AM. J . DRUG ALCOHOL ABUSE, 18(3), pp. 343-354 (1992)
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Suicidal Behavior and History of Substance Abuse* Dalia M. Adams James C. Overholser,+ Ph.D. Department of Psychology Case Western Reserve University 1 1220 Bellflower Road, Cleveland, Ohio 44 106-3922
ABSTRACT Substance abuse is frequently associated with suicidal behavior. However, it is unclear to what degree substance abuse in a family member is related to suicide. In the present study, personal and family histories of substance abuse were examined in 716 psychiatric emergency room patients. Suicide attempters, suicide ideators, and nonsuicidal controls were compared across demographic, clinical, and substance abuse variables. Results showed that suicidal patients differed from nonsuicidal controls on many of the dependent variables. Suicidal patients were more likely to be depressed and report a history of previous suicidal tendencies. Also, almhol and drug abuse occurred more frequently in suicidal patients. Furthermore, a family history of alcohol abuse was reported more often by suicidal than nonsuicidal patients. These patterns of substance abuse in suicidal patients were especially prominent among older subjects. Results are discussed in terms of the implications for identifying psychiatric emergency room patients at risk for suicide.
LNTRODUCTION Alcoholism is a known risk factor for suicidal behavior [8, 23, 251. Both attempted and completed suicide occur more frequently among alcoholics as compared to normal controls [18, 261. In a long-term prospective follow-up study,
*Presented at the American Psychological Association convention, Boston, August 1990 90whom correspondence should be addressed.
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the diagnosis of alcoholism predicted subsequent death by suicide 141. Furthermore, nonabusive levels of alcohol use increase the risk of suicidal behavior [8]. This may be due to the reduced impulse control associated with alcohol consumption [5], causing more frequent but less intentional suicidal behavior [6]. In addition to alcohol, the abuse of other drugs has been related to suicidal behavior [ 14, 281, especially when combined with high levels of life stress [24]. Substance abuse (both alcohol and drug abuse) is associated with a higher frequency of suicidal ideation, suicide attempts, and suicide completion [16, 181. The rate of suicide attempts among opiate addicts is equivalent to that found in alcoholics, with the rate of suicide attempts in both groups substantially higher than in the general population [27]. Among persons seeking drug treatment, the suicide attempt rate is as much as 12 times greater than in the general population [29]. Substance abusing patients who avoid professional treatment may be at even higher risk for suicidal behavior [ 111. Substance abuse in a family member may also be related to suicide. From a family systems perspective, alcoholism is considered a family problem because of the powerful impact one person’s alcoholism can have on all family members [15]. Families with a history of alcoholism often display instability and conflict [131. Family conflict is related to suicidal ideation [211 and suicide attempts [ 141. As a result of the ongoing conflict and trauma often found in alcoholic homes, children raised by alcoholic parents are likely to exhibit a spectrum of maladaptive coping responses, including suicidal ideation and suicidal behaviors [ 19, 20, 321. Thus, both alcohol abuse and suicidal behavior may be used as means of escaping from serious interpersonal problems. In addition to family conflict, genetic factors may be involved in the relationship between suicidal behavior and family history of alcohol abuse. However, if genetic factors do link alcoholism and suicide, the linkage is probably indirect (see Ref. 22). This relationship is most likely mediated through the physiological basis of depression. Low levels of serotonin have been found to play a role in depression [ 11, suicide [2, 301, and alcoholism [3]. Thus, neurophysiological factors may provide a link between suicide and a family history of alcoholism. Few studies have specifically examined the relationship between a family history of substanceabuse and suicidality, and results have varied according to the population being studied. Maris [18] found that alcoholism occurred frequently in the families of suicide attempters and completers. However, alcohol abuse occurred frequently in nonsuicidal families as well. The differences become more pronounced in studies on adolescent samples. Parents of adolescent suicide attempters have been found to consume more alcohol [31] and display a higher frequency of substance abuse than is found among parents of nonsuicidal
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adolescents [9]. In adults, higher rates of parental alcoholism have been found among suicidal versus nonsuicidal alcoholics [ 121. Also, a positive relationship between paternal alcoholism and suicide attempts has been found in both alcoholic and nonalcoholic women [lo]. Thus, a relationship between suicide attempts and a family history of substance abuse has been supported. However, it remains unclear whether both a family history of alcohol abuse and a family history of drug abuse increase the likelihood of suicide attempts. Also, it is unclear whether the relationship only pertains to parental substance abuse or to other family members as well. Finally, it may be possible to examine suicidal ideation as it relates to a personal history of substance abuse, thereby determining whether the relationships between substance abuse and suicidal tendencies exist at a lower severity of suicidal urges. In the present study, suicide attempters, suicide ideators, and nonsuicidal controls were assessed to examine the relationship between both a personal and a family history of substance abuse and suicidal behavior. In order to clarify any differences between the two substances, alcohol abuse and drug abuse were considered separately. It was hypothesized that both a personal and a family history of substance abuse would occur at higher frequencies in patients reporting either suicidal ideation or suicide attempts. Also, it was predicted that suicidal behavior would reflect a quantitative but not qualitative difference from suicidal ideation. Thus, it was predicted that the same factors associated with suicidal ideation would be related to suicide attempts, but their effects would be more prominent in the suicide attempter group.
METHOD Subjects Approximately 10% (n = 716) of patient charts were randomly selected from the 7,522 patients seen in the psychiatric emergency room of a large metropolitan hospital during 1988 (January 1, 1988, through December 31, 1988). The sample contained six children under the age of 12. In order to focus on adolescent and adult patients, these six children were excluded from the study. In the remaining sample, subjects ranged in age from 12 to 95 years with a mean age of 33.7 years (SD = 12.8). The sample was evenly split between male (51.5%) and female (48.5%)patients. The racial composition of the sample included 45.3% White and 54.7% Black patients. Only eight subjects were of different racial origins, and they were excluded from analyses in order to reduce the heterogeneity
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of the sample. The patients in the sample had a wide variety of presenting problems including chronic schizophrenia with acute psychotic episodes, depression, substance-related crises, and others. Approximately half of the subjects were suicidal, being admitted after a suicide attempt or expressing some level of suicidal ideation. Because suicidal ideation may be viewed as an important precursor to suicidal behavior, three groups of subjects were identified: suicide attempters, suicide ideators, and nonsuicidal controls. This allowed us to evaluate whether suicide ideators appear more similar to suicide attemptors or nonsuicidal controls. This may shed light on the risk of self-harm in suicide ideators.
Procedure At the time of the initial evaluation, patients were evaluated by a clinical social worker, a psychiatric nurse, and a psychiatrist. Diagnoses were based on a combination of unstructured clinical interviews, medical examinations, and laboratory tests. The majority of information was collected through interviews with the patient. Also, when possible, staff interviewed a family member or the patient’s case manager. These interviews were used to gather demographic and clinical information, and were conducted independently by a social worker and a nurse. Additional background information was obtained from a review of previous medical and mental health records. The information gathered included demographic information, current and previous suicide attempts and ideation, personal and family history of alcohol abuse, personal and family history of drug abuse, and personal and family history of mental illness. In order to reduce the possibility of false negative diagnoses, only clear and definitely stated information was included. Vague or incomplete informationon a patient’s chart was coded as missing. This resulted in excluding 53 subjects from statistical analyses.
RESULTS Demographicand clinical comparisons were made across three groups: suicide ideators (n = 257), suicide attempters (n = 88), and nonsuicidal controls (n = 304). Because the demographic and clinical variables were potentially related, a familywise error rate for these 25 analyses was set at an alpha level of .05. Using the Bonferroni adjustment procedure to protect against Type I error, a
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Table 1. Demographic Characteristics across Suicide Groups ~~
Variable
Current suicide attempt
statistic
304
257
88
36.6 (13.8)
31.7 (12.1)
28.9 (8.9)
127 (41.8%) 177 (58.2%)
132 (51.4%) 125 (48.6%)
35 (39.8%) 53 (60.2%)
~ ~ (= 2 )6.42
168 (55.3%) 136 (44.7%)
132 (51.6%) 124 (48.4%)
34 (38.6%) 54 (61.4%)
x2(2) = 7.55
132 (61.1%) 54 (25.0%) 30 (13.9%)
106 (52.2%) 46 (22.7%) 51 (25.1%)
43 (61.4%) 17 (24.3%) 10 (14.3%)
x2(4) = 9.83
Marital status: Single Married Divorced/widowed/separated
169 (59.1%) 39 (13.6%) 78 (27.3%)
144 (57.8%) 36 (14.5%) 69 (27.7%)
46 (52.9%)
~ ~ (= 4 )1.53
Employment: Employed Unemployed
42 (14.5%) 247 (85.5%)
76 (3 1.OX) 169 (69.0%)
31 (36.0%) 55 (64.0%)
n
Age M Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Newcastle on 01/03/15 For personal use only.
Nonsuicidal control
Current suicide ideation
(SD) Race: white Black
F = 17.95****
sex: Male Female Religion: protestant
Catholic Other
...*
=p
16 (18.4%) 25 (28.7%) x2(4) = 27.64****
< .oOol.
comparison error rate was set at an alpha level of .002 (.05/25). Significant differences across groups were found on two demographic variables (see Table l), with controls being significantly older and less likely to be employed as compared to the two suicide groups. Significant differences across groups were found on several clinical variables (see Table 2). The two suicide groups were more likely to have a diagnosis of depression or adjustment disorder. Also, not surprisingly, the two suicide groups reported significantly higher rates of previous suicidal ideation and attempts. The nonsuicidal controls were more likely to have a history of inpatient and outpatient psychiatric treatment and a history of treatment with psychotropic medications. Suicide attempters were significantly more likely than the nonsuicidal controls to have a history of drug abuse, but not necessarily alcohol abuse (seeTable 3).
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Table 2. Clinical Variables across Suicide Groupsa ~
~
NonsuicidaJ control
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Variable
n
(96)
Diagnosis: Depression Schizophrenia Adjustment disorder Bipolar disorder Substance abuse other
15 (4.9) 120 (39.5) 11 (3.6) 15 (4.9) 55 (18.1) 88 (28.9)
Hisory of inpatient treatment
Current suicide ideation
n
(%)
Current suicide attempt n
(X)
Chi-square
(20.2) (16.7) (15.6) (4.3) (23.3) (19.8)
24 (27.3) 1 (1.1) 29 (33.0) 3 (3.4) 20 (22.7) 11 (12.5)
151.60****
196 (73.0)
140 (58.1)
45 (51.7)
20.20'
History of outpatient treatment
172 (73.8)
120 (55.3)
34 (42.0)
31.46****
History of psychotropic medications
186 (69.9)
126 (51.0)
35 (41.2)
30.36""
History of suicide ideation
72 (34.3)
156 (87.2)
48 (70.6)
116.37""
History of suicide attempts
47 (22.3)
104 (55.6)
38 (54.3)
52.38****
Family history of mental illness
48 (40.7)
63 (41.4)
17 (33.3)
52 43 40 11 60 5
1.10
aFor the diagnosis analysis, df = 10; for all other analyses, df = 2. = p < .OOol.
. . . I
However, this finding seemed to be age dependent. Insufficient sample sizes were obtained to use more detailed analyses of age, so patients were categorized as younger or older than the sample median (31.O). When only older patients were considered, the suicide attempters were more likely than the other two groups to have a personal history of alcohol and drug abuse. In terms of family history, suicide ideators were significantly more likely than nonsuicidal controls to have a family history of alcohol abuse. When age was controlled, this relationship remained significant only for older patients. Finally, no significant relationship was found between suicidality and a family history of drug abuse. In order to examine closely the relationship between suicidality and substance abuse, separate analyses were conducted on patients reporting a history of
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Table 3. Personal and Family History of Substance Abuse Variables Compared across Suicide Groups
Nonsuicidal control
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Variable
n
History of alcohol abuse (% 136 Full sample 5 30 years 61 75 > 30 years
(%)
positive): (58.4) (64.9) (54.0)
Current suicidal ideation n
(%)
Current suicide anempt n
(%)
Chi-square (df = 2)
142 (63.4) 71 (60.2) 71 (67.0)
58 (64.0) 32 (62.7) 26 (78.8)
3.26 0.50 8.87"
117 (50.0) 68 (56.2) 49 (43.4)
48 (58.5) 28 (56.0) 20 (62.5)
9.90"' 0.19 16.86'
Family history of alcohol abuse (% positive): 56 (49.6) 108 (78.3) Full sample 28 (56.0) 54 (75.0) I30years > 30 years 28 (44.4) 54 (81.8)
27 (60.0) 15 (57.7) 12 (63.2)
22.84' ' 5.58 19.43' *
Family history of drug abuse (% positive): 23 (20.2) Full sample 10 (19.6) 5 30 years 13 (20.6) > 30years
39 (27.9) 10 (38.5) 5 (25.0)
History of drug abuse (% positive): 100 (40.2) Full sample 60 (58.8) I30years > 30 years 40 (27.2)
~
15 (32.6) 25 (34.2) 14 (20.9)
3.32 4.14 0.19
~
* * = p < .01. . . I = p < ,001. .*.*= p < .OOol.
parental alcohol abuse (see Table 4). Because these final analyses focused on a smaller subset of subjects, the alpha level was set at .05. In order to evaluate any suicidal tendencies, subjects were categorized according to the lifetime presence of suicidal ideation or attempts. Whenever both responses were present (e.g., current suicidal ideation and previous suicide attempts), the most severe coding was used (e.g., a patient with no suicidal tendencies at present but a history of suicide attempts was classified as a suicide attempter). These results showed that suicidal patients were much more likely than nonsuicidal controls to describe one or both parents as alcoholic. These results were influenced by the patient's age and sen, but were independent of a personal history of alcohol abuse. The increased risk of parental alcohol abuse in suicidal patients remained significant for older patients ( ~ ~ ( = 2 20.06, ) p < .OO01) but not younger patients. Furthermore, when examining the sexes separately, a positive history of parental
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Table 4. History of Parental Alcohol Abuse Compared across Lifetime Suicide Groups' Nonsuicidal control group
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n
(46)
Past or current suicidal ideation n
(96)
Past or current suicide attempts n
(%)
Chi-square (df = 2)
AU subjects with data available on past and current suicidal urges: (a) Positive history of parental alcohol abuse (b)
7 (13.5)
28 (47.5)
62 (48.8)
45 (86.5)
31 (52.5)
65 (51.2)
6 (23.1)
13 (48.1)
26 (50.0)
20 (76.9)
14 (51.9)
26 (50.0)
1 (3.8)
15 (46.9)
36 (48.0)
25 (96.2)
17 (53.1)
39 (52.0)
13 (44.8)
39 (54.2)
16 (55.2)
33 (45.8)
13 (48.1)
15 (36.6)
14 (51.9)
26 (63.4)
20.56'
No history of parental alcohol abuse
Controlling for sex: I. Males (n = 105): (a) positive history of parental alcohol abuse
5.55
(b) No history of parental
alcohol abuse II. Females ( n = 133): (a) Positive history of parental alcohol abuse (b)
16.88. *
No history of parental alcohol abuse
Controlling for alcohol abuse: I. Subjects with a personal history of alcohol abuse: (a) Positive history of parental 4 (21.1) alcohol abuse
6.68'
(b) No history of parental
alcohol abuse
15 (78.9)
II. Subjects with no personal history of alcohol abuse: (a) Positive history of parental 1 (3.7) alcohol abuse
13.82' *
(b) No history of parental
alcohol abuse
26 (96.3)
aLifetime suicide groupings were formed by combining data on presenting suicidality with data on history of suicidal behavior. The analyses were based on a subsample of 238 subjects for whom adequate data were available regarding history of suidical ideation and history of parental alcohol abuse. ' p < .01. ****p < . m 1 .
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alcohol abuse was associated with increased suicidal tendencies in women but not in men. Parental alcohol abuse was very uncommon in female control patients, whereas parental alcohol abuse was observed in approximately 50% of all suicidal groups, whether male or female. Finally, the relationship between suicidality and parental alcohol abuse remained significant even when controlling for a personal history of alcohol abuse. Thus, both alcoholic and nonalcoholic suicidal patients reported an increased frequency of parental alcohol abuse.
DISCUSSI 0N Results showed that suicidal patients differed from nonsuicidal controls on many of the clinical variables examined in this study. However, the differences between suicide attempters and ideators were infrequent and subtle. Furthermore, it was common for the suicide ideators to display more severe levels of pathology than the attempters or controls. Thus, suicide ideators and attempters form distinct but overlapping groups. Future research should examine the similarities and differences between suicide ideators and attemptors. Also, relevant control groups are essential for examining psychosocial variables related to suicide [ 171. In the present study, the nonsuicidal controls reported the highest frequency of previous psychiatric treatment, hospitalization, and use of psychotropic medications. Thus, the suicidal groups did not simply differ in severity from the nonsuicidal controls, but displayed a different pattern to their problems. In the present study, a substantially higher percentage of suicidal patients were diagnosed as depressed. This is in agreement with previous research suggesting the intervening variable of depression. Alcohol abuse can cause depressive reactions [8]. Depressed alcoholics are more likely than nondepressed alcoholics to commit suicide 271. Thus, depression (or hopelessness) may be the intervening variable between alcohol abuse and suicide. Results showed that a family history of alcohol abuse occurred more frequently in the suicidal groups as compared to the nonsuicidal controls. Suicide attempters and especially suicide ideators were likely to report alcohol abuse in one or more family members. Surprisingly, this relationship did not hold for nonalcoholic drug abuse. No significant differences across groups were found in the family history of drug abuse. This suggests that different patterns of etiology may exist across alcohol and drug-abusing families Previous research [ 121 has shown that alcoholic suicide attempters have higher rates of parental alcoholism than do nonsuicidal alcoholics. Also, as compared to nonsuicidal women, female suicide attempters (both alcoholic and nonalcoholic)
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ADAMS AND OVERHOLSER
are more likely to have a father who abused alcohol [lo]. In the present study, the effects of alcohol abuse in the family appear independent of personal abuse patterns. Even nonalcoholic suicidal patients were significantly more likely to report a history of parental alcohol abuse than were nonsuicidal controls. Both sex and age may mediate the relationship between suicidality and substance abuse. A positive history of parental alcohol abuse was observed in suicidal females, while this finding was nonsignificant in males. Thus, parental alcoholism may have a more severe impact on females and seems more directly tied to suicidality in females. The observed patterns between alcohol abuse and suicidality were especially prominent among older subjects. Thus, the relationships between age, alcohol abuse, and suicidal behavior need to be examined more closely. Among alcoholics, the increased risk of suicide attempts with age may be the result of an accumulation of stressors, deterioration of social supports, and a reduction of adaptive coping mechanisms. This corresponds to the concept of a “suicidal career” described by Maris [18]. An increased rate of alcohol consumption with age may also be involved. Results from the present study have implications for identifying psychiatric emergency room patients at risk for suicide. Older patients who abuse drugs or alcohol are at risk for suicidal ideation and attempts. Thus, two risk factors in combination (older age and substance abuse) can greatly increase a person’s risk of suicide. However, age did not contribute an independent risk factor. Across the entire sample, the two suicidal groups were significantly younger than the nonsuicidal controls. Thus, in the present study, patients without a history of personal or family substance abuse did not become more suicidal with age. A family history of alcohol abuse may be a useful early marker for suicide risk. A family history of alcohol abuse may denote the dysfunctional family origins of a patient or may imply a genetic predisposition toward alcoholism or depression. In either case, it suggests the need for a more thorough assessment of family history and family conflict. Results from the present study should be interpreted with caution. A retrospective research design cannot adequately control for the numerous variables capable of influencing the results. Nonetheless, the present study used a large number of patients and remained conservative in its categorical ratings. Patients with incomplete data were excluded from analyses, thereby reducing the risk of false negative ratings. Thus, the possibility of erroneous conclusions has been reduced somewhat. Our results are limited to a psychiatric emergency room population. The present sample may not be representative of the broader spectrum of alcoholics, drug abusers, or suicidal adults. Thus, conclusions from the present study may only help professionals working with this delimited segment of psychiatric patients.
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ACKNOWLEDGMENTS The authors would like to thank Bahman Sharif, Ann Dobelstein, Bill Hill, and the entire staff of St. Vincent’s psychiatric emergency room for their cooperation with this study.
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REFERENCES [ l ] Asberg, M., Bertilsson, L., Manensson, B., Scalia-Tomba, G., Thoren, P., and TraskmanBendz, L., CSF monoamine metabolites in melancholia, Acra Psychiarr. Scad. 69:201-219 ( 1984). [2] Asberg, M., Nordstrom, P., and Traskman-Bendz, L., Cerebrospinal fluid studies in suicide, Ann. N. Y. Acad. Sci. 487:243-255 (1986). [3] Ballenger, J., G d w i n , F., Major, L., and Brown, G . , Alcohol and central serotonin metabolism in man, Arch. Gen. Psychiatry 36:224-227 (1979). [41 Beck, A. T.. and Steer, R. A , , Clinical predictors of eventual suicide: A 5- to 10-year prospective study of suicide attempters, J . Agective Disorders 17:203-209 (1989). Beck, A. T . , Steeer, R. A., and Trexler, L. D., Alcohol abuse and eventual suicide: A 5to 10-year prospective study of alcohol-abusing suicide attempters, J . Sfd. Alcohol 50:202-209 (1 989). Beck, A. T., Weissman, A , , and Kovacs, M., Alcoholism, hopelessness and suicidal behavior, J . Stud. Alcohol 37:66-77 (1976). Berglund, M., Suicide in alcoholism, Arch. Gen. Psychiatry 41:888-891 (1984). Frances, R. J., Franklin, J., and Flavin, D. K., Suicide and alcoholism, Am. J . Drug Alcohol Abuse 13:327-341 (1987). 191 Garfinkel. B. D., Froese, A., and Hood, J . , Suicide attempts in children and adolescents, Am. 1. Psychiatry 139: 1257-1261 (1982). Gomberg, E. S . L . , Suicide risk among women with alcohol problems. Am. J. Public Health 79: 1363- I365 (1989). Hasin, D., Grant, B., and Endicott, I.. Treated and untreated suicide attempts in substance abuse patients, J. New. Menr. Dis. 176:289-294 (1988). Hesselbrock, M., Hesselbrock, V . , Syzmanski, K . , and Weidenman, M., Suicide attempts and alcohol, J . Stud. Alcohol 49:436-442 (1988). Jacob, T., Favorini, A,, Meisel, S. S., and Anderson, C. M., The alcoholic’s spouse, children and family interactions, J . Stud. Alcohol 39: 1231-1247 (1978). Kosky, R., Silburn, S., and Zubrick, S. R., Are children and adolescents who have suicidal thoughts different from those who attempt suicide?, J . New. Ment. Dis. 178:38-43 (1990). Levin, J. D., Alcoholism: A Bio-psycho-social Approach, Hemisphere, New York, 1990. [16] Levy, J. C., and Deykin, E. Y., Suicidality, depression, and substance abuse in adolescence, Am. J. Psychiatry 146:1462-1467 (1988). [I71 Linehan, M. M., Suicidal people: One population or two?, Ann. N. Y. Acud. Sci. 487:16-33 ( 1986). [ 181 Maris, R., Pufhways to Suicide: A Survey of Self-Destructive Behaviors, Johns Hopkins University Press, Baltimore, 1981. [ 191 Marlin, E., Hope: New Choices und Recovery Strategies for Adulr Children of Alcoholics, Harper & Row, New York, 1987. [20] McKearn, J., Post-traumatic stress disorder: Implications for the treatment of family members of alcoholics, Alcoholism Treat. Q. 5 : 141-144 (1988). [21] Meneese, W., and Yutrzenka, B., An Analysis of Adolescent Suicidal Ideation, Presented at the American Psychological Association Meeting, Boston, August 1990.
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[22] Merikangas, K., Leckman, J., Prusoff, B., Pauls, D.,and Weissman, M., Familial transmission of depression and alcoholism, Arch. Gen. Psychiatry 42:367-372 (1985). [23] Motto, J., Suicide risk factors in alcohol abuse, Suicide Life-7hreat. Behav. 10230-238 (1980). [24] Murphy, G. E., Suicide in alcoholism, in Suicidp (A. Roy, 4 . ) . Williams & Wilkins, Baltimore, 1986, p. 89-96. [25] Murphy, G. E., Suicide and substance abuse, Arch. Gen. Psychiatry 45593-594 (1988). [26] Murphy, G. E., and Wetzel, R. D.,The lifetime risk of suicide in alcoholism, Arch. Gen. Psychiatry 47:383-392 (1990). [27] Murphy, S. L., Rounsaville, S. E., and Kleber, H. D.,Suicide attempts in treated opiate addicts, Compr. Psychiatry 24:79-89 (1983). [28] Pfeffer, C. R., Newcorn, J., Kaplan, G., Mizruchi, M. S.. and Plutchik, R., Subtypes of suicidal and assaultive behaviors in adolescent psychiatric inpatients: A research note, J. Child Psychol. Psychiatry 30: I5 1- 163 ( 1989). [29] Saxon, S., Kuncel, E., and Aldrich, S., Drug abuse and suicide, Am. J. Drug Alcohol Abuse 5:485-495 (1978). [30] Stanley, M., and Stanley, B., Biochemical studies in suicide victims: Current findings and future implications, Suicide Life-7hreut. Behav. 19:30-42 (1989). [31] Tishler, C. L., and McKenry, P. C., Parental negative self and adolescent suicide attempts, J. Am. Acad. Child Psychiatry 21:404-408 (1982). [32] Whitfield, C. L., Co-alcoholism: Recognizing a treatable illness, Fum. Commun. Heulrh 7 :16-27 ( 1984).
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Suicidal Behavior and History of Substance Abuse* Dalia M. Adams James C. Overholser,+ Ph.D. Department of Psychology Case Western Reserve University 1 1220 Bellflower Road, Cleveland, Ohio 44 106-3922
ABSTRACT Substance abuse is frequently associated with suicidal behavior. However, it is unclear to what degree substance abuse in a family member is related to suicide. In the present study, personal and family histories of substance abuse were examined in 716 psychiatric emergency room patients. Suicide attempters, suicide ideators, and nonsuicidal controls were compared across demographic, clinical, and substance abuse variables. Results showed that suicidal patients differed from nonsuicidal controls on many of the dependent variables. Suicidal patients were more likely to be depressed and report a history of previous suicidal tendencies. Also, almhol and drug abuse occurred more frequently in suicidal patients. Furthermore, a family history of alcohol abuse was reported more often by suicidal than nonsuicidal patients. These patterns of substance abuse in suicidal patients were especially prominent among older subjects. Results are discussed in terms of the implications for identifying psychiatric emergency room patients at risk for suicide.
LNTRODUCTION Alcoholism is a known risk factor for suicidal behavior [8, 23, 251. Both attempted and completed suicide occur more frequently among alcoholics as compared to normal controls [18, 261. In a long-term prospective follow-up study,
*Presented at the American Psychological Association convention, Boston, August 1990 90whom correspondence should be addressed.
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the diagnosis of alcoholism predicted subsequent death by suicide 141. Furthermore, nonabusive levels of alcohol use increase the risk of suicidal behavior [8]. This may be due to the reduced impulse control associated with alcohol consumption [5], causing more frequent but less intentional suicidal behavior [6]. In addition to alcohol, the abuse of other drugs has been related to suicidal behavior [ 14, 281, especially when combined with high levels of life stress [24]. Substance abuse (both alcohol and drug abuse) is associated with a higher frequency of suicidal ideation, suicide attempts, and suicide completion [16, 181. The rate of suicide attempts among opiate addicts is equivalent to that found in alcoholics, with the rate of suicide attempts in both groups substantially higher than in the general population [27]. Among persons seeking drug treatment, the suicide attempt rate is as much as 12 times greater than in the general population [29]. Substance abusing patients who avoid professional treatment may be at even higher risk for suicidal behavior [ 111. Substance abuse in a family member may also be related to suicide. From a family systems perspective, alcoholism is considered a family problem because of the powerful impact one person’s alcoholism can have on all family members [15]. Families with a history of alcoholism often display instability and conflict [131. Family conflict is related to suicidal ideation [211 and suicide attempts [ 141. As a result of the ongoing conflict and trauma often found in alcoholic homes, children raised by alcoholic parents are likely to exhibit a spectrum of maladaptive coping responses, including suicidal ideation and suicidal behaviors [ 19, 20, 321. Thus, both alcohol abuse and suicidal behavior may be used as means of escaping from serious interpersonal problems. In addition to family conflict, genetic factors may be involved in the relationship between suicidal behavior and family history of alcohol abuse. However, if genetic factors do link alcoholism and suicide, the linkage is probably indirect (see Ref. 22). This relationship is most likely mediated through the physiological basis of depression. Low levels of serotonin have been found to play a role in depression [ 11, suicide [2, 301, and alcoholism [3]. Thus, neurophysiological factors may provide a link between suicide and a family history of alcoholism. Few studies have specifically examined the relationship between a family history of substanceabuse and suicidality, and results have varied according to the population being studied. Maris [18] found that alcoholism occurred frequently in the families of suicide attempters and completers. However, alcohol abuse occurred frequently in nonsuicidal families as well. The differences become more pronounced in studies on adolescent samples. Parents of adolescent suicide attempters have been found to consume more alcohol [31] and display a higher frequency of substance abuse than is found among parents of nonsuicidal
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adolescents [9]. In adults, higher rates of parental alcoholism have been found among suicidal versus nonsuicidal alcoholics [ 121. Also, a positive relationship between paternal alcoholism and suicide attempts has been found in both alcoholic and nonalcoholic women [lo]. Thus, a relationship between suicide attempts and a family history of substance abuse has been supported. However, it remains unclear whether both a family history of alcohol abuse and a family history of drug abuse increase the likelihood of suicide attempts. Also, it is unclear whether the relationship only pertains to parental substance abuse or to other family members as well. Finally, it may be possible to examine suicidal ideation as it relates to a personal history of substance abuse, thereby determining whether the relationships between substance abuse and suicidal tendencies exist at a lower severity of suicidal urges. In the present study, suicide attempters, suicide ideators, and nonsuicidal controls were assessed to examine the relationship between both a personal and a family history of substance abuse and suicidal behavior. In order to clarify any differences between the two substances, alcohol abuse and drug abuse were considered separately. It was hypothesized that both a personal and a family history of substance abuse would occur at higher frequencies in patients reporting either suicidal ideation or suicide attempts. Also, it was predicted that suicidal behavior would reflect a quantitative but not qualitative difference from suicidal ideation. Thus, it was predicted that the same factors associated with suicidal ideation would be related to suicide attempts, but their effects would be more prominent in the suicide attempter group.
METHOD Subjects Approximately 10% (n = 716) of patient charts were randomly selected from the 7,522 patients seen in the psychiatric emergency room of a large metropolitan hospital during 1988 (January 1, 1988, through December 31, 1988). The sample contained six children under the age of 12. In order to focus on adolescent and adult patients, these six children were excluded from the study. In the remaining sample, subjects ranged in age from 12 to 95 years with a mean age of 33.7 years (SD = 12.8). The sample was evenly split between male (51.5%) and female (48.5%)patients. The racial composition of the sample included 45.3% White and 54.7% Black patients. Only eight subjects were of different racial origins, and they were excluded from analyses in order to reduce the heterogeneity
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of the sample. The patients in the sample had a wide variety of presenting problems including chronic schizophrenia with acute psychotic episodes, depression, substance-related crises, and others. Approximately half of the subjects were suicidal, being admitted after a suicide attempt or expressing some level of suicidal ideation. Because suicidal ideation may be viewed as an important precursor to suicidal behavior, three groups of subjects were identified: suicide attempters, suicide ideators, and nonsuicidal controls. This allowed us to evaluate whether suicide ideators appear more similar to suicide attemptors or nonsuicidal controls. This may shed light on the risk of self-harm in suicide ideators.
Procedure At the time of the initial evaluation, patients were evaluated by a clinical social worker, a psychiatric nurse, and a psychiatrist. Diagnoses were based on a combination of unstructured clinical interviews, medical examinations, and laboratory tests. The majority of information was collected through interviews with the patient. Also, when possible, staff interviewed a family member or the patient’s case manager. These interviews were used to gather demographic and clinical information, and were conducted independently by a social worker and a nurse. Additional background information was obtained from a review of previous medical and mental health records. The information gathered included demographic information, current and previous suicide attempts and ideation, personal and family history of alcohol abuse, personal and family history of drug abuse, and personal and family history of mental illness. In order to reduce the possibility of false negative diagnoses, only clear and definitely stated information was included. Vague or incomplete informationon a patient’s chart was coded as missing. This resulted in excluding 53 subjects from statistical analyses.
RESULTS Demographicand clinical comparisons were made across three groups: suicide ideators (n = 257), suicide attempters (n = 88), and nonsuicidal controls (n = 304). Because the demographic and clinical variables were potentially related, a familywise error rate for these 25 analyses was set at an alpha level of .05. Using the Bonferroni adjustment procedure to protect against Type I error, a
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Table 1. Demographic Characteristics across Suicide Groups ~~
Variable
Current suicide attempt
statistic
304
257
88
36.6 (13.8)
31.7 (12.1)
28.9 (8.9)
127 (41.8%) 177 (58.2%)
132 (51.4%) 125 (48.6%)
35 (39.8%) 53 (60.2%)
~ ~ (= 2 )6.42
168 (55.3%) 136 (44.7%)
132 (51.6%) 124 (48.4%)
34 (38.6%) 54 (61.4%)
x2(2) = 7.55
132 (61.1%) 54 (25.0%) 30 (13.9%)
106 (52.2%) 46 (22.7%) 51 (25.1%)
43 (61.4%) 17 (24.3%) 10 (14.3%)
x2(4) = 9.83
Marital status: Single Married Divorced/widowed/separated
169 (59.1%) 39 (13.6%) 78 (27.3%)
144 (57.8%) 36 (14.5%) 69 (27.7%)
46 (52.9%)
~ ~ (= 4 )1.53
Employment: Employed Unemployed
42 (14.5%) 247 (85.5%)
76 (3 1.OX) 169 (69.0%)
31 (36.0%) 55 (64.0%)
n
Age M Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Newcastle on 01/03/15 For personal use only.
Nonsuicidal control
Current suicide ideation
(SD) Race: white Black
F = 17.95****
sex: Male Female Religion: protestant
Catholic Other
...*
=p
16 (18.4%) 25 (28.7%) x2(4) = 27.64****
< .oOol.
comparison error rate was set at an alpha level of .002 (.05/25). Significant differences across groups were found on two demographic variables (see Table l), with controls being significantly older and less likely to be employed as compared to the two suicide groups. Significant differences across groups were found on several clinical variables (see Table 2). The two suicide groups were more likely to have a diagnosis of depression or adjustment disorder. Also, not surprisingly, the two suicide groups reported significantly higher rates of previous suicidal ideation and attempts. The nonsuicidal controls were more likely to have a history of inpatient and outpatient psychiatric treatment and a history of treatment with psychotropic medications. Suicide attempters were significantly more likely than the nonsuicidal controls to have a history of drug abuse, but not necessarily alcohol abuse (seeTable 3).
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Table 2. Clinical Variables across Suicide Groupsa ~
~
NonsuicidaJ control
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Variable
n
(96)
Diagnosis: Depression Schizophrenia Adjustment disorder Bipolar disorder Substance abuse other
15 (4.9) 120 (39.5) 11 (3.6) 15 (4.9) 55 (18.1) 88 (28.9)
Hisory of inpatient treatment
Current suicide ideation
n
(%)
Current suicide attempt n
(X)
Chi-square
(20.2) (16.7) (15.6) (4.3) (23.3) (19.8)
24 (27.3) 1 (1.1) 29 (33.0) 3 (3.4) 20 (22.7) 11 (12.5)
151.60****
196 (73.0)
140 (58.1)
45 (51.7)
20.20'
History of outpatient treatment
172 (73.8)
120 (55.3)
34 (42.0)
31.46****
History of psychotropic medications
186 (69.9)
126 (51.0)
35 (41.2)
30.36""
History of suicide ideation
72 (34.3)
156 (87.2)
48 (70.6)
116.37""
History of suicide attempts
47 (22.3)
104 (55.6)
38 (54.3)
52.38****
Family history of mental illness
48 (40.7)
63 (41.4)
17 (33.3)
52 43 40 11 60 5
1.10
aFor the diagnosis analysis, df = 10; for all other analyses, df = 2. = p < .OOol.
. . . I
However, this finding seemed to be age dependent. Insufficient sample sizes were obtained to use more detailed analyses of age, so patients were categorized as younger or older than the sample median (31.O). When only older patients were considered, the suicide attempters were more likely than the other two groups to have a personal history of alcohol and drug abuse. In terms of family history, suicide ideators were significantly more likely than nonsuicidal controls to have a family history of alcohol abuse. When age was controlled, this relationship remained significant only for older patients. Finally, no significant relationship was found between suicidality and a family history of drug abuse. In order to examine closely the relationship between suicidality and substance abuse, separate analyses were conducted on patients reporting a history of
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349
Table 3. Personal and Family History of Substance Abuse Variables Compared across Suicide Groups
Nonsuicidal control
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Variable
n
History of alcohol abuse (% 136 Full sample 5 30 years 61 75 > 30 years
(%)
positive): (58.4) (64.9) (54.0)
Current suicidal ideation n
(%)
Current suicide anempt n
(%)
Chi-square (df = 2)
142 (63.4) 71 (60.2) 71 (67.0)
58 (64.0) 32 (62.7) 26 (78.8)
3.26 0.50 8.87"
117 (50.0) 68 (56.2) 49 (43.4)
48 (58.5) 28 (56.0) 20 (62.5)
9.90"' 0.19 16.86'
Family history of alcohol abuse (% positive): 56 (49.6) 108 (78.3) Full sample 28 (56.0) 54 (75.0) I30years > 30 years 28 (44.4) 54 (81.8)
27 (60.0) 15 (57.7) 12 (63.2)
22.84' ' 5.58 19.43' *
Family history of drug abuse (% positive): 23 (20.2) Full sample 10 (19.6) 5 30 years 13 (20.6) > 30years
39 (27.9) 10 (38.5) 5 (25.0)
History of drug abuse (% positive): 100 (40.2) Full sample 60 (58.8) I30years > 30 years 40 (27.2)
~
15 (32.6) 25 (34.2) 14 (20.9)
3.32 4.14 0.19
~
* * = p < .01. . . I = p < ,001. .*.*= p < .OOol.
parental alcohol abuse (see Table 4). Because these final analyses focused on a smaller subset of subjects, the alpha level was set at .05. In order to evaluate any suicidal tendencies, subjects were categorized according to the lifetime presence of suicidal ideation or attempts. Whenever both responses were present (e.g., current suicidal ideation and previous suicide attempts), the most severe coding was used (e.g., a patient with no suicidal tendencies at present but a history of suicide attempts was classified as a suicide attempter). These results showed that suicidal patients were much more likely than nonsuicidal controls to describe one or both parents as alcoholic. These results were influenced by the patient's age and sen, but were independent of a personal history of alcohol abuse. The increased risk of parental alcohol abuse in suicidal patients remained significant for older patients ( ~ ~ ( = 2 20.06, ) p < .OO01) but not younger patients. Furthermore, when examining the sexes separately, a positive history of parental
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ADAMS AND OVERHOLSER
Table 4. History of Parental Alcohol Abuse Compared across Lifetime Suicide Groups' Nonsuicidal control group
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n
(46)
Past or current suicidal ideation n
(96)
Past or current suicide attempts n
(%)
Chi-square (df = 2)
AU subjects with data available on past and current suicidal urges: (a) Positive history of parental alcohol abuse (b)
7 (13.5)
28 (47.5)
62 (48.8)
45 (86.5)
31 (52.5)
65 (51.2)
6 (23.1)
13 (48.1)
26 (50.0)
20 (76.9)
14 (51.9)
26 (50.0)
1 (3.8)
15 (46.9)
36 (48.0)
25 (96.2)
17 (53.1)
39 (52.0)
13 (44.8)
39 (54.2)
16 (55.2)
33 (45.8)
13 (48.1)
15 (36.6)
14 (51.9)
26 (63.4)
20.56'
No history of parental alcohol abuse
Controlling for sex: I. Males (n = 105): (a) positive history of parental alcohol abuse
5.55
(b) No history of parental
alcohol abuse II. Females ( n = 133): (a) Positive history of parental alcohol abuse (b)
16.88. *
No history of parental alcohol abuse
Controlling for alcohol abuse: I. Subjects with a personal history of alcohol abuse: (a) Positive history of parental 4 (21.1) alcohol abuse
6.68'
(b) No history of parental
alcohol abuse
15 (78.9)
II. Subjects with no personal history of alcohol abuse: (a) Positive history of parental 1 (3.7) alcohol abuse
13.82' *
(b) No history of parental
alcohol abuse
26 (96.3)
aLifetime suicide groupings were formed by combining data on presenting suicidality with data on history of suicidal behavior. The analyses were based on a subsample of 238 subjects for whom adequate data were available regarding history of suidical ideation and history of parental alcohol abuse. ' p < .01. ****p < . m 1 .
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35 1
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alcohol abuse was associated with increased suicidal tendencies in women but not in men. Parental alcohol abuse was very uncommon in female control patients, whereas parental alcohol abuse was observed in approximately 50% of all suicidal groups, whether male or female. Finally, the relationship between suicidality and parental alcohol abuse remained significant even when controlling for a personal history of alcohol abuse. Thus, both alcoholic and nonalcoholic suicidal patients reported an increased frequency of parental alcohol abuse.
DISCUSSI 0N Results showed that suicidal patients differed from nonsuicidal controls on many of the clinical variables examined in this study. However, the differences between suicide attempters and ideators were infrequent and subtle. Furthermore, it was common for the suicide ideators to display more severe levels of pathology than the attempters or controls. Thus, suicide ideators and attempters form distinct but overlapping groups. Future research should examine the similarities and differences between suicide ideators and attemptors. Also, relevant control groups are essential for examining psychosocial variables related to suicide [ 171. In the present study, the nonsuicidal controls reported the highest frequency of previous psychiatric treatment, hospitalization, and use of psychotropic medications. Thus, the suicidal groups did not simply differ in severity from the nonsuicidal controls, but displayed a different pattern to their problems. In the present study, a substantially higher percentage of suicidal patients were diagnosed as depressed. This is in agreement with previous research suggesting the intervening variable of depression. Alcohol abuse can cause depressive reactions [8]. Depressed alcoholics are more likely than nondepressed alcoholics to commit suicide 271. Thus, depression (or hopelessness) may be the intervening variable between alcohol abuse and suicide. Results showed that a family history of alcohol abuse occurred more frequently in the suicidal groups as compared to the nonsuicidal controls. Suicide attempters and especially suicide ideators were likely to report alcohol abuse in one or more family members. Surprisingly, this relationship did not hold for nonalcoholic drug abuse. No significant differences across groups were found in the family history of drug abuse. This suggests that different patterns of etiology may exist across alcohol and drug-abusing families Previous research [ 121 has shown that alcoholic suicide attempters have higher rates of parental alcoholism than do nonsuicidal alcoholics. Also, as compared to nonsuicidal women, female suicide attempters (both alcoholic and nonalcoholic)
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are more likely to have a father who abused alcohol [lo]. In the present study, the effects of alcohol abuse in the family appear independent of personal abuse patterns. Even nonalcoholic suicidal patients were significantly more likely to report a history of parental alcohol abuse than were nonsuicidal controls. Both sex and age may mediate the relationship between suicidality and substance abuse. A positive history of parental alcohol abuse was observed in suicidal females, while this finding was nonsignificant in males. Thus, parental alcoholism may have a more severe impact on females and seems more directly tied to suicidality in females. The observed patterns between alcohol abuse and suicidality were especially prominent among older subjects. Thus, the relationships between age, alcohol abuse, and suicidal behavior need to be examined more closely. Among alcoholics, the increased risk of suicide attempts with age may be the result of an accumulation of stressors, deterioration of social supports, and a reduction of adaptive coping mechanisms. This corresponds to the concept of a “suicidal career” described by Maris [18]. An increased rate of alcohol consumption with age may also be involved. Results from the present study have implications for identifying psychiatric emergency room patients at risk for suicide. Older patients who abuse drugs or alcohol are at risk for suicidal ideation and attempts. Thus, two risk factors in combination (older age and substance abuse) can greatly increase a person’s risk of suicide. However, age did not contribute an independent risk factor. Across the entire sample, the two suicidal groups were significantly younger than the nonsuicidal controls. Thus, in the present study, patients without a history of personal or family substance abuse did not become more suicidal with age. A family history of alcohol abuse may be a useful early marker for suicide risk. A family history of alcohol abuse may denote the dysfunctional family origins of a patient or may imply a genetic predisposition toward alcoholism or depression. In either case, it suggests the need for a more thorough assessment of family history and family conflict. Results from the present study should be interpreted with caution. A retrospective research design cannot adequately control for the numerous variables capable of influencing the results. Nonetheless, the present study used a large number of patients and remained conservative in its categorical ratings. Patients with incomplete data were excluded from analyses, thereby reducing the risk of false negative ratings. Thus, the possibility of erroneous conclusions has been reduced somewhat. Our results are limited to a psychiatric emergency room population. The present sample may not be representative of the broader spectrum of alcoholics, drug abusers, or suicidal adults. Thus, conclusions from the present study may only help professionals working with this delimited segment of psychiatric patients.
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353
ACKNOWLEDGMENTS The authors would like to thank Bahman Sharif, Ann Dobelstein, Bill Hill, and the entire staff of St. Vincent’s psychiatric emergency room for their cooperation with this study.
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