Alcohol & Alcoholism Vol. 41, No. 5, pp. 473–478, 2006 doi:10.

1093/alcalc/agl060
Advance Access publication 4 August 2006

THE ASSOCIATION BETWEEN ALCOHOL MISUSE AND SUICIDAL BEHAVIOUR

JOHN BRADY
Specialist Registrar in General Adult Psychiatry, Holywell Hospital, 60 Steeple Road, Antrim BT41 2RJ, Northern Ireland

(Received 4 April 2006; in revised form 26 June 2006; accepted 8 July 2006; advance access publication 4 August 2006)

Abstract — Aims: Despite recent small reductions in overall suicide rates, rates among those aged 25–44 have remained high. The aim
of this paper was to examine the evidence for a link between alcohol misuse/consumption and suicidal behaviour, explore the reasons for
this association, and consider the implications for reducing rates of suicidal behaviour. Methods: A medline search was performed to
find relevant research evidence. Results: There is evidence to suggest alcohol misuse predisposes to suicidal behaviour through its
depressogenic effects and promotion of adverse life events, and both behaviours may share a common genetic predisposition. Acute
alcohol use can also precipitate suicidal behaviours through induction of negative affect and impairment of problem-solving skills, as
well as aggravation of impulsive personality traits, possibly through effects on serotonergic neurotransmission. Conclusions: Effective
interventions for problem drinking may help reduce suicide rates. At a public health level, reducing overall alcohol consumption may be

Downloaded from https://academic.oup.com/alcalc/article/41/5/473/109923 by guest on 05 May 2023

beneficial, and the measures shown to be most effective in this regard are those that aim to restrict availability of alcohol.

INTRODUCTION drawn between suicide attempts and completed suicide, as

the characteristics of the two populations can be quite differ-
Suicide rates have increased globally by 60% over the past 45 ent, particularly in respect to gender. Therefore, this review
years and it has been estimated to represent 1.8% of the total will examine both types of suicidal behaviour, and will exam-
burden of disease in 1998 (World Health Organization, ine risk factors as predisposing or precipitating, even though
2005a). Despite a recent drop in overall suicide rates in the the distinction between these can be sometimes arbitrary. For
USA (World Health Organization, 2004) and England and instance, on an epidemiological level, levels of alcohol con-
Wales (Office for National Statistics, 2005), rates in males sumption have frequently been shown to be associated with
aged 25–44 have remained relatively constant, or even risen, the suicide rate (Stack, 2000), but this association, if causal,
especially in Ireland and Scotland (Samaritans, 2005). It is can be seen as both predisposing and precipitating.
the second most common cause of death in young males in This review takes a broader outlook than most, focussing
most industrialised countries, and the most common in some not just on the evidence for a link between alcohol misuse
(e.g. Ireland, Sweden). Possible reasons for this have included and suicidal behaviour, but also possible clinical or biological
rising unemployment, drug misuse, increased availability of factors that may mediate this link, and the implications of this
methods used for suicide, HIV infection, media exposure, evidence for suicide prevention.
family breakdown, lessened social integration, increase in
psychiatric disorders, male reluctance to seek help, and greater
acceptability of suicide as an option (Hawton, 1998). One of
the more compelling reasons is the relationship of alcohol EVIDENCE FOR A LINK BETWEEN ALCOHOL
dependence (and to a lesser degree, alcohol abuse) to suicide MISUSE AND SUICIDE
and suicidal behaviour. Although alcohol consumption among
adults has fallen in most developed countries since 1980, it has The relationship between per capita alcohol consumption and
risen in developing countries, countries of the former Soviet suicide mortality is complex and varies internationally. In a
Union, and the UK and Ireland. Ireland, in particular, has review of literature on suicide, Stack (2000) found that 55
seen consumption double since 1970 (OECD Health Data, studies from 89 done, in 17 countries, showed that the greater
2005). Patterns of drinking have also changed, with young the alcohol consumption, the greater the suicide rate. The
people being more likely to binge drink (Firel et al., 1999). strength of the association varied considerably, with a one litre
The relationship between alcohol misuse and suicidal beha- per capita increase in consumption associated with an increase
viour can be conceptualised in a number of different ways. It in suicide of 2.6% in France and 16% in Norway. Ramstedt
can be examined from a perspective of biological, psycholo- (2001) also found wide regional differences in Europe, with
gical or social effects, or it can be analysed by the temporal the suicide rate being more responsive to changes in alcohol
relationship between the use of alcohol and the suicidal beha- consumption in low-consumption countries (i.e. Scandinavia)
viour. Terms such as‘acute risk factors’, ‘potentiating factors’, than medium or high-consumption (i.e. Mediterranean) countries.
‘proximal risk factors’, ‘acute risk factors and precipitants’ In contrast, Makela (1996) found no significant effect over-
have been variously used to describe events temporally close all, but did find that the suicide rate in those <50 years old was
to the actual suicidal behaviour. Other terms, such as ‘predis- significantly associated with per capita alcohol consumption.
posing factors’, ‘constant-risk factors’ and ‘distal risk factors’ A more significant association between alcohol and suicidal
have been used to describe events more distant from the sui- behaviour in younger age groups has also been shown by
cidal behaviour (Hufford, 2001). A distinction can also be blood alcohol measurements in suicide attempters (Suokas
and Lonnqvist, 1995), follow-up studies of alcohol-
dependent subjects (Preuss et al., 2003), and psychological
Author to whom correspondence should be addressed: Tel.: +44 28 94465211; autopsy studies (Pirkola et al., 2000). Ramstedt (2001) found
E-mail: [email protected] that the association was stronger in younger people in northern

473

Ó The Author 2006. Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved
474 J. BRADY

and central European countries, the difference possibly being a Among those with alcohol use disorders, the severity of the
more intoxication-oriented drinking pattern, and subsequently disorder (as measured by heavier drinking pattern, alcohol-
more binge drinking. related medical problems, and duration of alcoholism) distin-
Most studies find that male suicide victims are more likely guishes alcoholics who die from suicide from those that do
then females to have a history of alcohol misuse (Pirkola not (Conner and Duberstein, 2004).
et al., 2000) or to have detectable blood alcohol at autopsy
(Ohberg et al., 1996), one exception being the forensic study WHY IS ALCOHOL MISUSE A
by Garlow (2002) which found no difference between men PREDISPOSING FACTOR?
and women in the percentages of victims who were ethanol
positive. It should, however, be pointed out that men have a Comorbidity
higher prevalence of heavy drinking and intoxication than
women in the general population, so a higher prevalence of The depressogenic effects of alcohol are well known (Regier
alcohol misuse among male suicide victims may not reflect et al., 1990) and where both conditions co-exist, the depress-
any particular susceptibility among men to suicide- ive illness can sometimes be identified as independent of the
promoting effects of alcohol. Indeed, Ramstedt (2001) found alcohol abuse, or may even pre-date it. It is clear, though,
that female alcohol abusers committed suicide more often that when both disorders are present together, there is a greater

Downloaded from https://academic.oup.com/alcalc/article/41/5/473/109923 by guest on 05 May 2023

compared with women in general than did male abusers in risk of suicidal behaviour.
comparison with men in general, and hypothesised that female Chignon et al. (1998) found that alcoholic suicide
alcohol abusers may be relatively more at risk of suicidal attempters were more likely to be depressed than non-
behaviour because they are more exposed to social stigmatisa- alcoholic attempters. In another study of alcohol-dependent
tion and weakened social integration than men. patients, Driessen et al. (1998) found that the greatest risk
for suicidal ideation was in those who also had co-morbid
anxiety and depressive disorders or personality disorders.
ALCOHOL AS A PREDISPOSING RISK FACTOR Cornelius et al. (1995) found that level of suicidality was the
symptom which most strongly distinguished between
That alcohol dependence is a significant risk factor for all depressed alcoholics and two other groups with depression
types of suicidal behaviour would appear to be beyond dispute and alcohol dependence alone. Other distinguishing factors
(Cornelius et al., 1995). The role of alcohol abuse alone is less were low self-esteem and greater impulsivity. In psycholo-
clear, as some studies have failed to find an association gical autopsy studies, 89% of alcohol-dependent suicides
between it and suicide (Lesage et al., 1994). Traditionally, it were found to have another psychiatric diagnosis by Foster
has been stated that the lifetime risk of suicide in those with et al. (1997), with 25% of these having unipolar depression,
alcohol dependence is 15%, with the risk being similar and Henriksson et al. (1993) found 22% of alcohol-
throughout the lifetime of the disorder. However, this figure dependent suicide victims to have major depression.
has been challenged by Inskip et al. (1998), who, using mod- There is also some evidence that the effects of alcohol on
ern computerised curve modelling techniques, found the life- suicidal behaviour are not mediated through depression. In
time risk of suicide to be 7% in those with alcohol the US National Co-Morbidity Survey (Borges et al., 2000)
dependence, which is still considerably more than the risk it was found that alcohol and drug abuse predicted subsequent
for the general population. suicide attempts, but this relationship was independent of
In psychological autopsies in Finland and Northern Ireland, socio-demographic factors and co-morbid mental disorders.
respectively (Henriksson et al., 1993; Foster et al., 1997) 44 Also, Schuckit et al. (1997) differentiated between
and 43% of suicide victims were found to be suffering from substance-induced and independent depressive episodes in
alcohol abuse or dependence. Pirkola et al. (1999), examined alcoholics, and found that 41% of alcoholics had had depress-
106 adolescent suicides (13–22 years) and found that 42% ive episodes, with 26% being substance induced and 15%
had an alcohol use disorder. These were more likely to have independent. Those who had independent episodes were
co-morbid mental disorders, antisocial behaviour, disturbed more likely to have attempted suicide than those with
family backgrounds and life events. alcohol-dependent episodes.
In a prospective study, Rossow and Amundsen (1995) fol-
lowed up 40 000 Norwegian conscripts over 40 years and Adverse life events
examined the prevalence of alcohol abuse among suicides. Kendall (1983) and Lester (1992) have proposed that alcohol
The relative risk (RR) of suicide among alcohol abusers was abuse leads to lowered self-esteem, and ultimately increased
estimated at 6.9. In contrast with epidemiological studies dem- risk of suicide, through a process of negative life events
onstrating greater risk in younger age groups, alcohol abusers (such as marital separation and work problems), loss of social
aged >40 years had a RR of 12.8 and those <40 years a RR of networks and social isolation. In a study of adult suicides,
4.5. The lifetime risk of suicide (before the age of 60 years) Pirkola et al. (2000) found that 35% were alcohol misusers,
was estimated as 4.76% in those categorised as alcohol and these were more often male, young, divorced, separated,
abusers. Alcohol dependence has also been found to be associ- or recently unemployed. Preuss et al. (2002) also found that
ated with attempted suicide, for example by Chignon et al. current unemployment, separation, or divorce distinguished
(1998), who conducted a cross-sectional study examining alcohol-dependent individuals with a history of suicide
507 alcohol-dependent patients, and found that 25% had attempts from alcohol-dependent individuals without such a
attempted suicide in their lifetime. The attempter group also history. In another study comparing depressed alcoholics
had a younger age of onset of alcohol dependence. with never-depressed alcoholics, Roy (1996) found that the
 ASSOCIATION BETWEEN ALCOHOL MISUSE AND SUICIDAL BEHAVIOUR 475

depressed alcoholics had more suicide attempts, but also more consumption. These studies found that 51–62% of attempters
life events than the other group. It was proposed that life had recently consumed alcohol, figures higher than in most
events are a risk factor for secondary depression in alcoholics. studies using self-report measures.
In particular, disruptions in interpersonal relationships are the
most common negative life event occurring before suicide in
alcoholics (Duberstein et al., 1993; Heikkinen et al., 1994). WHY IS ALCOHOL MISUSE A PRECIPITATING
RISK FACTOR?
Genetic predisposition
Intoxication and psychological distress
Alcohol misuse and suicidal behaviour may share a common
Alcohol has a biphasic effect on emotion, with low doses
genetic predisposition. Because of the evidence for serotoner-
often ameliorating negative affect, but higher doses producing
gic dysfunction in suicidal behaviour (Mann et al., 1999),
central nervous system depressant effects (Hufford, 2001).
genes involved in serotonin metabolism and regulation have
Many adults and adolescents believe alcohol can be used as a
been studied most. For instance, Nielsen et al. (1998), using
form of self-medication, but unfortunately this effect reverses
association and sib-pair linkage analysis of a polymorphism
itself at higher levels of intoxication (Pihl and Smith, 1983),
in intron 7 of the tryptophan hydroxylase (TPH) gene, found
and can precipitate suicidal behaviour. Borges et al. (2000)

Downloaded from https://academic.oup.com/alcalc/article/41/5/473/109923 by guest on 05 May 2023

significant evidence for linkage to suicidality, severe suicide
found that alcohol’s effects were mainly on suicidal ideation
attempts and alcoholism. This suggests that a variant in the
and unplanned attempts rather than planned attempts, thus
TPH gene may predispose individuals to suicidality and other
lending more evidence to the theory that acute intoxication is
behaviours thought to be influenced by serotonin.
more significant, in relation to suicide, than chronic abuse.
Another well-studied gene is the serotonin transporter gene
(5-HTTLPR), a polymorphism of which has been associated
with mood disorders (Collier et al., 1996), alcohol dependence Constricted thinking/impaired problem solving
(Sander et al., 1998) and increased risk for suicide attempts Young suicide attempters have been found to have difficulties
(Preuss et al., 2001). There is, however, much conflicting with problem-solving style (Rotherham-Borus et al., 1990) and
data about these associations, with Gorwood et al. (2000), constricted thinking (Leenaars et al., 1999). Inability to gener-
for example, confirming that the S-allele is associated with ate alternative solutions is particularly associated with suicide
an increased risk for suicide attempts but not with alcohol attempts, and this, and other stages of problem-solving, are
dependence or co-morbid depression. likely to be interfered with by alcohol (Hawton, 1994).

Alcohol as a precipitating risk factor Aggression/impulsivity

The acute effects of alcohol intake have been implicated in It is probably not the case that all individuals with alcohol
suicidal behaviour as much as the chronic effects of alcohol abuse and dependence are prone to suicidal behaviour, but
misuse. Post-mortem studies have shown detectable blood what makes some more vulnerable are particular personality
alcohol in 28.3% of suicides in San Diego (Mendelson and traits. Experimental, individual-level, and macro-level studies
Rich, 1993), 28.9% in Georgia (Garlow, 2002), 20% in the all support an association between alcohol and violence to oth-
Netherlands (Hansen et al., 1995), and 35.9% in Finland ers (Lipsey et al., 1997), which is probably causal, but very
(Ohberg et al., 1996), in significantly more males than females complex with regard to which individuals are susceptible
in the latter study. In a similar study, Ferrada-Noli et al. (1996) and the degree of provocation that may be necessary. In the
detected blood alcohol in 45% of suicide victims, but only case of suicide, or violence to the self, those with more impuls-
found organic signs of alcohol abuse at autopsy in 33%, ive and aggressive traits are known to be at greater risk of sui-
suggesting that the presence of alcohol at autopsy reflected cidal behaviour (Plutchik and van Praag, 1989; Greenwald
‘incidental intake rather than habitual over-consumption’. et al., 1994; Horesh et al., 1999). In particular, individuals
The Accident and Emergency Department provides an prone to ‘reactive aggression’ (i.e. impulsive, angry responses
opportunity to assess the contribution of alcohol to suicidal to perceived threats, often of an interpersonal nature) seem to
behaviour, soon after an event, although this is complicated be at increased risk of suicide (Dodge and Coie, 1987). This is
by variation in length of time between intake of alcohol, the evidenced by the consistent finding that a diagnosis of border-
suicide attempt, and estimation of blood alcohol concentra- line (or emotionally unstable) personality disorder is a potent
tion, if indeed it is measured at all (Cherpitel et al., 2004). risk factor for completed suicide (Cheng et al., 1997; Foster
The method used by investigators most often is to interview et al., 1999). It is plausible to conclude that excessive alcohol
attempters after the attempt, and assess self-reported alcohol consumption would exacerbate these traits, leading to a direct
consumption. For example, Kolacinski et al. (1997) estimated effect on suicide risk, but also one through an increased
that 30% of suicide attempters had ‘acted under the influence propensity for interpersonal disruption.
of alcohol’, but only 6% of them were dependent on alcohol. Suominen et al. (1997) compared suicide attempters in four
Merrill et al. (1992) found that 46% of patients admitted groups: those with depression, those with alcohol dependence,
after self-poisoning had consumed alcohol within 12 h of those with both, and those with neither. They found that those
the attempt. Three studies directly measured alcohol consump- with alcohol dependence alone had had lower suicidal intent
tion (Suokas and Lonnqvist, 1995; Borges and Rosovsky, and were more impulsive than those with depression alone,
1996; McMahon and McGarry, 2001) by blood alcohol again suggesting that impulsivity may be an important factor.
measurement or breathalyser estimates. These found a signi- Cornelius et al. (1996) studied a group of alcoholics with
ficant association between suicide attempts and recent alcohol co-morbid major depression, and found a significant
476 J. BRADY

association between recent very heavy drinking and recent sui- As well as serotonin, research has shown an effect of alco-
cide attempts. They also found that the quantity of alcohol hol on monoamine oxidase activity (Hallman et al., 1996)
drunk was higher in those who had made a recent suicide and brain cholecystokinin receptors in rats (Harro et al.,
attempt, but was not associated with suicidal ideation. They 1994) which have both been found to be affected in those
concluded that recent heavy alcohol use primarily affects sui- who attempt and complete suicide. However, these may
cidality by increasing the likelihood of acting on suicidal idea- merely function as markers of suicidal activity, rather than
tion rather than by inducing suicidal ideation per se. having any causal effect.

Biochemical effects of alcohol CONCLUSIONS

There is some evidence that the common denominator in this
complex relationship between alcohol, aggression, impulsiv- Although the link between alcohol misuse and suicidal behavi-
ity, and suicide may be serotonergic dysfunction. This is sug- our is robust, this relationship is very complex. The long-term
gested by: effects of alcohol misuse are probably mediated through inter-
(i) Post-mortem studies, measurement of serotonin metabol- related effects on mood and social processes. Those not actu-
ally dependent on alcohol are at risk through the short-term

Downloaded from https://academic.oup.com/alcalc/article/41/5/473/109923 by guest on 05 May 2023

ites in CSF, and assessment of the prolactin response to
fenfluramine have consistently shown that serotonergic effects of alcohol on mood, cognitive processes and impulsiv-
dysfunction is present in those who complete and attempt ity. Young people appear to be particularly susceptible to
suicide, independent of alcohol use (Mann et al., 1999). alcohol-associated suicidal behaviour, and the pattern of
(ii) A deficient serotonergic system is also implicated as a drinking, especially binge-drinking, may be of relevance.
predisposing factor to impulsivity and aggression, with Conner and Duberstein (2004) have proposed a conceptualisa-
strong evidence of lowered CSF 5-HIAA (the major meta- tion of suicide among alcoholics that includes aggression/
bolite of serotonin) levels in those with a history of impulsivity, alcoholism severity, hopelessness and negative
aggression, as well as suicide attempts (Brown et al., affect as predisposing factors, and interpersonal life events
1982; Traskman-Bendz et al.,1992). and depression as precipitating factors.
(iii) As already mentioned, consumption of alcohol can pro- Much needs to be done to elucidate what determines the risk
mote aggression and impulsive actions (Bushman and for an individual, whether it is the amount consumed, the
Cooper, 1990). Impulsiveness has been found to be signi- pattern of drinking, certain personality traits, psychiatric
ficantly higher in non-depressed alcoholic suicide co-morbidity, or genetic predisposition.
attempters than in depressed non-alcoholic attempters
(Suominen et al., 1997). Alcohol is known to have pro-
found effects on the serotonergic system. For example, IMPLICATIONS FOR SUICIDE PREVENTION
consumption of a moderate dose of ethanol (0.8 g/kg
body weight, or roughly 2–2.5 pints of normal-strength As already stated, national suicide rates tend to rise with
beer) causes a decrease of 20% in cerebral serotonin greater per capita consumption of alcohol. It has also been
(and its precursor, tryptophan) in the average social drin- shown that reducing levels of consumption can lead to reduced
ker, reflecting a reduction in total serum concentrations overall suicide rates in Scandinavia, and Canada (Smart and
probably caused by activation of the enzyme tryptophan Mann, 1990). In the former USSR, from 1984 to 1990, the
pyrrolase (Badawy et al. 1995). Chronic alcohol use is political process of perestroika (restructuring), with much
also associated with upregulated 5HT2 receptors, prob- stricter controls on alcohol and raised prices, led to signific-
ably reflecting low 5HT function (Virkunnen et al., antly lower alcohol consumption. During this time the suicide
1994). This is particularly true of the ‘Type II alcoholics’ rate fell by 32% for men and 19% for women, compared with
Cloninger, 1987), usually men, who have an early onset of decreases of 8 and 17%, respectively in 22 other European
alcoholism, antisocial traits and high impulsivity, sug- countries (Wassermann and Varnik, 1998). Of course, this
gesting that serotonergic dysfunction may predispose to association is not necessarily causal, but coupled with the
specific subtypes of alcohol dependence that may be asso- evidence of an effect of alcohol misuse on suicidal behaviour,
ciated with higher suicidal risks (Gorwood, 2001). it does suggest that prevention and appropriate treatment of
alcohol misuse can be a key factor in reducing suicide rates.
Badawy (1998) synthesised these links into the ‘serotonin Public health measures that have been shown to be most
deficiency hypothesis of alcohol-induced aggressive behavi- effective in limiting alcohol misuse include taxing alcoholic
our’, proposing that susceptible individuals exhibit a marked beverages, restricting consumption, enforcement of stricter
depletion of their brain serotonin after alcohol consumption, drink–drive laws, and interventions aimed at servers of alco-
rendering them prone to aggression. Some support for this hol (Jernigan et al., 2000). Birckmayer and Hemenway
theory has been found in studies on non-aggressive subjects, (1999) examined the suicide rate in those aged 18–20 in the
but has not been examined in those known to be aggressive United States, and found the rate to be 8% higher in states
after alcohol consumption. Tryptophan depletion can induce where the minimum legal drinking age was 18, compared
a negative mood in normal subjects (Young et al., 1988), with 20 years of age. They estimated that lowering the drink-
cause reversal of antidepressant-induced remission in ing age to 18 in all states would lead to 125 more suicides
patients with depression (Delgado et al., 1990), and increase per year in the 18–20 age group. A more restrictive policy is
aggressive responding to provocation (Pihl et al., 1995). The ‘selective prohibition’ (Watt and Naidu, 2002), whereby those
same mechanism could also lead to suicidal behaviour. with a history of alcohol-related violence are prohibited from
 ASSOCIATION BETWEEN ALCOHOL MISUSE AND SUICIDAL BEHAVIOUR 477

buying alcohol. Those at risk of mental health problems Cherpitel, C. J., Borges, G. L. and Wilcox, H. C. (2004) Acute alco-
(including suicide) could voluntarily opt in to this scheme. hol use and suicidal behaviour: a review of the literature. Alcohol-
ism, Clinical and Experimental Research 28 (5, Suppl.), 18S–28S.
‘The Surgeon General’s Call To Action To Prevent Suicide’ Chignon, J. M., Cortes, M. J., Martin, P. et al. (1998) Attempted sui-
(U.S. Public Health Service, 1999) places much emphasis on cide and alcohol dependence: results of an epidemiologic survey.
the role of substance abuse, including raising awareness of Encephale 24, 347–354.
resources for assessment and treatment of substance abuse dis- Cloninger, C. R. (1987) Neurogenetic adaptive mechanisms in alco-
orders, improving the ability of primary care providers to holism. Science 236, 410–416.
Collier, D. A., Stöber, G., Li, T. et al. (1996) A novel functional poly-
recognise and treat them, and eliminating barriers to their morphism within the promoter of the serotonin transporter gene:
treatment in insurance programmes. A Cochrane review possible role in susceptibility to affective disorders. Molecular
(Dinh-Zarr et al., 2003) concluded that interventions for prob- Psychiatry 1, 453–60.
lem drinking may reduce injuries, including suicide and sui- Conner, K. R. and Duberstein, P. R. (2004) Predisposing and precip-
itating factors for suicide among alcoholics: empirical review and
cide attempts, although the exact effect size was difficult to conceptual integration. Alcoholism Clinical and Experimental
ascertain. Because of the high levels of co-morbidity with Research 28 (5, Suppl.), 6S–17S.
alcohol use disorders, treatment must have a broader scope. Cornelius, J. R., Salloum, I. M., Mezzich, J. et al. (1995) Dispropor-
It has been estimated that more effective treatment of depres- tionate suicidality in patients with comorbid major depression and
sion, alcohol-related disorders and schizophrenia could reduce alcoholism. American Journal of Psychiatry 152, 358–364.

Downloaded from https://academic.oup.com/alcalc/article/41/5/473/109923 by guest on 05 May 2023

Cornelius, J. R., Salloum, I. M., Day, N. L. et al. (1996) Patterns of
suicide rates by 20.5% (Bertolote et al., 2003). suicidality and alcohol use in alcoholics with major depression.
The World Health Organization (2005b) suggests that Alcoholism, Clinical and Experimental Research 20, 1451–1455.
measures to restrict availability and consumption of alcohol Delgado, P. L., Charney, D. S., Price, L. H. et al. (1990) Serotonin
(e.g. increased taxes and restrictions on the hours of sale) are function and the mechanism of antidepressant action: reversal of
antidepressant-induced remission by rapid depletion of plasma
the best way to reduce the alcohol-related burden, but also tryptophan. Archives of General Psychiatry 47, 411–418.
emphasises that policies should be guided by local considera- Dinh-Zarr, T., DiGuiseppi, C., Heitman, E. et al. (2003) Interventions
tions, such as patterns of drinking. A recent relaxation in the for preventing injuries in problem drinkers (Cochrane Review).
licensing laws in England and Wales, allowing some premises In: The Cochrane Library, Issue 3, Oxford: Update Software.
to serve alcohol 24 h a day, does not follow this reasoning, and Dodge, K. A. and Coie, J. D. (1987) Social-information-processing fac-
tors in reactive and proactive aggression in children’s peer groups.
has been criticised by the Royal College of Physicians, Police Journal of Personality and Social Psychology 53, 1146–1158.
Federation and the British Association for Emergency Medi- Driessen, M., Veltrup, C., Weber, J. et al. (1998) Psychiatric co-
cine (The Guardian, 23rd November, 2005). Whichever strate- morbidity, suicidal behaviour and suicidal ideation in alcoholics
gies are adopted, they need to be comprehensive, involving seeking treatment. Addiction 93, 889–894.
Duberstein, P. R., Conwell, Y. and Caine, E. D. (1993) Interpersonal
mental health professionals, health promotion agencies, and stressors, substance abuse, and suicide. Journal of Nervous and
general practitioners, and they particularly need the support Mental Disease 181, 80–85.
of government and those who are involved in the alcohol Ferrada-Noli, M., Ormstad, K. and Asberg, K. (1996) Pathoanatomic
industry to prevent the public receiving mixed messages on findings and blood alcohol analysis at autopsy (BAC) in forensic
the subject of alcohol. diagnoses of undetermined suicide. A cross-cultural study.
Forensic Science International 78,157–163.
Firel, S., Nic Gabhainn, S. and Kelleher, C. (1999) The National
Health and Lifestyle Surveys (SLAN, HBSC). Centre for Health
REFERENCES Promotion Studies, National University of Ireland, Galway.
Foster, T., Gillespie, K., McClelland, R. (1997) Mental disorders and
Badawy, A. A. B. (1998) Alcohol, aggression and serotonin: meta- suicide in Northern Ireland. British Journal of Psychiatry 170,
bolic aspects. Alcohol and Alcoholism 33, 66–72. 447–452.
Badawy, A. A. B., Morgan, C. J., Lovett J. W. T. et al. (1995) Foster, T., Gillespie, K., McClelland, R. et al. (1999) Risk factors for
Decrease in circulating tryptophan availability to the brain after suicide independent of DSM III-R axis I disorder. British Journal
acute ethanol consumption by normal volunteers: implications of Psychiatry 175, 175–179.
for alcohol-induced aggressive behaviour and depression. Phar- Garlow, S. J. (2002) Age, gender, and ethnicity differences in patterns
macopsychiatry 28 (Suppl.), 93–97. of cocaine and ethanol use preceding suicide. American Journal
Bertolote, J. M., Fleischmann, A., De Leo, D. et al. (2003) Suicide of Psychiatry 159, 615–619.
and mental disorders: do we know enough? British Journal of Gorwood, P., Batel, P., Ades, J. et al. (2000) Serotonin transporter
Psychiatry 183, 382–383. gene polymorphisms, alcoholism, and suicidal behaviour.
Birckmayer, J., Hemenway, D. (1999) Minimum-age drinking laws Biological Psychiatry 48, 259–264.
and youth suicide, 1970-1990. American Journal of Public Health Gorwood, P. (2001) Biological markers for suicidal behaviour in
89, 1365–1368. alcohol dependence. European Psychiatry, 16, 410–417.
Borges, G. and Rosovsky, H. (1996) Suicide attempts and alcohol Greenwald, D. J., Reznikoff, M. and Plutchik, R. (1994) Suicide risk
consumption in an emergency room sample. Journal of Studies and violence risk in alcoholics: predictors of aggressive risk.
on Alcohol 57, 543–548. Journal of Nervous and Mental Disease 182, 3–8.
Borges, G., Walters, E. E. and Kessler, R. C. (2000) Associations of Hallman, J., von Knorring, L. and Oreland, L. (1996) Personality
substance use, abuse, and dependence with subsequent suicidal disorders according to DSM-III-R and thrombocyte monoamine
behaviour. American Journal of Epidemiology 151, 781–789. oxidase activity in type 1 and type 2 alcoholics. Journal of Studies
Brown, G. L., Ebert, M. H., Goyer, P. F. et al. (1982) Aggression, on Alcohol 57, 155–161.
suicide, and serotonin: relationships to CSF amine metabolites. Hansen, A. C., Kristensen, I. B., Dragsholt, C. et al. (1995) Alcohol,
American Journal of Psychiatry 139, 741–746. drugs and narcotics in suicides in the Aarhus police district.
Bushman, B. J. and Cooper, H. M. (1990) Effects of alcohol on Ugeskrift For Laeger 157, 1524–1527.
human aggression: an integrative research review. Psychological Harro, J., Wahlstrom, G. and Oreland, L. (1994) Cholecystokinin
Bulletin 107, 341–354. receptor binding after long-term ethanol treatment in rats. Alcohol
Cheng, A. T. A., Mann, A. H. and Chan, K. A. (1997) Personality and Alcoholism 29, 575–581.
disorder and suicide: a case-control study. British Journal of Hawton, K. (1998) Why has suicide increased in young males? Crisis
Psychiatry 170, 441–446. 19, 119–124.
478 J. BRADY

Hawton, K. (1994) Adolescent suicide and attempted suicide: the alcohol-dependent inpatient sample. Biological Psychiatry 50,
importance of substance abuse. Crisis 15, 13–14. 636–639.
Heikkinen, M. E., Aro, H. M., Henriksson, M. M. et al. (1994) Differ- Preuss, U. W., Schuckit, M. A., Smith, T. L. et al. (2002) Comparison
ences in recent life events between alcoholic and depressive of 3190 alcohol-dependent individuals with and without suicide
non-alcoholic suicides. Alcoholism, Clinical and Experimental attempts. Alcoholism, Clinical and Experimental Research 26,
Research 18, 1143–1149. 471–477.
Henriksson, M. M., Aro, H. M., Marttunen, M. J. et al. (1993) Mental Preuss, U. W., Schuckit, M. A., Smith, T. L. et al. (2003) Predictors
disorders and comorbidity in suicide. American Journal of and correlates of suicide attempts over 5 years in 1,237 alcohol-
Psychiatry 150, 935–940. dependent men and women. American Journal of Psychiatry
Horesh, N., Gothelf, D., Ofek, H. et al. (1999) Impulsivity as a correl- 160, 56–63.
ate of suicidal behaviour in adolescent psychiatric inpatients. Ramstedt, M. (2001) Alcohol and suicide in 14 European countries.
Crisis 20,8–14. Addiction 96 (Suppl. 1), S59–S75.
Hufford, M. R. (2001) Alcohol and suicidal behaviour. Clinical Regier, D. A., Farmer, M. E., Rao, D. S. et al. (1990) Comorbidity of
Psychology Review 21, 797–811. mental disorders with alcohol and other drug use. Journal of the
Inskip, H. M., Harris, E. C. and Barraclough, B. (1998) Lifetime risk American Medical Association 264, 2511–2518.
of suicide for affective disorder, alcoholism and schizophrenia. Rossow, I. and Amundsen, A. (1995) Alcohol abuse and suicide: a
British Journal of Psychiatry 172, 35–37. 40-year prospective study of Norwegian conscripts. Addiction
Jernigan, D. H., Monteiro, M., Room, R. et al. (2000) Towards a 90, 685–691.
global alcohol policy: alcohol, public health and the role of Rotherham-Borus, M. J., Trautman, P. D., Dopkins, S. C. et al. (1990)

Downloaded from https://academic.oup.com/alcalc/article/41/5/473/109923 by guest on 05 May 2023

WHO. Bulletin of the World Health Organization 78, 491–499. Cognitive style and pleasant activities among female adolescent
Kendall, R. (1983) Alcohol and suicide. Substance and Alcohol suicide attempters. Journal of Consulting and Clinical Psycho-
Actions/Misuse 4, 121–127. logy 58, 554–561.
Kolacinski, Z., Rosa, K., Wiese, M. et al. (1997) Alcohol and suicide Roy, A. (1996) Aetiology of secondary depression in male alcoholics.
attempts. Przeglad Lekarski 54, 438–440. British Journal of Psychiatry 169, 753–757.
Leenaars, A., Lester, D. and Wenckstern, S. (1999) Suicide notes in Samaritans (2005) Suicide statistics. http://www.samaritans.org/
alcoholism. Psychological Reports 85, 363–364. know/suicide_stats.shtm
Lesage, A. D., Boyer, R., Grunberg, F. et al. (1994) Suicide and Sander, T., Harms, H., Dufeu, P. et al. (1998) Serotonin transporter
mental disorders: a case-control study of young men. American gene variants in alcohol-dependent subjects with dissocial person-
Journal of Psychiatry 151, 1063–1068. ality disorder. Biological Psychiatry 43, 908–912.
Lester, D. (1992) Why people kill themselves. Spingfield IL: Charles Schuckit, M. A., Tipp, J. E., Bergman, M. et al. (1997) Comparison
Thomas. of induced and independent major depressive disorders
Lipsey, M. W., Wilson, D. B., Cohen, M. A. et al. (1997) Is there a in 2,945 alcoholics. American Journal of Psychiatry 154,
causal relationship between alcohol use and violence? A synthesis 948–957.
of evidence. Recent Developments in Alcoholism 13, 245–282. Smart, R. G. and Mann, R. E. (1990) Changes in suicide rates after
Makela, P. (1996) Alcohol consumption and suicide mortality by age reductions in alcohol consumption and problems in Ontario,
among Finnish men, 1950-1991. Addiction 91, 101–112. 1975-1983. British Journal of Addiction 85, 463–468.
Mann, J. J., Oquendo, M., Underwood, M. D. et al. (1999) The Stack, S. (2000) Suicide: a 15-year review of the sociological literat-
neurobiology of suicide risk: a review for the clinician. Journal ure. Part II: modernization and social integration perspectives.
of Clinical Psychiatry 60 (Suppl. 2), 7–11. Suicide and Life-Threatening Behaviour 30, 163–176.
Mendelson, W. B. and Rich, C. L. (1993) Sedatives and suicide: the Suokas, J. and Lonnqvist, J. (1995) Suicide attempts in which alcohol
San Diego study. Acta Psychiatrica Scandinavica 88, 337–341. is involved: a special group in general hospital emergency rooms.
Merrill, J., Milner, G., Owens, J. et al. (1992) Alcohol and attempted Acta Psychiatrica Scandinavica 91, 36–40.
suicide. British Journal of Addiction 87, 83–89. Suominen, K., Isometsa, E., Henriksson, M. et al. (1997) Hopeless-
McMahon, G. T. and McGarry, K. (2001) Deliberate self-poisoning ness, impulsiveness and intent among suicide attempters with
in an Irish county hospital. Irish Journal of Medical Science major depression, alcohol dependence, or both. Acta Psychiatrica
170, 94–97. Scandinavica 96, 142–149.
Nielsen, D. A., Virkkunen, M., Lappaleinen, J. et al. (1998) A trypto- The Guardian. (2005) November 23rd ‘Government admits new
phan hydroxylase gene marker for suicidality and alcoholism. drinking hours could lead to increase in offences’ http://www.
Archives of General Psychiatry 55, 593–602. guardian.co.uk/crime/article/0,,1648634,00.html
OECD (2005) OECD Health Data 2005: Statistics and Indicators for Traskman-Bendz, M., Alling, C., Oreland, L., et al. (1992) Prediction
30 Countries. http://www.oecd.org/dataoecd/7/39/35530139.xls of suicidal behaviour from biologic tests. Journal of Clinical
Office for National Statistics (2005) Suicides: UK numbers reach Psychopharmacology 12, 21S–26S.
30 year low in 2003. http://www.statistics.gov.uk/CCI/nugget. U.S. Public Health Service (1999) The Surgeon General’s Call To
asp?ID=1092&Pos=3&ColRank=2&Rank=1000 Action To Prevent Suicide. Washington, DC.
Ohberg, A., Vuori, E., Ojanpera, I. et al. (1996) Alcohol and drugs in Virkunnen, M., Rawlings, R., Tokola, R. et al. (1994) CSF bio-
suicides. British Journal of Psychiatry 169, 75–80. chemistries, glucose metabolism and diurnal activity rhythms in
Pihl, R. and Smith, S. (1983) Of affect and alcohol. In Stress and alcoholic, violent attenders, fire setters and healthy volunteers.
alcohol use, Pohorecky, L. and Brick, J., eds, pp. 249–257. Archives of General Psychiatry 51, 20–27.
Elsevier, New York. Wassermann, D. and Varnik, A. (1998) Suicide-preventive effects of
Pihl, R. O., Young, S. N., Harden, P. et al. (1995) Acute effect of perestroika in the former USSR: the role of alcohol restriction.
altered tryptophan levels and alcohol on aggression in normal Acta Psychiatrica Scandinavica 98 (Suppl. 394), 1–4.
human males. Psychopharmacology 119, 353–360. Watt, G. C. and Naidu, M. (2002) Noble experiment II: selective pro-
Pirkola, S. P., Isometsa, E. T., Heikkinen, M. E. et al. (2000) Suicides hibition. British Journal of Psychiatry 181, 3–5.
of alcohol misusers and non-misusers in a nationwide population. World Health Organization (2004) http://www.who.int/mental_
Alcohol and Alcoholism 35, 70–75. health/media/en/374.pdf
Pirkola, S. P., Marttunen, M. J., Henriksson, M. M. et al. (1999) World Health Organization (2005a) Background of SUPRE. Preven-
Alcohol-related problems among adolescent suicides in Finland. tion of Suicidal Behaviours: A Task For All. Geneva, World
Alcohol and Alcoholism 34, 320–329. Health Organization.
Plutchik, R. and Van Praag, H. (1989) The measurement of suicidal- World Health Organization (2005b) Public Health Problems Caused
ity, aggressivity and impulsivity. Progress in Neuropsychophar- By Harmful Use Of Alcohol: Report by the Secretariat. Geneva,
macology and Biological Psychiatry 13 (Suppl.), 23–34. World Health Organization.
Preuss, U. W., Koller, G., Soyka, M. et al. (2001) Association Young, S. N., Pihl R. O. and Ervin F. R. (1988) The effect of altered
between suicide attempts and 5-HTTLPR-S-allele in alcohol- tryptophan levels on mood and behaviour in normal human males.
dependent and control subjects: further evidence from a German Clinical Neuropharmacology 11 (Suppl. 1), 207–215.