In the National Suicide Prevention Project in Finland a total nationwide population of completed suicides during one year was investigated by the psychological autopsy method. The thorough data collection included police and medicolegal examinations, interviews of the relatives and attending health and other care professionals, and the gathering of police, social agency and medical records. In the present study the role of alcohol and other substance misuse in suicide was investigated. Subjects with a DSM-III-R psychoactive substance dependence were male (N=68) victims from a diagnostic random sample (N=229) of the total suicide population and female (N=49) victims from the total female suicide population (N=320), and they were compared in the search for previously unknown sex-differences in their characteristics (study I). In addition, their treatment careers were thoroughly evaluated by sex (study II). Adolescent suicide victims with subthreshold or DSM-III-R diagnosed alcohol misuse (N=44) were characterised by comparison with adolescent victims with no apparent alcohol misuse (N=62) (study III). From the total population of 1397 suicides, a separate informant-based estimate of the victim's misuse of alcohol was made in cases of sufficient and reliable information (N=997), and the characteristics of the misusers (N=349) and nonmisusers (N=648) were compared (studies IV-V).

Male and female suicide victims with a DSM-III-R psychoactive substance dependence (PSD) had comorbid axis I-III disorders in most cases (91% and 96%, respectively). Among females the age of onset of a comorbid axis I disorder preceded the substance dependence more often than among males (45% vs 18%). Females were more likely to have prescribed drug use disorders (37% vs 10%), which associated with anxiety and depressive disorders. The sexes also differed in the age distribution of personality disorders, which were relatively common among younger females and usually constituted borderline personality disorders among them. Generally, female victims with PSD seemed to represent a more heterogeneous group than males in terms of age, psychiatric morbidity, and socioeconomic features. Within the year before suicide up to two thirds of PSD victims had contacted primary health care or general medical services, and approximately one third of males and two thirds of females had received psychiatric care. However, in only one sixth of the males and one third of the females were substance use problems currently recognised, although the suicide victims, particularly females, had had contacts with several organisations during the last year. In their lifetime, PSD suicide victims utilised specific substance use services less often than other services.

Among adolescents, 42% were estimated to have suffered from subdiagnostic or diagnosed alcohol misuse (SDAM), and this associated with more severe psychopathology in terms of comorbid categorical DSM-III-R diagnoses, disturbed family backgrounds, precipitating life-events as stressors and more severe psychosocial impairment. Furthermore, victims with SDAM were more often alcohol intoxicated at the time of suicide, which appeared to be a weekend more often among them than others, indicating a contribution of a weekend oriented drinking pattern to their final act of suicide.

Alcohol misusing victims in the total suicide population differed from the nonmisusing victims by being younger, more often male (91% vs 70%), having more often had an active working career, but being more often (25% vs 8%) recently unemployed. Overall, they seemed to have more recent adverse life events before suicide that were possibly consequent on their own behaviour. They had also more often been separated or divorced from a marriage, and were more likely to have children, which together with fewer psychiatric contacts indicates a better long term psychosocial coping that had recently been disrupted, possibly due to problems with alcohol use. Compared to the nonemployed, employed misusers committed suicide more often during weekends (52% vs 34%) probably because of a weekly drinking pattern based on regular work during weekdays and a risk time for drinking during weekends.

In conclusion, alcohol and other substance misuse, in terms of either categorical DSM-III-R psychoactive substance dependence or habitual and frequent alcohol inebriation contribute to the suicide process in various ways. The role of alcohol and other substance misuse varies by age and gender, ranging from an indicator or source of short and long term psychosocial problems during the life course to a severe dependence syndrome with comorbid other psychiatric disorders. The treatment contacts of suicide completers with alcohol and other substance misuse tend to be irregular before suicide and problems with substance use are often not recognised. In addition, alcohol intoxication per se may act as a catalyst in the final suicidal act of the misusers in the form of inebriation, and possibly also by strengthening the lethality of another intoxicating substance. These contributions, in addition to the morbidity of substance use disorders as psychiatric illnesses, should be clearly recognised, and appropriate treatment with proper follow-up should be assessed and managed in health and other care contacts among subjects with alcohol or other substance misuse.

http://ethesis.helsinki.fi/julkaisut/laa/kliin/vk/pirkola/alcohola.html

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