Research report
Impulsive and non-impulsive suicide attempts in patients treated for alcohol dependence

https://doi.org/10.1016/j.jad.2008.09.001Get rights and content

Abstract

Background

Suicidal behavior has been recognized as an increasing problem among alcohol-dependent subjects. The aim of the study was to identify correlates of impulsive and non-impulsive suicide attempts among a treated population of alcohol-dependent patients.

Methods

A total of 154 patients with alcohol dependence consecutively admitted for addiction treatment participated in the study. Suicidal behavior was assessed together with severity of alcohol dependence, childhood abuse, impulsivity, and family history. A stop-signal procedure was used as a behavioral measure of impulsivity.

Results and conclusions

Lifetime suicide attempts were reported by 43% of patients in alcohol treatment; of which 62% were impulsive. Compared to patients without a suicide attempt, those with a non-impulsive attempt were more likely to have a history of sexual abuse (OR = 7.17), a family history of suicide (OR = 4.09), and higher scores on a personality measure of impulsiveness (OR = 2.27). The only significant factor that distinguished patients with impulsive suicide attempts from patients without a suicide attempt and from patients with a non-impulsive suicide attempt was a higher level of behavioral impulsivity (OR = 1.84–2.42).

Limitations

Retrospective self-report of suicide attempts and family history. Lack of diagnostic measure.

Introduction

Suicide is a major, potentially preventable, public health problem (Institute of Medicine, 2002, Office of the Surgeon General, 1999). The rate of suicide varies significantly from one country to another with some of the highest rates in Eastern Europe, the Baltic Nations and Russia (World Health Organization, 2003). In Poland, suicide is the seventh leading cause of death, accounting for approximately 4000–5000 deaths each year (Komenda Główna Policji, 2008). These rates of suicide in the Polish population have remained relatively stable over the past two decades; however, others have noted the rates of suicide in some former Eastern European countries decreased during the period of time known as Perestroika, particularly in men (Varnik et al., 1998). At the present time, Poland has an annual rate of suicide comparable to that of the United States—12.1 per 100,000 in 2005 (Centers for Disease Control and Prevention, 2007).

Alcohol use and misuse are strongly linked to suicide risk. The estimated lifetime risk for completed suicide among individuals with alcohol dependence is 7% (Inskip et al., 1998), and those with alcohol dependence are at a 6.5 times greater risk for attempted suicide compared with those without alcohol dependence (Kessler et al., 1999). Consequently, many patients seeking alcohol dependence treatment have a prior history of suicide attempts (Hesselbrock et al., 1988, Roy, 2003, Whitters et al., 1985). Research on patients treated for drug and or alcohol problems indicates that these patients remain at a high risk for suicidal behaviors following treatment (Ilgen et al., 2007a, Ilgen et al., 2007b). Therefore, more work is needed to better understand suicidal behaviors in treatment-seeking alcohol-dependent individuals (Cornelius et al., 2004).

In alcohol-dependent patients, those with prior suicidal behavior are more likely to be female, younger, unemployed, and divorced or separated compared to those without a lifetime suicide attempt (Hesselbrock et al., 1988, Preuss et al., 2002, Roy, 2001, Roy, 2003, Roy et al., 1990). Those with a prior attempt also report more depression and anxiety, higher rates of other drug use and dependence, more alcohol-related problems, and more alcohol consumed per day than other alcohol-dependent individuals without prior suicide attempts (Hesselbrock et al., 1988, Koller et al., 2002, Preuss et al., 2002, Roy, 2001, Roy et al., 1990, Whitters et al., 1985). Additionally, individuals with alcohol dependence and suicide attempts report higher rates of childhood physical and/or sexual abuse and more family members with a history of suicidal behaviors than those without an attempt (Kingree et al., 1999, Preuss et al., 2002, Roy, 2000, Roy, 2001, Roy, 2003).

Impulsivity is hypothesized to be a predisposing factor that places individuals with alcohol use disorders at increased risk for suicidal behaviors (Conner and Duberstein, 2004). Consistent with this theory, alcohol-dependent individuals with a history of suicidal behavior score higher on measures of impulsive traits than those without prior suicidal behavior (Koller et al., 2002). Similarly, many suicide attempts are impulsive, as defined by a limited amount of planning prior to the attempt, and these impulsive attempts may be particularly common in those with alcohol use disorders (Suominen et al., 1997). For example, Conner et al. (2006) found that over 50% of individuals with alcohol dependence and a suicide attempt reported that they had spent less than 1 week thinking about the attempt. Others have found that anywhere from 24% to 40% of individuals with a suicide attempt spent less than 5 min planning the attempt (Simon et al., 2001, Williams et al., 1980). In general, individuals with an impulsive suicide attempt tend to report lower levels of depression, hopelessness, and less expectation of lethality than those who make more planned attempts (Baca-García et al., 2001, Baca-Garcia et al., 2005, Conner et al., 2006, Simon et al., 2001, Williams et al., 1980, Wyder and De Leo, 2007). Despite the lack of expectation of lethality, many impulsive attempts are still potentially life-threatening (e.g., Simon et al., 2001).

Somewhat surprisingly, self-report measures of impulsive traits do not readily distinguish those with an impulsive suicide attempt from those with a non-impulsive attempt (Wyder and De Leo, 2007). In a recent study of adolescents, Witte et al. (2008) found that those with an impulsive attempt reported lower levels of impulsivity than those with a planned attempt. However, other evidence indicates that those with impulsive attempts report a history of more impulsive aggressive behaviors than those who make a non-impulsive suicide attempt, suggesting that behavioral measures of impulsivity may be able to distinguish between those with impulsive and non-impulsive attempts (Simon et al., 2001). The stop-signal task is a measure of behavioral impulsivity that is associated with risk for developing alcohol and drug use (Nigg et al., 2004, Nigg et al., 2006, Stoltenberg et al., 2008, Wong et al., 2006). To the best of our knowledge, no prior research has examined how stop-signal performance relates to suicidal behaviors.

Partially by definition, identifying individuals at risk for an impulsive suicide attempt is difficult because of the lack of warning given prior to an attempt. Additionally, these individuals may be missed by other efforts to reduce suicide risk that target more longstanding symptoms, such as depression (e.g., Szanto et al., 2007). The present study was undertaken to examine differences between alcohol-dependent patients in Poland who reported no prior suicide attempt, a prior non-impulsive attempt, and a prior impulsive attempt. Patients were compared on demographic features, alcohol use severity, family history, prior childhood abuse, as well as self-report and behavioral measures of impulsivity.

Section snippets

Participants

A total of 154 patients [117 (76%) men and 37 women (24%)] were recruited from four addiction treatment centers (2 outpatient and 2 residential) in Warsaw, Poland. Participants ranged in age from 20 to 73 years (mean = 43.7, SD = 9.6) and all were Caucasian. In terms of educational status, approximately 12% of participants had completed elementary school, 57% graduated from high school, 17% attended some college, and 14% earned a university degree. With regard to marital status, 18% of study

Suicide attempts in the study sample

Approximately 43% of the sample (n = 66) reported making a suicide attempt in their lifetime as previously reported by our research group (Wojnar et al., 2008). Of those who made an attempt, 45 patients (68%) reported making an attempt during a heavy drinking period, and 41 (62%) reported that they spent less than 30 min planning the attempt; these were classified as impulsive attempts. Among all suicide attempters, 55% (n = 36/66) reported a violent suicide attempt. The most common method of

Discussion

Prior suicide attempts were common in patients seeking treatment for alcohol use disorders in Poland, and the majority of these attempts were impulsive. Individuals with higher severity of alcohol use, prior sexual or physical abuse, a family history of suicidal behaviors, and self-reported impulsivity were more likely to make a suicide attempt. Those individuals with non-impulsive suicide attempts had a similar set of correlates. Of the features examined, only the behavioral measure of

Conflict of interest

All authors declare that they have no conflicts of interests.

Role of funding source

This work was supported by the Fogarty International Center/NIDA International Substance Abuse Research Program grant D43 TW05818, the Fogarty International Center/NIAAA International Collaborative Alcohol & Injury Research Training Program grant D43 TW007569, NIAAA grant R21 AA016104, and the Polish Ministry of Science and Higher Education grant 2P05D 004 29.

Authors have not signed an agreement with any sponsor of the study reported in this paper that has a clause which prevents them from

Acknowledgments

We would like to thank all members of the research team (especially, Izabela Nowosad, MD, Anna Wnorowska, MD; Malgorzata Marusa, MS; Aleksandra Konopa, MD) as well as the medical staff and patients at “Kolska”, “Pruszkow”, “Petra” and “Solec” Addiction Treatment Centers in Warsaw, Poland for their support of this research.

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