New research on hundreds of emergency department patients shows a complex relationship between substance misuse and suicide risk, with combined alcohol and cocaine use standing out as a major warning sign.
Clinical observations and popular culture alike long have suggested a link between substance misuse and suicidal behavior. A detailed new analysis of 874 patients who presented to emergency departments (EDs) across the United States confirms that connection but shows it is not uniform: the association varies by substance type, age, sex and race. Most notably, patients who reported using both alcohol and cocaine faced substantially higher odds of attempting suicide within a year.
“When examined alone, alcohol misuse showed no significant association with later attempts and cocaine use was only marginally associated,” the authors report in the journal Crisis. “Yet reporting both alcohol misuse and cocaine use together was significantly associated with a future suicide attempt.”
Led by Sarah Arias, assistant professor (research) of psychiatry and human behavior at the Alpert Medical School of Brown University, the research team analyzed participants enrolled in the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study. Between 2010 and 2012, 874 men and women who either had recently attempted suicide or were actively experiencing suicidal thoughts were identified at eight emergency departments nationwide. These participants received standard clinical care and provided demographic and substance use information, then were followed for 12 months to track outcomes.
The primary outcome measured was any suicide attempt during the year following the initial ED visit. Overall, 195 of the 874 participants (about 22%) made at least one suicide attempt in that 12-month period.
Although the patients reported misuse of many substances — including marijuana, prescription opioids, tranquilizers and stimulants — the analyses found a clear signal only for the combination of alcohol and cocaine. Within the study population, 298 participants reported alcohol misuse, 72 reported cocaine use, and 41 reported using both substances. Those who reported both alcohol and cocaine use had a 2.4-fold greater likelihood of attempting suicide within the subsequent year compared with participants who did not report both substances.
The study also identified demographic patterns in the relationship between substance misuse and suicidal behavior. Substance misuse was a less consistent indicator of future suicide attempts for white patients and for women. By contrast, older participants were more likely to show an association between substance misuse and later suicide attempts.
The researchers emphasize that these differences do not mean women are less suicidal overall. In fact, women in the sample were more likely than men to report prior suicide attempts. What the data suggest is that substance misuse may play a different role in the pathway to suicidal behavior for women than for men.
“These disparate findings emphasize the complex interaction of sex, substance use, and suicide attempts,” the authors note. “They also suggest that women may have different risk profiles depending on whether they report substance use or past suicide attempts.”
The study reports associations and cannot establish causal relationships between substance misuse and suicidal behavior. Nonetheless, the results point to specific substance combinations and demographic subgroups where suicide risk appears elevated. Arias and her colleagues hope the findings will improve clinical suicide risk assessment by highlighting when substance use information is most predictive.
“Substance use is often cited as a strong predictor of suicidal intentions and behaviors, but when we examine individual substances the picture is not straightforward,” Arias said. “Identifying the particular cases in which substance misuse signals higher risk — for example, comorbid alcohol and cocaine use — can help clinicians better assess and intervene.”
Improved understanding of how specific substances interact with demographic factors to influence suicide risk could guide targeted screening and prevention strategies in emergency departments and other clinical settings.
In addition to Sarah Arias, the study’s authors are Orianne Dumas, Ashley Sullivan, Edwin Boudreaux, Ivan Miller and Carlos Camargo Jr.
Funding: The research was supported by the National Institute of Mental Health (grant U01MH088278).
Source: David Orenstein – Brown University
Image Source: The image is in the public domain.
Original Research: Abstract for “Substance Use as a Mediator of the Association Between Demographics, Suicide Attempt History, and Future Suicide Attempts in Emergency Department Patients” by Sarah A. Arias et al., published in Crisis. Published online April 4, 2016; doi:10.1027/0227-5910/a00038
Abstract
Substance Use as a Mediator of the Association Between Demographics, Suicide Attempt History, and Future Suicide Attempts in Emergency Department Patients
Background: Identifying factors that predict and protect against suicide attempts is essential for effective prevention and intervention. This study investigates whether substance use mediates the relationship between demographic characteristics, prior suicide attempts, and subsequent suicide attempts within 12 months after an ED visit for active suicidal ideation or behavior.
Method: Data came from the first two phases of the ED-SAFE study and included baseline interviews, chart reviews at 6 and 12 months, and telephone follow-ups at multiple time points up to 52 weeks. Structural equation modeling tested mediation hypotheses. All p values are two-tailed with p < .05 considered statistically significant.
Results: Of 874 subjects, 195 (22%) reported a suicide attempt within 12 months after the index ED visit. Among those who attempted suicide, 59% were under 40 years old, 59% were female, and 76% were non-Hispanic white. Mediation analyses indicate that combined alcohol misuse and cocaine use may help explain associations between race, sex, and suicide attempts during the 12 months after the index ED visit.
Conclusion: These mediation findings shed light on how substance use contributes to future suicide attempts in different sociodemographic groups and may inform more precise risk assessment in clinical practice.
“Substance Use as a Mediator of the Association Between Demographics, Suicide Attempt History, and Future Suicide Attempts in Emergency Department Patients” by Sarah A. Arias, Orianne Dumas, Ashley F. Sullivan, Edwin D. Boudreaux, Ivan Miller, and Carlos A. Camargo, Jr., Crisis, published online April 4, 2016; doi:10.1027/0227-5910/a00038