substance abuse/dependence among adolescents (1) is attenuated when temporal priority of exposure and outcome are taken into account, (2) extends to substance use (i.e. without disorder), (3) applies to tobacco use and dependence independent of illicit drugs and alcohol use/disorder, and (4) is confounded by comorbid mental illness. Design: Discrete-time survival models were applied to retrospectively reported age of onset of first suicidal ideation, plan and attempt and age of onset of first substance use and disorder. Participants: 3005 adolescents aged 12-17 residing in the Mexico City Metropolitan Area in 2005. Measurements: The World Mental Health computer-assisted adolescent version of the Composite International Diagnostic Interview was used to assess suicidal outcomes and psychiatric disorders including substance dependence/abuse. Findings: Use of and dependence on tobacco is as strong a predictor of subsequent suicidality as is use of and dependence with abuse of alcohol and drugs. The association between substance use and subsequent suicidality is not fully accounted for by comorbid mental illness. Conclusion: Efforts to reduce the use as well as the abuse of alcohol, drugs and tobacco may help reduce the risk of subsequent suicidal behaviors among adolescents in Mexico.

Mohatt NV; Fok CCT; Burket R; Henry D; Allen J. Assessment of awareness of connectedness as a culturally-based protective factor for Alaska native youth. Cultural Diversity & Ethnic Minority Psychology 17(4): 444-455, 2011. (47 refs.)

Research with Native Americans has identified connectedness as a culturally based protective factor against substance abuse and suicide. Connectedness refers to the interrelated welfare of the individual, one's family, one's community, and the natural environment. We developed an 18-item quantitative assessment of awareness of connectedness and tested it with 284 Alaska Native youth. Evaluation with confirmatory factor analysis and item response theory identified a 12-item subset that functions satisfactorily in a second-order four-factor model. The proposed Awareness of Connectedness Scale (ACS) displays good convergent and discriminant validity, and correlates positively with hypothesized protective factors such as reasons for living and communal mastery. The measure has utility in the study of culture-specific protective factors and as an outcomes measure for behavioral health programs with Native American youth.

Moore E. Lifetime nicotine dependence shows a cross-sectional association with lifetime incomplete suicide attempts. (commentary). Evidence-Based Mental Health 14(4): 92, 2011

This is a commentary on the article by Yaworski D, et al. The relation between nicotine dependence and suicide attempts in the general population published in the Canadian Journal of Psychiatry, 56: 161-170, 20011. A synopsis of the article is included.

Moore TJ; Furberg CD; Glenmullen J; Maltsberger JT; Singh S. Suicidal behavior and depression in smoking cessation treatments. PLoS ONE 6(11): e-article 27016, 2011. (40 refs.)

Background: Two treatments for smoking cessation -- varenicline and bupropion -- carry Boxed Warnings from the U. S. Food and Drug Administration (FDA) about suicidal/self-injurious behavior and depression. However, some epidemiological studies report an increased risk in smoking or smoking cessation independent of treatment, and differences between drugs are unknown. Methodology: From the FDA's Adverse Event Reporting System (AERS) database from 1998 through September 2010 we selected domestic, serious case reports for varenicline (n = 9,575), bupropion for smoking cessation (n = 1,751), and nicotine replacement products (n = 1,917). A composite endpoint of suicidal/self-injurious behavior or depression was defined as a case with one or more Preferred Terms in Standardized MedDRA Query (SMQ) for those adverse effects. The main outcome measure was the ratio of reported suicide/self-injury or depression cases for each drug compared to all other serious events for that drug. Results: Overall we identified 3,249 reported cases of suicidal/self-injurious behavior or depression, 2,925 (90%) for varenicline, 229 (7%) for bupropion, and 95 (3%) for nicotine replacement. Compared to nicotine replacement, the disproportionality results (OR (95% CI)) were varenicline 8.4 (6.8-10.4), and bupropion 2.9 (2.3-3.7). The disproportionality persisted after excluding reports indicating concomitant therapy with any of 58 drugs with suicidal behavior warnings or precautions in the prescribing information. An additional antibiotic comparison group showed that adverse event reports of suicidal/self-injurious behavior or depression were otherwise rare in a healthy population receiving short-term drug treatment. Conclusions: Varenicline shows a substantial, statistically significant increased risk of reported depression and suicidal/self-injurious behavior. Bupropion for smoking cessation had smaller increased risks. The findings for varenicline, combined with other problems with its safety profile, render it unsuitable for first-line use in smoking cessation.

Nordentoft M; Mortensen PB; Pedersen CB. Absolute risk of suicide after first hospital contact in mental disorder. Archives of General Psychiatry 68(10): 1058-1064, 2011. (35 refs.)

Context: Estimates of lifetime risk of suicide in mental disorders were based on selected samples with incomplete follow-up. Objective: To estimate, in a national cohort, the absolute risk of suicide within 36 years after the first psychiatric contact. Design: Prospective study of incident cases followed up for as long as 36 years. Median follow-up was 18 years. Setting: Individual data drawn from Danish longitudinal registers. Participants: A total of 176 347 persons born from January 1, 1955, through December 31, 1991, were followed up from their first contact with secondary mental health services after 15 years of age until death, emigration, disappearance, or the end of 2006. For each participant, 5 matched control individuals were included. Main Outcome Measures: Absolute risk of suicide in percentage of individuals up to 36 years after the first contact. Results: Among men, the absolute risk of suicide (95% confidence interval [CI]) was highest for bipolar disorder, (7.77%; 6.01%-10.05%), followed by unipolar affective disorder (6.67%; 5.72%-7.78%) and schizophrenia (6.55%; 5.85%-7.34%). Among women, the highest risk was found among women with schizophrenia (4.91%; 95% CI, 4.03%-5.98%), followed by bipolar disorder (4.78%; 3.48%-6.56%). In the nonpsychiatric population, the risk was 0.72% (95% CI, 0.61%-0.86%) for men and 0.26% (0.20%-0.35%) for women. Comorbid substance abuse and comorbid unipolar affective disorder significantly increased the risk. The co-occurrence of deliberate self-harm increased the risk approximately 2-fold. Men with bipolar disorder and deliberate self-harm had the highest risk (17.08%; 95% CI, 11.19%-26.07%). Conclusions: This is the first analysis of the absolute risk of suicide in a total national cohort of individuals followed up from the first psychiatric contact, and it represents, to our knowledge, the hitherto largest sample with the longest and most complete follow-up. Our estimates are lower than those most often cited, but they are still substantial and indicate the continuous need for prevention of suicide among people with mental disorders.

Norstrom T; Stickley A; Shibuya K. The importance of alcoholic beverage type for suicide in Japan: A time-series analysis, 1963-2007. Drug and Alcohol Review 31(3): 251-256, 2012. (47 refs.)

Background. Japan has one of the highest suicide rates in the world. Cohort analysis has suggested that alcohol consumption is a risk factor for suicide in Japan. However, this relationship has not been observed at the population level when a measure of per capita total alcohol consumption has been analysed. The present study employed a time-series analysis to examine whether these contradictory findings may be due to the existence of beverage-specific effects on suicide. Methods. An autoregressive integrated moving average model was used to assess the relationship between the consumption of different types of alcohol and suicide rates from 1963 to 2007. The data comprised age-adjusted suicide rates for the ages 15-69, and information on beverage-specific alcohol consumption per capita (15+). The unemployment rate was included as a control variable. Results. During 1963-2007, male suicide rates increased substantially whereas female rates decreased slightly. Consumption of distilled spirits was significantly related to male suicide rates (but not in women) with a 1 L increase in consumption associated with a 21.4% (95% confidence interval: 3.2-42.9) increase in male suicide rates. There was no statistically significant relationship between suicide and any other form of alcohol consumption (beer, wine, other alcohol). Conclusion. This is the first study that has shown an association between spirits consumption and male suicide in Japan. Potentially beneficial policy changes include increasing spirits prices through taxation, reducing the physical availability of alcohol and discouraging the practice of heavy drinking.

Nussbaum A; Thurstone C; Binswanger I. Medical marijuana use and suicide attempt in a patient with major depressive disorder. (editorial). American Journal of Psychiatry 168(8): 778-781, 2011. (17 refs.)

O'Donnell S; Meyer IH; Schwartz S. Increased risk of suicide attempts among Black and Latino lesbians, gay men, and bisexuals. American Journal of Public Health 101(6): 1055- 1059, 2011. (30 refs.)

Members of racial/ethnic minority groups have a lower lifetime prevalence than have Whites of mental disorders, a risk factor for suicide attempts; paradoxically, however, lesbian, gay, and bisexual (LGB) ethnic minority youths may be at increased risk for suicide attempts relative to White LGB youths. We found that the increased risk of suicide attempts among racial/ethnic minority LGB respondents in our sample relative to White respondents was not explained by excess youth onset of depression and substance abuse or by a higher susceptibility to suicide in the racial/ethnic minority LGB group.

Oladeji BD; Gureje O. Parental mental disorders and suicidal behavior in The Nigerian Survey of Mental Health and Well-Being. Archives of Suicide Research 15(4): 372-383, 2011. (33 refs.)

The objective of this study was to determine which parental mental disorders predict offspring suicidal behavior in a general adult population sample of a sub-Saharan African country. The World Health Organization Composite International Diagnostic Interview, version 3 was used to assess respondents' suicidal behaviors as well as psychopathology in their parents. The effects of parental disorders in predicting offspring suicide ideation and attempts were examined in a series of bivariate and multi-variate models. Sections on suicidality were administered to the entire sample (n = 6752), but associations with parental psychopathology were examined in a sub-sample of respondents (n 2143). Lifetime prevalence (95% confidence interval) of suicide ideation, plans, and attempts was 3.2% (1.4-6.5), 1.0% (0.4-7.5), and 0.7% (0.5-1.0) respectively. Parental panic disorder and substance abuse were associated with suicide ideation in offspring, but only parental panic disorder was linked to suicide attempts. Parental panic disorder predicted the onset and persistence of suicide ideation and attempts and also which persons with suicide ideation go on to make a suicide attempt. This study further affirms findings from previous studies of the role of disorders characterized by anxiety and impulse control in suicide attempts and as being a probable link in the transmission of suicidal behavior to offspring.

Pae CU; Koh JS; Lee SJ; Han C; Patkar AA; Masand PS. Association of sedative-hypnotic medications with suicidality. (review). Expert Review of Neurotherapeutics 11(3): 345-349, 2011. (30 refs.)

Several studies have investigated the association between sedative-hypnotics and suicidality, as such medications not only serve as a method for suicide, but are also involved in the usual options for treating psychiatric and medico-surgical disorders. According to population-based studies in Europe, Asia and the USA, sedative-hypnotic medications were significantly associated with suicide. However, these studies failed to address psychiatric comorbidities, new hypnotic medications, such as zolpidem, and the specific times at which such medications were used. Recently, Brower and colleagues have investigated the association of the prescription of sedative-hypnotic drugs with suicidality, to determine whether such medications were associated with suicidal ideation, suicide plans and suicide attempts in a large-cohort sample. They found that the use of sedative-hypnotic medications was significantly associated with suicidal ideation, suicide plans and suicide attempts. In addition, the use of sedative-hypnotic medications was a stronger predictor than insomnia of both suicidal ideation and suicide attempts. This article will discuss the relationship between prescription of sedative-hypnotic medications and suicide in the context of the potential limitations and significance of this recent research.

Pavarin RM; Berardi D. Mortality risk in a cohort of subjects reported by authorities for cannabis possession for personal use. Results of a longitudinal study. Epidemiologia & Prevenzione 35(2): 89-93, 2011. (24 refs.)

Objective: to study mortality risk in a cohort of cannabis comsumers. Design: longitudinal study on a cohort of 2,511 subjects reported to the Drug Addiction Control Force (DACF) for cannabis possession for personal use between 1990 and 2004 among residents in the metropolitan area of Bologna. Methods: to identify people already treated for drug dependence, the cohort was linked with the clinical archive of the public treatment centers for drug addiction (PTC) in the metropolitan area of Bologna and the results were separated into PTC clients (subjects in treatment at a PTC, all heroin users) and non-PTC clients (subjects not in treatment at a PTC, no knowledge regarding other illicit drugs being used besides cannabis). Results: an excess of mortality was observed for all causes in the cohort compared to the general population, both among PTC clients (SMR 14.61 CI 95% 9.21-23.19) and non-clients (SMR 2.43 CI 95% 1.67-3.55). Among PTC clients the highest and most statistically significant SMRs were for overdose, suicide, and AIDS. Among non PTC clients there was an excess for traffic accidents and overdose. Conclusions: the results of the study show an elevated risk of death for consumers of cannabis, a percentage of which probably also consumed other substances, and a very few which presented themselves for treatment at a public drug treatment center.

Poeschla B; Combs H; Livingstone S; Romm S; Klein MB. Self-immolation: Socioeconomic, cultural and psychiatric patterns. Burns 37(6): 1049-1057, 2011. (51 refs.)

Introduction: Self-immolation remains a significant contemporary problem. Its epidemiology and causes, and the intervention strategies these suggest vary significantly between higher- and lower-income countries. We summarize what is known about suicide by self-immolation in terms of its demographic and psychiatric risk factors, causes, local patterns and means employed, and points of possible intervention. Methods: We reviewed the literature for all published papers on self-immolation between 1973 and 2010. Epidemiologic and psychiatric risk factors and aspects of method, locale and timing of self-immolation were compared between higher- and lower-income countries. Results: In higher-income countries self-immolation tends to be rare and the majority of self-immolation patients are male. In lower-income countries, the incidence of self-immolation is much higher, and the majority of patients are female. Self-immolation was more frequently associated with a history of mental illness or substance abuse history in higher-income countries than in lower-income countries. Conclusion: Reports in the literature of self-immolation divide most informatively into two groups according to the higher- or lower-income of the societies affected. This classification is not arbitrary, as it correlates with other measures of development, and the epidemiologic patterns revealed show distinct differences, suggesting differing causes and intervention strategies. Analytical studies are needed to distinguish associations from underlying causes and identify efficient points of intervention.

Proenca P; Franco JM; Mustra C; Marcos M; Pereira AR; Corte-Real F et al. An UPLC-MS/MS method for the determination of valproic acid in blood of a fatal intoxication case. Journal of Forensic and Legal Medicine 18(7): 320-324, 2011. (50 refs.)

Valproic acid (VPA) has been used as an anticonvulsant for the treatment of epilepsy. The authors present a fatal case involving a 45-year-old female, found dead lying in bed with empty tablets of Diplexil (R) next to her. She was a chronic alcoholic and epileptic who had been under psychiatric treatment, having repeatedly demonstrated intent to commit suicide. A rapid method was developed and validated to determine VPA in blood by ultra-performance liquid chromatography (UPLC) coupled with tandem mass spectrometry (MS/MS) with electrospray ionization source in negative ion mode. The method involved sample treatment with phosphoric acid followed by solid-phase extraction. Chromatographic separation was achieved using an Acquity UPLC (R) BEH (2.1 x 50 mm id, 1.7 mu m) column and a mobile phase containing ammonium acetate and acetonitrile, at a 0.5 mL/min flow rate. Detection and quantification of VPA was achieved using multiple reaction monitoring (MRM). The MS/MS transitions used for monitoring were m/z 143.1-143.1 for valproic acid and m/z 296.1-205.0 for hydrochlorothiazide used as an internal standard (IS). The limit of quantification (LOQ) was 0.5 mu g/mL and the method was linear in the concentration range of 0.5-100 mu g/mL. The coefficients of variation obtained for accuracy and precision were less than 10% and the mean recovery was 95% for the three concentrations levels studied (5 mu g/mL,10 mu g/mL and 50 mu/mL). Toxicological results showed high concentration of VPA (556 mu g/mL) and therapeutic concentrations of tiapride, mirtazapine, oxazepam and nordiazepam. Blood sample analysis also revealed the presence of ethanol at a concentration of 1.34 g/L. A specific, selective and sensitive method for the determination of VPA in blood was developed and can be used in routine forensic investigation. Toxicological results led the pathologist to rule that death was due to an intoxication caused by the simultaneous ingestion of high VPA concentrations and alcohol, with a suicidal legal-medical etiology.

Randall JR; Rowe BH; Colman I. Emergency department assessment of self-harm risk using psychometric questionnaires. Canadian Journal of Psychiatry 57(1): 21, 2012. (37 refs.)

Objective: To examine several potential predictive screening tools for emergency department assessment of risk of self-harm. Methods: Adult patients presenting with self-harm or suicidal ideation were enrolled at 2 emergency departments at large teaching hospitals in Edmonton, Alberta. Patients completed a brief interview assessing demographics and psychiatric history and several questionnaires (the Beck Hopelessness Scale, the Barrett Impulsiveness Scale [BIS], and the Brief Symptom Inventory [BSI]) and drug and alcohol abuse screens (Drug Abuse Screening Test [DAST-10] and the Cut down, Annoyed, Guilt, Eye-opener [commonly referred to as CAGE] Questionnaire). At 3 months, patients were followed up via telephone and electronic health records to ascertain self-harm outcome. Questionnaires and their subscales were assessed using logistic regression. Receiver operating characteristic (ROC) analysis was performed on the results. Results: Among the 157 patients enrolled, 49% were women and 36% (of the total) were aged 18 to 29 years. Several of the subscales of the BSI and BIS as well as the DAST-10 were significant predictors of self-harm (P < 0.05). ROC analysis showed that none of the scales in isolation were very strong predictors. Hierarchical regression analysis that combined the significant scales with clinical risk factors that were significantly related to self-harm (that is, age, education level, history of self-harm, and whether they presented with self-harm or only suicidal ideation) indicated that the BIS and DAST-10 questionnaires each added significantly to the predictive ability of a model with these risk factors. Conclusions: While many of the questionnaires and their related constructs are related to future self-harm, none of them are particularly strong and their diagnostic usefulness is limited.

Razvodovsky YE. The effects of beverage type on suicide rate in Russia. Psychiatria Danubina 23(4): 378-383, 2011. (40 refs.)

Background: Research evidence has suggested that the consumption of different types of alcoholic beverage may have a differential effect on suicide rate. The aim of this study was to examine the relation between the consumption of different beverage types and suicide rates in Russia. Subjects and methods: Age-standardized sex- and age-specific suicide rate for the period 1980-2005 and data on beverage-specific alcohol sale were obtained from the Russian State Statistical Committee. Time-series analytical modeling techniques (ARIMA) were used to examine the relationship between the sale of different alcoholic beverages and suicide rates. Results: Vodka consumption as measured by sale was significantly associated with both male and female suicide rate. The consumption of beer and wine were not associated with suicide rate. The estimates of the age specific models for men were positive (except for the 75+ age group) and ranging from 0.069 (60-74 age group) to 0.123 (30-44 age group). The estimates for women were positive for the 15-29 age group (0.08), 30-44 age group (0.096) and 45-59 age group (0.057). Conclusions: These findings suggest that public health efforts should focus on both reducing overall consumption and changing beverage preference away from distilled spirits in order to reduce suicide rate in Russia.

Reyes JC; Robles RR; Colon HM; Negron JL; Matos TD; Calderon JM. Polydrug use and attempted suicide among Hispanic adolescents in Puerto Rico. Archives of Suicide Research 15(2): 151- 159, 2011. (43 refs.)

This study was aimed at examining the relationship between suicidal attempts, polydrug use, and depression in adolescents. A sample of 691 adolescents and their parents were interviewed. Subjects who met the criteria for depression and those who used alcohol were significantly more likely to be suicidal attempters (OR=6.8, p0.001; OR=7.5, p0.001). Polydrug users were significantly more likely to attempt suicide (OR=8.8, p=0.032). Adolescents with mothers who met the criteria for depression were more likely to report suicide attempts (OR=2.4, p=0.069). Health professionals need to screen for polydrug use and depression to prevent future suicidal behaviors.

Ringmets I; Tuusov J; Lang K; Vali M; Parna K; Tonisson M et al. Alcohol and premature death in Estonian men: a study of forensic autopsies using novel biomarkers and proxy informants. BMC Public Health 12: e-article 146, 2012. (29 refs.)

Background: Alcohol makes an important contribution to premature mortality in many countries in Eastern Europe, including Estonia. However, the full extent of its impact, and the mechanisms underlying it, are challenging issues to research. We describe the design and initial findings of a study aimed at investigating the association of alcohol with mortality in a large series of forensic autopsies of working-age men in Estonia. Methods: 1299 male deaths aged 25-54 years were subject to forensic autopsy in 2008-2009. The routine autopsy protocol was augmented by a more systematic inspection of organs, drug testing, assay of liver enzymes and novel biomarkers of alcohol consumption (EtG, EtS and PEth), together with proxy interviews with next of kin for deaths among men who lived in or close to a major town. Results: 595 augmented autopsies were performed. Of these, 66% were from external causes (26% suicide, 25% poisoning). 17% were attributed to circulatory system diseases and 7% to alcoholic liver disease. Blood alcohol concentrations (BAC) of >= 0.2 mg/g were found for 55% of deaths. Interviews were conducted with proxy informants for 61% of the subjects who had resided in towns. Of these, 28% were reported in the previous year to have been daily or almost daily drinkers and 10% had drunk non-beverage alcohols. Blood ethanol and the liver enzyme GGT were only associated with daily drinking. However, the novel biomarkers showed a more graded response with recent consumption. In contrast, the liver enzymes AST and ALT were largely uninformative because of post-mortem changes. The presence of extremely high PEth concentrations in some samples also suggested post-mortem formation. Conclusion: We have shown the feasibility of deploying an extended research protocol within the setting of routine forensic autopsies that offer scope to deepen our understanding of the alcohol-related burden of premature mortality. The most unique feature of the study is the information on a wide range of informative alcohol biomarkers, several of which have not been used previously in this sort of post-mortem research study. We have demonstrated, for the first time, the epidemiological value and validity of these novel alcohol biomarkers in post-mortem samples.

Roy A; Carli V; Sarchiapone M. Resilience mitigates the suicide risk associated with childhood trauma. Journal of Affective Disorders 133(3): 591-594, 2011. (26 refs.)

Objective: We wished to examine whether resilience might be a protective factor in relation to suicidal behavior. Method: To do this resilience was examined in relation to childhood trauma, a well established risk factor for suicidal behavior, in two samples. In a preliminary sample 20 abstinent substance abuse patients who had attempted suicide were matched for age and their score on the Childhood Trauma Questionnaire (CTQ) with 20 substance abuse patients who had never attempted suicide. The two age and CTQ matched attempter (N =20) and non-attempter (N= 20) groups were then compared for their scores on the Connor-Davidson Researchilience Scale (CD-RISC). In the second sample 166 prisoners who had attempted suicide were matched for age and their scores on the CTQ with 166 prisoners who had never attempted suicide. These two age and CTQ matched attempter (N= 166)and non-attempter (N= 166) groups were similarly compared for their CD-RISC resilience scores. Results: In the preliminary substance abuse sample, patients who had never attempted suicide (N = 20) had significantly higher mean CD-RISC resilience scores than the age and CTQ matched patients who had attempted suicide (N= 20). Similarly in the prisoner sample, those who had never attempted suicide (N= 166) had significantly higher CD-RISC resilience scores than the age and CTQ matched prisoners who had attempted suicide (N= 166). Conclusions: The results from these two studies suggest that resilience may be a protective factor mitigating the risk of suicidal behavior associated with childhood trauma.

Sarin E; Samson L; Sweat M; Beyrer C. Human rights abuses and suicidal ideation among male injecting drug users in Delhi, India. International Journal of Drug Policy 22(2): 161- 166, 2011. (56 refs.)

Background: Human rights abuses, denial of care, police surveillance, and violence directed at IDUs have been found to impact HIV prevention efforts due to decreased attendance in harm reduction programs. The association of mental health status with rights abuses has not been examined extensively among drug users. In India, drug control laws are often in conflict with harm reduction policies, thus increasing the likelihood of rights abuses against IDUs. The purpose of this study was to describe human rights abuses occurring among IDUs in Delhi and examine their association with suicidal ideation. Methods: 343 IDUs were recruited in two research sites in Delhi through respondent driven sampling and were interviewed with a cross sectional survey questionnaire that included items on human rights and socio demographics. Results: IDUs in the study experienced many human rights abuses. Notably among these were denial of admission into hospital (38.5%), denial of needles and syringes (20%), police arrests for carrying needles and using drugs (85%), verbal abuse (95%) and physical abuse (88%). Several human rights abuses were associated with suicidal ideation. These include being denied needles and syringes (OR: 7.28, 95% CI: 3.03-17.49); being arrested by police for carrying needles and using drugs (OR: 2.53,95% CI: 1.06-6.03), and being physically abused (OR: 1.66, 95% CI: 1.05-2.23). The likelihood of suicidal ideation is also strongly related to the cumulative number of abuses. Conclusions: These findings demonstrate that there is a high prevalence of human rights abuses among IDUs in Delhi. Given the alarming rate of suicidal ideation and its close relationship with human rights abuses it is essential that IOU interventions are executed within a rights-based framework.

Schinka JA; Schinka KC; Casey RJ; Kasprow W; Bossarte RM. Suicidal behavior in a national sample of older homeless veterans. American Journal of Public Health 102(Supplement 1): S147-S153, 2012. (24 refs.)

Objectives. We examined self-reported suicidal behavior of older homeless veterans to establish frequencies and predictors of recent suicidal behaviors, and their impact on transitional housing interventions. Methods. We analyzed the records of a national sample of 10 111 veterans who participated in a transition housing program over a 6-year period, ending in 2008. Results. Approximately 12% of homeless veterans reported suicidal ideation before program admission; 3% reported a suicide attempt in the 30 days before program admission. Older homeless veterans exhibiting suicidal behavior had histories of high rates of psychiatric disorders and substance abuse. Regression analyses showed that self-report of depression was the primary correlate of suicidal behavior. Suicidal behavior before program entry did not predict intervention outcomes, such as program completion, housing outcome, and employment. Conclusions. Suicidal behavior was prevalent in older homeless veterans and was associated with a history of psychiatric disorder and substance abuse. Self-reported depression was associated with these behaviors at the time of housing intervention. Despite the association with poor mental health history, suicidal behavior in older homeless veterans did not impact outcomes of transitional housing interventions.

Schneider B; Baumert J; Schneider A; Marten-Mittag B; Meisinger C; Erazo N et al. The effect of risky alcohol use and smoking on suicide risk: Findings from the German MONICA/KORA-Augsburg Cohort Study. Social Psychiatry and Psychiatric Epidemiology 46(11): 1127-1132, 2011. (36 refs.)

Smoking and heavy alcohol use predicts suicidal behaviour. Whether the simultaneous presentation of both conditions induces an amplified effect on risk prediction has not been investigated so far. In a community-based cohort study, a total of 12,888 subjects (6,456 men, 6,432 women; age range of 25-74 years at assessment) from three independent population-based cross-sectional MONICA surveys (conducted in 1984/85, 1989/90, and 1994/95), representative for the Southern German population, was followed up until 31 December 2002. Standardized mortality ratios (SMR) for deaths from suicide using German population rates were calculated for smoking and high alcohol consumption. After a mean follow-up time of 12.0 (SD 4.4) years and 154,275 person-years at risk, a total of 1,449 persons had died from all causes and 38 of them from suicide. Compared to the general population, mortality from suicide was increased for risky alcohol consumption (SMR = 2.37; 95% CI 1.14-4.37) and for smoking (SMR = 2.30; 95% CI 1.36-3.63). A substantial increase in suicide mortality (SMR = 4.80; 95% CI 2.07-9.46) was observed for smokers with risky alcohol consumption. The approximately fourfold increased relative risk for completed suicide in subjects with smoking and risky alcohol consumption indicates a synergistic effect which deserves an increased alertness.

Son CH; Topyan K. The effect of alcoholic beverage excise tax on alcohol-attributable injury mortalities. European Journal of Health Economics 12(2): 103-113, 2011. (51 refs.)

This study examines the effect of state excise taxes on different types of alcoholic beverages (spirits, wine, and beer) on alcohol-attributable injury mortalities-deaths caused by motor vehicle accidents, suicides, homicides, and falls-in the United States between 1995 and 2004, using state-level panel data. There is evidence that injury deaths attributable to alcohol respond differently to changes in state excise taxes on alcohol-specific beverages. This study examines the direct relationship between injury deaths and excise taxes without testing the degree of the association between excise taxes and alcohol consumption. The study finds that beer taxes are negatively related to motor vehicle accident mortality, while wine taxes are negatively associated with suicides and falls. The positive coefficient of the spirit taxes on falls implies a substitution effect between spirits and wine, suggesting that an increase in spirit tax will cause spirit buyers to purchase more wine. This study finds no evidence of a relationship between homicides and state excise taxes on alcohol. Thus, the study concludes that injury deaths attributable to alcohol respond differently to the excise taxes on different types of alcoholic beverages.

Song JH; Yu BH; Lee D; Yoon SC; Jeon HJ. Uncontrolled self-medication with venlafaxine in a patient with major depressive disorder. Psychiatry Investigation 8(1): 74-76, 2011. (18 refs.)

Antidepressants are known to have no significant ability to cause addiction. However, a recent study showed many individuals with mood disorders self-medicated with antidepressants to relieve symptoms. We report here a male physician, diagnosed five years ago with major depressive disorder, with insomnia, anxiousness, and chest heaviness. He began self-medicating with 150 mg of venlafaxine daily, without any monitoring. During his most recent severe depressive episode, he was taking up to 1,500 mg of venlafaxine daily. Without this medication, he experienced discontinuation syndrome, which included severe anxiety, chest heaviness, and breathing difficulty, and which he judged as indicating a more severely depressed state. He also experienced overdose symptoms, such as hypertension and tachycardia. He attempted suicide with drugs that he possessed. In conclusion, careful monitoring is needed when treating patients with venlafaxine, because its discontinuation syndrome is similar to symptoms of major depressive disorder, and suicidality may result from an overdose.

Stickley A; Jukkala T; Norstrom T. Alcohol and suicide in Russia, 1870-1894 and 1956-2005: Evidence for the continuation of a harmful drinking culture across time? Journal of Studies on Alcohol and Drugs 72(2): 341-347, 2011. (57 refs.)

Objective: Previous research suggests that a strong relation exists between alcohol consumption and suicide in Soviet and post-Soviet Russia. This study extends this analysis across a much longer historical time frame by examining the relationship between heavy drinking and suicide in tsarist and post-World War 11 Russia. Method: Using alcohol poisoning mortality data as a proxy for heavy drinking, time-series analytical modeling techniques were used to examine the strength of the alcohol-suicide relation in the provinces of European Russia in the period 1870-1894 and for Russia in 1956-2005. Results: During 1870-1894, a decreasing trend was recorded in heavy drinking in Russia that contrasted with the sharp increase observed in this phenomenon in the post-World War 11 period. A rising trend in suicide was recorded in both study periods, although the increase was much greater in the latter period. The strength of the heavy drinking suicide relation nevertheless remained unchanged across time, with a 10% increase in heavy drinking resulting in a 3.5% increase in suicide in tsarist Russia and a 3.8% increase in post-World War II Russia. Conclusions: Despite the innumerable societal changes that have occurred in Russia across the two study periods and the growth in the level of heavy drinking, the strength of the heavy drinking-suicide relation has remained unchanged across time. This suggests the continuation of a highly detrimental drinking culture where the heavy episodic drinking of distilled spirits (vodka) is an essential element in the alcohol-suicide association.

Sundin M; Spak F; Spak L; Sundh V; Waern M. Substance use/abuse and suicidal behavior in young adult women: A populationion-based study. Substance Use & Misuse 46(13): 1690-1699, 2011. (43 refs.)

Associations between substance use variables and suicidal behavior were analyzed in an urban population sample from ("the Women and Alcohol in Gothenburg" study). In Phase I, 20-year-old women (n = 2,069) completed a screening questionnaire. Interviews were carried out with a stratified sample (n = 560). Data, collected in 1995 and 2000, were analyzed using logistic regression to generate odds ratios. Drug use, but not risky alcohol consumption, was associated with suicidal thoughts after adjusting for current depression. Study limitations and implications for suicide prevention are discussed.

Swahn MH; Ali B; Bossarte RM; Van Dulmen M; Crosby A; Jones AC et al. Self-harm and suicide attempts among high-risk, urban youth in the U.S.: Shared and unique risk and protective factors. International Journal of Environmental Research and Public Health 9(1): 178-191, 2012. (55 refs.)

The extent to which self-harm and suicidal behavior overlap in community samples of vulnerable youth is not well known. Secondary analyses were conducted of the "linkages study" (N = 4,131), a cross-sectional survey of students enrolled in grades 7, 9, 11/12 in a high-risk community in the U.S. in 2004. Analyses were conducted to determine the risk and protective factors (i.e., academic grades, binge drinking, illicit drug use, weapon carrying, child maltreatment, social support, depression, impulsivity, self-efficacy, parental support, and parental monitoring) associated with both self-harm and suicide attempt. Findings show that 7.5% of participants reported both self-harm and suicide attempt, 2.2% of participants reported suicide attempt only, and 12.4% of participants reported self-harm only. Shared risk factors for co-occurring self-harm and suicide attempt include depression, binge drinking, weapon carrying, child maltreatment, and impulsivity. There were also important differences by sex, grade level, and race/ethnicity that should be considered for future research. The findings show that there is significant overlap in the modifiable risk factors associated with self-harm and suicide attempt that can be targeted for future research and prevention strategies.

Swahn MH; Bossarte RM; Choquet M; Hassler C; Falissard B; Chau N. Early substance use initiation and suicide ideation and attempts among students in France and the United States. International Journal of Public Health 57(1): 95-105, 2012. (40 refs.)

In response to recent research documenting a link between early substance use and suicidal behaviors among youth, the current study sought to examine the associations between ages of substance use initiation and suicidal behavior among students in France and the USA. Cross-sectional logistic regression analyses based on the 2003 European School Survey Project on Alcohol and Other Drugs (ESPAD) survey (France; n = 13,187) and the 2003 Youth Risk Behavior Survey (YRBS) (United States; n = 15,136) assessed associations between early substance use initiation (i.e., alcohol, cigarette and cannabis/marijuana) and suicide ideation and attempts while controlling for potential confounders. Early alcohol use initiation (ORadj = 1.52; 95% CI 1.17-1.97) and early cannabis/marijuana use initiation (ORadj = 2.90; 95% CI 2.20-3.83) were associated with suicide attempt in France. Early smoking was associated with suicide attempt in both France (ORadj = 1.92; 95% CI 1.55-2.37) and the USA (ORadj = 1.53; 95% CI 1.02-2.28). Sex differences were also noted. The associations between substance use initiation and suicidal behaviors differed in the United States and France. These findings, placed into context, can assist the development and implementation of prevention strategies that seek to reduce the harmful consequences of early substance use among youth.

Szerman N; Lopez-Castroman J; Arias F; Morant C; Babin F; Mesias B et al. Dual diagnosis and suicide risk in a Spanish outpatient sample. Substance Use & Misuse 47(4): 383-389, 2012. (24 refs.)

The present study compares dual-diagnosis patients with other groups of psychiatric patients to determine the differential characteristics in suicide risk and other clinical variables between them. During 2008 in Madrid, 837 outpatients were evaluated in addiction and mental health services. Three comparison groups were created according to current diagnosis: (i) dual patients, (ii) patients with substance use disorders but no other mental disorders, and (iii) patients with mental disorders but no substance use disorders. A multinomial logistic regression model was built to explore the risk associated with dual diagnosis. Criteria for dual diagnosis were met at the time of the study by 440 patients (52.6%). Dual patients showed several demographic and clinical differences and a higher risk for suicide than the other two comparison groups. Further research is needed to define suicide preventive strategies for dual patients.

Tanaka M; Wekerle C; Schmuck ML; Paglia-Boak A. The linkages among childhood maltreatment, adolescent mental health, and self-compassion in child welfare adolescents. Child Abuse & Neglect 35(10): 887-898, 2011. (80 refs.)

Objectives: Childhood maltreatment is a robust risk factor for poor physical and mental health. Child welfare youths represent a high-risk group, given the greater likelihood of severe or multiple types of maltreatment. This study examined the relationship between childhood maltreatment and self-compassion - a concept of positive acceptance of self. While not applied previously to a child welfare sample, self-compassion may be of value in understanding impairment among maltreatment victims. This may be most pertinent in adolescence and young adulthood, when self-identity is a focal developmental process. Methods: The present sample was drawn from the Maltreatment and Adolescent Pathways (MAP) Longitudinal Study, which followed randomly selected adolescents receiving child protection services across two years within an urban catchment area. Child maltreatment was assessed at baseline using the Childhood Trauma Questionnaire (Bernstein at al., 1994, 2003). Mental health, substance and alcohol use problems, suicide attempt, and self-compassion were assessed at the two-year follow-up point. There were 117 youths, aged 16-20 years (45.3% males) who completed the self-compassion scale (Neff, 2003). Bivariate correlations were computed between adolescent self-compassion and each form of self-reported maltreatment (physical abuse, sexual abuse, emotional abuse, emotional neglect, and physical neglect). Finally, hierarchical, stepwise regression was used to examine unique contributions of child maltreatment subtypes in predicting adolescent self-compassion, as well as maltreatment-related impairment. Results: Higher childhood emotional abuse, emotional neglect, and physical abuse were associated with lower self-compassion. Controlling for age and gentler, emotional abuse was significantly associated with reduced self-compassion, even when the effects of emotional neglect and physical abuse were taken into account. Youths with low self-compassion were more likely to have psychological distress, problem alcohol use, and report a serious suicide attempt, as compared with those with high self-compassion. A number of maltreatment-related areas of impairment, identified by screening instruments, were significantly associated with lower self-compassion. Conclusion: Self-compassion may be a fruitful aspect of research to pursue in an effort to better understand the impact of childhood emotional abuse on adolescent functioning, particularly considering the under-researched group of those receiving child protective services.

Ting SA; Sullivan AF; Miller I; Espinola JA; Allen MH; Camargo CA et al. Multicenter study of predictors of suicide screening in emergency departments. Academic Emergency Medicine 19(2): 239-243, 2012. (10 refs.)

Objectives: The objective was to provide estimates and predictors of screening for suicide in emergency departments (EDs). Methods: Eight geographically diverse U. S. EDs each performed chart reviews of 100 randomly selected patients, ages 18 years or older, with visits in October 2009. Trained chart abstractors collected information on patient demographics, presentation, discharge diagnosis, suicide screening, and other mental health indicators. Univariate logistic regression was used to determine factors associated with suicide screening. Results: The cohort of 800 patients had a median age of 41 years (interquartile range = 27 to 53 years) with 57% female, 16% Hispanic, 58% white, 23% black or African American, and 10% other race. Suicide screenings were documented for 39 patients (4.9%; 95% confidence interval [CI] = 3.4% to 6.4%). Of those screened, 23 (2.9% of total sample; 95% CI = 1.7% to 4.0%) were positive for suicidal ideation or behavior. Approximately 90% of those screened had documented complaints of a psychiatric nature at triage. About one-third had either documentation of alcohol abuse (33%) or intentional illegal or prescription drug misuse (36%). Conclusions: The presence of known psychiatric problems and substance use had the strongest associations with suicide screening, yet even patients presenting with these indicators were not screened for suicide. Understanding factors that currently influence suicide screening in the ED will guide the design and implementation of improved suicide screening protocols and related interventions.

Toprak S; Cetin I; Guven T; Can G; Demircan C. Self-harm, suicidal ideation and suicide attempts among college students. Psychiatry Research 187(1-2): 140- 144, 2011. (45 refs.)

Self-harm, suicidal ideation, and suicide attempts are well represented behaviours in the general population of both developed and developing countries. These behaviours are indicative of underlying risk factors that show a strong interdependent correlation. In this study we attempted to define correlates for and prevalence of self-harm, suicidal ideation, and suicide attempts among Turkish college students. This 2006 study included 636 students from two Turkish state universities. Our results showed that the lifetime prevalence of self-harm was 15.4%, the prevalence of suicidal ideation was 11.4%, and the prevalence of suicide attempts was 7.1%. We uncovered correlates for self-harm, including low income, unsatisfying familial relationships, smoking, and alcohol, inhalant, and tranquilizer abuse. Tranquilizer abuse shared a dual role as a correlate for suicide ideation and as a means to attempt suicide. Additionally, we found that drug abusers and adolescents who practise self-harm presented the highest suicide risk.

Tse R; Sims N; Byard RW. Alcohol ingestion and age of death in hanging suicides. Journal of Forensic Sciences 56(4): 922-924, 2011. (15 refs.)

Retrospective review of 100 consecutive, nondecomposed cases of suicide because of hanging was conducted at Forensic Science SA, Australia. Alcohol was detected in 38 cases (38%). The percentage of victims who had ingested alcohol significantly decreased with age (r(2) = 0.81), with alcohol detected in 57.1% of those aged <= 24 years, compared to 28.5% of those aged between 55 and 64 years, and 0% of those aged >= 65 years. A similar linear relationship between alcohol ingestion and age was found for cases with blood alcohol levels > 0.05 g/100 mL (r(2) = 0.73). The mean ages of those with detectable alcohol (35.2 years) levels > 0.05 g/100 mL (35.1 years) and levels > 0.1 g/100 mL (37.2 years) were all significantly less than in those with no detectable alcohol (44.4 years) (p < 0.005, < 0.005, < 0.05 respectively). A clear relationship between alcohol ingestion and younger age was shown in hanging suicides.

Varnik A; Sisask M; Varnik P; Wu J; Kolves K; Arensman E et al. Drug suicide: A sex-equal cause of death in 16 European countries. BMC Public Health 11: e-article 61, 2011. (40 refs.)

Background: There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex-and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84). Methods: Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated. Results: No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (ICD X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (ICD X61) ranked second. The ICD X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low ICD X64 and high ICD X61 figures, Scotland had high levels of ICD X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category ICD X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk. Conclusions: Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category ICD X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level.

Vaszari JM; Bradford S; O'Leary CC; Ben Abdallah A; Cottler LB. Risk factors for suicidal ideation in a population of community-recruited female cocaine users. Comprehensive Psychiatry 52(3): 238- 246, 2011. (53 refs.)

Introduction: Suicide, as the 11th leading cause of death in America, is a significant public health concern. Previous studies have shown that drug users are a population at especially high risk for suicidal ideation (SI). Although most people who think about killing themselves do not ultimately commit suicide, identifying those at risk for such thoughts is important. Methods: In this analysis, data from a sample of 462 cocaine-using women (87% African American) recruited using street outreach methods for a National Institute on Drug Abuse-funded study were examined to identify risk factors for lifetime SI. Sociodemographic factors, adverse childhood experiences, sexual behaviors, psychiatric comorbidities, and drug abuse and dependence were examined as potential risk factors using both bivariate and logistic regression analysis. Results: Fifty percent of the sample met at least one criterion for lifetime SI, and 32% of the sample reported a lifetime suicide attempt. In the final logistic regression model, childhood physical abuse, childhood sexual abuse, rape after the age of 15 years, posttraumatic stress disorder, and number of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, depression criteria met emerged as significant independent predictors of lifetime SI. Conclusion: These findings identify important risk factors for SI among female substance abusers in community settings.

Vento AE; Schifano F; Corkery JM; Pompili M; Innamorati M; Girardi P; Ghodse H. Suicide verdicts as opposed to accidental deaths in substance-related fatalities (UK, 2001-2007). (review). Progress In Neuro-Psychopharmacology & Biological Psychiatry 35(5, special issue): 1279-1283, 2011. (26 refs.)

Background: Substance-related deaths account for a great number of suicides. Aim: To investigate levels and characteristics of suicide verdicts, as opposed to accidental deaths, in substance misusers. Methods: Psychological autopsy study of cases from the UK National Programme on Substance Abuse Deaths (np-SAD) during the period 2001-2007. Results: Between January 2001 and December 2007, 2108 suicides were reported to the np-SAD. Typical suicide victims were White and older than 50 (respectively 95% and 41% of cases). Medications, especially antidepressants (44%), were prescribed to 87% of victims. Significantly fewer suicide victims than controls presented positive blood toxicological results for illicit drugs (namely: cocaine, heroin, amphetamines, ecstasy-type drugs, cannabis, and GHB/GBL) and alcohol. Conclusions: Suicide prevention programmes should devote specific attention to deaths among substance misusers who are at high risk of fatal intentional self-harm. Specific characteristics distinguish those at risk; caregivers should be better educated as to what these factors are. Limitations of the current study included lack of provision of comprehensive information relating to the victims' psychosocial variables. Furthermore, no differentiation between different classes of antidepressants in terms of involvement in suicide was here provided.

Vignier N; Lert F; Salomon C; Hamelin C. Kava drinking associated with suicidal behaviour among young Kanaks using kava in New Caledonia. Australian and New Zealand Journal of Public Health 35(5): 427-433, 2011. (41 refs.)

Objective: To examine associations between recreational use of kava and indicators of suicidal behaviour among youth in New Caledonia. Methods: This cross-sectional community-based survey was administered to 1,400 young people aged 16-25 years. A multivariate analysis tested for associations between lifetime kava use and lifetime suicidal ideation and attempts. Because ethnicity affected the correlation between kava use and suicidal behaviour, data were analysed separately for Kanak youth and youth of other ethnic communities. Results: Overall, 42% of respondents reported any lifetime kava use, 34% reported past suicidal ideation and 12% any suicide attempts. Among Kanak youth, kava use increased the likelihood of reporting both suicidal ideation (aOR = 2.40, 95% CI: 1.58-3.66) and suicide attempts (aOR = 1.98, 95% CI: 1.11-3.52). No such association was found in the non-Kanak group. Conclusions: The discrepancy between the effects of kava drinking on suicidal behaviour between Kanak youth and youth of other ethnic groups may be related to differences in patterns and quantity of kava use. In view of the paucity of data on the effects of kava on mental health in young people, further investigation is required. Implications: The results call for an increased awareness of the potential adverse health effects of kava consumption in New Caledonia where it has spread in recent times and among communities where previously it was never used.

Vijayakumar L; Kumar MS; Vijayakumar V. Substance use and suicide. (review). Current Opinion in Psychiatry 24(3): 197-202, 2011. (49 refs.)

Purpose of review: To address gaps identified in earlier reviews, namely, the comparative influence of substance use on attempted suicide and completed suicide; the proximal role of substance use as a trigger of suicidal behaviour; the association between substances and suicidal behaviour; suicide and substance use disorders in youth; and the influence of combinations of risk factors, including psychiatric morbidity, on suicide. Recent findings: The presence of an alcohol use disorder is confirmed as a distal risk factor for completed suicide, as well as attempted suicide. Alcohol use at the time of the suicide attempt is associated with low-risk methods. The use of other substances as a trigger of suicidal behaviour is highlighted in recent studies, but the circumstances leading to the suicidal act and the direct influence of substances in suicidal behaviour need to be explored further. Inhalant use and cocaine use are particularly associated with suicidal behaviour. Young people with multiple risk behaviours, such as substance use and risky sexual behaviours, are at high risk for suicidal behaviour. Psychiatric comorbidity with substance use escalates the risk for suicidal behaviour. Environmental interventions, such as reduction in the number of bars, may be helpful in reducing alcohol-related morbidity, including suicides. Summary: Prevention strategies for reducing suicidal behaviour among substance users need to be prioritized at the individual and the national level through effective design, policy and implementation.

Wasserman D; Rihmer Z; Rujescu D; Sarchiapone M; Sokolowski M; Titelman D et al. The European Psychiatric Association (EPA) guidance on suicide treatment and prevention. (review). European Psychiatry 27(2): 129-141, 2012. (166 refs.)

Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. Suicidal crisis: Acute intervention should start immediately in order to keep the patient alive. Diagnosis: An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential. Treatment: Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. Treatment team: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. Family: The suicidal person independently of age should always be motivated to involve family in the treatment. Social support: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks. Safety: A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. Training of personnel: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Weiner J; Richmond TS; Conigliaro J; Wiebe DJ. Military veteran mortality following a survived suicide attempt. BMC Public Health 11(e-article 374), 2011. (47 refs.)

Background: Suicide is a global public health problem. Recently in the U. S., much attention has been given to preventing suicide and other premature mortality in veterans returning from Iraq and Afghanistan. A strong predictor of suicide is a past suicide attempt, and suicide attempters have multiple physical and mental comorbidities that put them at risk for additional causes of death. We examined mortality among U. S. military veterans after hospitalization for attempted suicide. Methods: A retrospective cohort study was conducted with all military veterans receiving inpatient treatment during 1993-1998 at United States Veterans Affairs (VA) medical facilities following a suicide attempt. Deaths occurring during 1993-2002, the most recent available year at the time, were identified through VA Beneficiary and Records Locator System data and National Death Index data. Mortality data for the general U. S. adult population were also obtained from the National Center for Health Statistics. Comparisons within the veteran cohort, between genders, and against the U. S. population were conducted with descriptive statistics and standardized mortality ratios. The actuarial method was used estimate the proportion of veterans in the cohort we expect would have survived through 2002 had they experienced the same rate of death that occurred over the study period in the U. S. population having the age and sex characteristics. Results: During 1993-1998, 10,163 veterans were treated and discharged at a VA medical center after a suicide attempt (mean age = 44 years; 91% male). There was a high prevalence of diagnosed alcohol disorder or abuse (31.8%), drug dependence or abuse (21.8%), psychoses (21.2%), depression (18.5%), and hypertension (14.2%). A total of 1,836 (18.1%) veterans died during follow up (2,941.4/100,000 person years). The cumulative survival probability after 10 years was 78.0% (95% CI = 72.9, 83.1). Hence the 10-year cumulative mortality risk was 22.0%, which was 3.0 times greater than expected. The leading causes overall were heart disease (20.2%), suicide (13.1%), and unintentional injury (12.7%). Whereas suicide was the ninth leading cause of death in the U. S. population overall (1.8%) during the study period, suicide was the leading and second leading cause among women (25.0%) and men (12.7%) in the cohort, respectively. Conclusions: Veterans who have attempted suicide face elevated risks of all-cause mortality with suicide being prominent. This represents an important population for prevention activities.

Wexler LM; Gone JP. Culturally responsive suicide prevention in indigenous communities: Unexamined assumptions and new possibilities. American Journal of Public Health 102(5): 800-806, 2012. (93 refs.)

Indigenous communities have significantly higher rates of suicide than non-Native communities in North America. Prevention and intervention efforts have failed to redress this disparity. One explanation is that these efforts are culturally incongruent for Native communities. Four prevalent assumptions that underpin professional suicide prevention may conflict with local indigenous understandings about suicide. Our experiences in indigenous communities led us to question assumptions that are routinely endorsed and promoted in suicide prevention programs and interventions. By raising questions about the universal relevance of these assumptions, we hope to stimulate exchange and inquiry into the character of this devastating public health challenge and to aid the development of culturally appropriate interventions in cross-cultural contexts.

Wrzosek M; Lukaszkiewicz J; Wrzosek M; Serafin P; Jakubczyk A; Klimkiewicz A et al. Association of polymorphisms in HTR2A, HTR1A and TPH2 genes with suicide attempts in alcohol dependence: A preliminary report. Psychiatry Research 190(1): 149-151, 2011. (26 refs.)

We investigated a relationship between selected polymorphisms: rs6313 in HTR2A, rs6295 in HTR1A and rs1386494 in 7PH2, and suicidal behaviour in 150 alcohol-dependent patients. There was a significant association between more frequent C102C genotype in HTR2A and suicide attempts in alcoholic females. No differences in genotype distribution in HTR1A and TPH2 SNPs were found between patients with and without suicide attempts.

Yaworski D; Robinson J; Sareen J; Bolton JM. The relation between nicotine dependence and suicide attempts in the general population. Canadian Journal of Psychiatry 56(3): 161-170, 2011. (47 refs.)

Objective: There has been much debate as to whether nicotine is a risk factor for suicidal behaviour. This study sought to examine the relation between nicotine dependence and suicide attempts in a population-based sample of adults. Method: Our study used the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (NESARC; 2004-2005), a large (n = 34 653) nationally representative survey of community-dwelling American adults. Multiple logistic regression analyses examined the relation between suicide attempts and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, nicotine dependence, compared with nonusers of nicotine. Associations between suicide attempts and other measures of nicotine use (nicotine cessation, age of first use, frequency, and amount of use) were also examined. Results: Lifetime (AOR 1.78; 95% CI 1.48 to 2.15) and past-year nicotine dependence (AOR 1.77; 95% CI 1.02 to 3.06) were independently associated with lifetime and past-year suicide attempts, respectively, even after adjusting for sociodemographic factors, other mental disorders, and physical disease. Nicotine dependence cessation was associated with a decreased likelihood of suicide attempt compared with people currently dependent on nicotine (AOR 0.15; 95% CI 0.05 to 0.43). Greater amount of daily cigarette use was associated with suicide attempts in the model that adjusted for sociodemographic factors and other mental disorders (AOR 1.53; 95% CI 1.05 to 2.24). Conclusions: Nicotine dependence is associated with suicide attempts, independently of comorbid mental disorders and physical disease. The association attenuates when a person ceases using nicotine, suggesting a state, rather than trait, effect. These findings provide evidence for additional concern regarding the deleterious health effects of tobacco.

Yazzie RA. Availability of treatment to youth offenders: Comparison of public versus private programs from a national census. Children and Youth Services Review 33(6): 804- 809, 2011. (23 refs.)

Across the United States, the availability of mental health, substance abuse, and recidivism reduction programs in the juvenile justice system (JJS) varies from none or few to a rich variety of programs. Within the last decade, prison privatization in the adult correctional system has influenced the onset of privatization in the JJS. The differences between public and private sectors in their availability of mental health services and treatment programs to juvenile offenders are understudied. In this article, a secondary analysis of a national census of 3163 juvenile facilities was conducted to determine differences in treatment availability as well as the impact of treatment accessibility on the event of a suicide. Results indicate private facilities more likely to offer treatment services and schedule mental health personnel more frequently. Those facilities reporting family counseling treatment programs were less likely to have reported a suicide event. Policy implications and a review of progress towards improvement in the AS are presented.

Zamparutti G; Schifano F; Corkery JM; Oyefeso A; Ghodse AH. Deaths of opiate/opioid misusers involving dihydrocodeine, UK, 1997-2007. British Journal of Clinical Pharmacology 72(2): 330-337, 2011. (58 refs.)

AIMS: Although its effectiveness is somewhat controversial, it appears that dihydrocodeine (DHC) is still prescribed in the UK as an alternative to both methadone and buprenorphine for the treatment of opiate addiction. METHODS: Data covering the period 1997-2007 voluntarily supplied by coroners were analysed. All cases pertaining to victims with a clear history of opiate/opioid misuse and in which DHC, either on its own or in combination, was identified at post-mortem toxicology and/or implicated in death, were extracted from the database. RESULTS: Dihydrocodeine, either alone or in combination, was identified in 584 fatalities meeting the selection criteria. In 44% of cases it was directly implicated in the cause of death. These cases represented about 6.8% of all opiate/opioid-related deaths during this period. Typical DHC cases identified were White males in their early thirties. Accidental deaths (96%) were likely to involve DHC in combination with other psychoactives, mainly heroin/morphine, hypnotics/sedatives and methadone. Both paracetamol and antidepressants were found in proportionately more suicide cases than in accidental overdoses. DHC had been prescribed to the decedent in at least 45% of cases. CONCLUSIONS: Opiate/opioid misusers should be educated about risks associated with polydrug intake. More in particular, co-administration of DHC with heroin, methadone and benzodiazepines may increase the risk of accidental fatal overdose. Prescribers should carefully consider pharmacological intervention alternative to DHC (e. g. methadone, buprenorphine) when managing and treating opiate addiction. More resources are required to do prospective research in this area.