Despite the large size of this cohort, statistical power was still limited for certain SUDs (hallucinogen, cannabis, and cocaine) because of low numbers. As in other large population-based studies, the reporting of suicides also involves some misclassification. Prior evidence has suggested that many suicides are misclassified as deaths of undetermined intent (Bjorkenstam et al., 2014; Ohberg and Lonnqvist, 1998), especially among persons with SUDs (Allebeck et al., 1991; Lindqvist and Gustafsson, 2002). Consequently, our analyses of these deaths and confirmed suicides as a combined outcome are likely the most relevant.
U.S. deaths each year (2020–
- Constructive and healthy activities offset the attraction to, or otherwise meet the needs usually filled by, alcohol, tobacco, and other drug use, which ultimately reduces suicidal tendencies.
- Combined subcategories may not add to totals in the topline and text due to rounding.
- There are several neurobiological and psychological theories proposed to explain the relationship between alcohol use and suicide.
- Part of preventing suicide is raising awareness around the topic and bringing it into conversations.
The median age for the entire cohort at the end of follow-up was 61.1 years (mean, 62.3 ± 18.7), and the median age at death by suicide was 54.1 years (mean, 54.8 ± 16.9). Women could be at greater risk because heavy drinking generally has more negative physical and cognitive consequences for women than men. For youth, perhaps the higher risk is due to the elevated rates of heavy and problematic drinking in young adults or that suicide is the second leading cause of death among 15 to 29-year-olds.
Supplementary material
Along these lines, a brief, straightforward suicide prevention training curriculum designed for substance abuse treatment providers led to increases in provider self-efficacy, knowledge, and suicide prevention practice behaviors,29 suggesting the importance of future research on patient outcomes. Prior studies of AUA and suicidal behavior have failed to consider that the circumstances and motivations for drinking prior to suicidal behavior may differ in key ways. For example, although seldom considered, alcohol may be used deliberately prior to suicidal behavior in order to remove psychological barriers by increasing courage and numbing fears; anesthetizing the pain of dying18,19; or to make death more likely (e.g., “I mixed alcohol with pills”). Although the use of alcohol for the purpose of facilitating suicidal behavior has rarely been examined, a large case series estimated that approximately one quarter of suicide attempters with AUA fit this pattern,22 suggesting it is common. Safety planning is a brief intervention to help individuals survive suicidal crises by having them develop a set of steps to reduce the likelihood of engaging in suicidal behavior. Safety planning is frequently included as an element in cognitive behavioral interventions for suicide prevention and can also be used as a brief standalone intervention, typically paired with a referral for mental health treatment.
AUA is a potent proximal risk factor for suicidal behavior, and the risk increases with the amount of alcohol consumed, consistent with a dose-response relationship. Research indicates that AUA increases risk for suicidal behavior by lowering inhibition and promoting suicidal thoughts. There is support for policies that serve to reduce alcohol availability in populations with high rates of AUD and suicide, that promote AUD treatment, and that defer suicide risk assessments in intoxicated patients to allow the blood alcohol concentration to decrease. The latest article from Alcohol Research Current Reviews explores links between alcohol use and suicidal behavior. Proximal risk factors for suicide in individuals with SUDs may include psychosocial dysfunction (Brook et al., 2009; Kendler et al., 2017), psychiatric symptoms (Kessler et al., 2005; Schuckit, 2006; Trivedi et al., 2015), and interpersonal stress (Conner and Ilgen, 2011). Further identification of the mechanisms by which specific SUDs are related to suicidal behavior is needed to account for the risk gradient observed in the present study.
As a psychologist and scientist, my research aims to understand whether alcohol actually increases the risk of dying by suicide. Model adjusted for gender, age, marital status, neighbourhood deprivation, educational qualification, employment status, self-reported mental health problems, past year drug use and number of physical health conditions. Alcohol use is a risk factor for suicidal behaviour, yet the nature of the relationship is unclear.
Our findings underscore the importance of organizing health care delivery to identify patients with these common disorders and to facilitate screening for psychiatric comorbidity and suicidality (Crump et al., 2020; Crump et al., 2021). Clinical interventions to prevent suicide have been shown to be effective but remain underutilized (Hofstra et al., 2020; Mann et al., 2005). Identification of SUDs in clinical settings should trigger further discussion of mental health with these high-risk patients, and prompt psychiatric follow-up for additional evaluation if suicidality or untreated psychiatric comorbidity is detected (Bauer et al., 2013). Furthermore, our analyses identified simple domains of alcohol misuse, such as others’ concerns about drinking, which can be readily understood by the public and targeted, perhaps through motivational interviewing,40 to reduce risk of future suicidal behaviour. Suicide claims more than 800,000 lives each year worldwide and is the second-leading cause of death among people ages 15 to 29.1 For every suicide, at least 20 nonlethal suicide attempts have occurred, primarily by attempted overdose.
Such event-based analysis of drinking and suicidal thoughts and behavior would inform theory and prevention efforts targeting alcohol-involved acts of suicide. We conducted the most comprehensive meta-analysis on the link between alcohol (ab)use and death by suicide to date. By analyzing the data from 33 longitudinal studies — and 10,253,101 participants — we determined that alcohol use is a substantial risk factor for death by suicide. In fact, we found that alcohol use increased the risk of death by suicide by a frightening 94 per cent. Psychological autopsy investigations worldwide show that substance use disorders, most often AUD, are the second most common group of mental disorders among suicide decedents and that AUD is a risk factor for suicide.11 Epidemiologic studies12 also show that AUD is a risk factor for suicide attempts. Several reports13–15 have examined risk factors for suicide attempts and suicide among individuals with AUD.
Data Availability Statement
Substance use disorders (SUDs) are among the strongest risk factors for suicide (Chesney et al., 2014; Crump et al., 2014; Fazel and Runeson, 2020; Harris and Barraclough, 1997; Wilcox et al., 2004). Men and women with SUDs have been reported to have more than 4-fold risks of suicide death compared with the general population, after adjusting for sociodemographic differences and comorbidities (Crump et al., 2014). Because of their high prevalence in most countries worldwide (Degenhardt et al., 2013; Rehm and Shield, 2019; Whiteford et al., 2013), SUDs are major contributors to the global burden of suicide (Ferrari et al., 2014). However, despite their importance for suicide risks, little is known about how risks vary by specific SUDs, because they seldom have been examined using the same data source to facilitate comparisons. A better understanding of comparative risks by specific SUDs is needed to improve risk stratification and help target interventions for the highest-risk subgroups. First, population-attributable fractions were calculated based on data including only persons who currently drank alcohol.
In secondary analyses, we explored interactions between the most common DUDs and AUD in relation to suicide death on the additive and multiplicative scale (VanderWeele, 2011), because they seldom have been formally assessed in large cohorts and could potentially reveal higher-risk subgroups. These analyses assessed whether associations between DUDs and risk of suicide death varied according to whether AUD was also present, or vice versa. In addition, a sensitivity analysis examined AUD and risk of suicide death after ascertaining AUD using only clinical diagnoses and not alcohol-related convictions. To address a potential multiple comparisons problem, the Benjamini-Hochberg procedure was applied post hoc to control the false discovery rate to 0.05 (Benjamini and Hochberg, 1995). Beyond current theories regarding the link between suicide and alcohol use, effective prevention requires knowing who is most at risk.
What Can Be Done to Understand and Lower Risk Associated with AUA
Many factors may have contributed to these increases in alcohol-related deaths. These include the availability of alcohol, increases in people experiencing mental health conditions, and challenges in accessing health care. Our study indicates these combine to produce a 282 per cent increased risk of death by suicide. Among people who die by suicide, alcoholism is the second-most common mental disorder, and is involved in roughly one in four deaths by suicide.
Shifting the adult children of alcoholics screening quiz research focus from binge drinking to other dimensions of alcohol use may be warranted, subject to the availability of sufficiently nuanced data. Qualitative research exploring drinking motives and contexts for alcohol consumption may further enhance our understanding of the role of alcohol use behaviours and links with suicidal and self-harming behaviour. Clinical policy interventions targeting AUD also have the potential to affect suicide rates in health systems that have high rates of AUD and suicide.