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Relationship between prescribed psychotropic medications and co-ingested alcohol in intentional self-poisonings

  • Kate M. Chitty (a1), Timothy Dobbins (a2), Andrew H. Dawson (a1), Geoffrey K. Isbister (a3) and Nicholas A. Buckley (a4)...
Abstract
Background

Acute alcohol consumption is a major risk factor for suicide, therefore investigating factors associated with alcohol-related self-harm warrant attention.

Aims

To investigate the influence of prescribed psychotropic medications on the odds of co-ingesting alcohol preceding or during intentional efforts to self-poison.

Method

A cross-sectional analysis of consecutive hospital presentations following intentional self-poisoning was conducted. A total of 7270 patients (4363 women) aged 18–96 were included.

Results

The odds of alcohol co-ingestion were increased in those not prescribed any medication (odds ratio (OR) = 1.27, 99% CI 1.10–1.46, P50.001) and in impulsive self-poisonings (OR= 1.39, 99% CI 1.11–1.74, P50.001). Odds were decreased in those prescribed anticonvulsants (OR = 0.69, 99% CI 0.51–0.93), antipsychotics (OR = 0.55, 99% CI 0.45–0.66) and antidepressants (OR = 0.87, 99% CI 0.77–0.99).

Conclusions

Findings indicate that being medicated for a psychiatric illness may reduce the likelihood of alcohol consumption during times of acute distress, hence perhaps may reduce the risk of intentional self-poisoning.

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Copyright
Corresponding author
Kate M. Chitty, Room 301, Blackburn Building, University of Sydney, Sydney, New South Wales, Australia. Email: kate.chitty@sydney.edu.au
Footnotes
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Declaration in interest

None.

Footnotes
References
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Relationship between prescribed psychotropic medications and co-ingested alcohol in intentional self-poisonings

  • Kate M. Chitty (a1), Timothy Dobbins (a2), Andrew H. Dawson (a1), Geoffrey K. Isbister (a3) and Nicholas A. Buckley (a4)...
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eLetters

Improving access to alcohol services remains essential to reduce alcohol related self-harm.

Kate M Chitty, Research Fellow, Translational Australian Clinical Toxicology Research Group, Discipline of Pharmacology, University of Sydney
Geoffrey K Isbister, Clinical Pharmacologist, Professor of Pharmacology, Translational Australian Clinical Toxicology Research Group, University of Newcastle, NSW
Andrew H Dawson, Clinical toxicologist, Clinical Professor, Clinical Toxicologist and Director National Poisons Register Royal Prince Alfred Hospital, Clinical Director, NSW Poisons Inform
Nicholas A Buckley, Professor of Clinical Pharmacology, Professor of Clinical Pharmacology, Sydney Medical School, University of Sydney Consultant in Clinical Pharmacology & Toxicology
13 April 2017

Thank you to Chick et al., and Witt et al., for their welcomed responses to our article1. We agree that both improving access and facilitating referral to alcohol services is an essential strategy with regards to reducing deliberate self-poisoning that may be a product of harmful use of alcohol.

We share the concerns of Chick and colleagues – it is dangerous to make causal assertions from cross-sectional data, especially if preliminary analyses and author interpretations are introduced into clinical practice from the abstract alone. We agree that people prescribed tricyclic antidepressants and typical antipsychotics are different from those on other drugs – that they are less likely to co-ingest alcohol during intentional self-poisoning is one such example. As highlighted by Chick et al., the underlying nature of this relationship (whether it be causal or correlated because of shared factors) has many possibilities for which we presented three interpretative and non-mutually exclusive speculations. As such, we agree with the further interpretation put forth in their letter – persons with increased access to higher toxicity medications may negate any perceived role of alcohol in the poisoning. Of course, this is only relevant in cases when alcohol is used as a tool to facilitate the self-harm (i.e. to “numb fears”) as opposed to being intoxicated before the desire to self-harm arises. It is noteworthy that a recent study found that over 70% of people interviewed after a suicide attempt that involved acute alcohol reported they did not use alcohol to facilitate the action2. However, we recognise that the method of suicide attempts in this aforementioned small sample size study were heterogeneous and that self-poisoning is more likely to involve alcohol as a substance perceived to increase the toxicity of the poison or mask the taste of the co-ingested substances. We are currently conducting a study to investigate patient self-reported reasons for use of alcohol before and during deliberate self-poisoning which will further shed light on this.

We are pleased that our analysis prompted Witt and colleagues to investigate a similar line of enquiry within their own cohort. The similarities between the data analysis conducted by Witt et al. with our findings are notable - those prescribed antipsychotics, anticonvulsants and stimulants were less likely to co-ingest alcohol during a non-fatal self-poisoning.

Compared to the Japanese study cited by Witt et al., in which nearly a half of suicide attempts or episodes of self-harm are not transported to hospital, our experience specific for deliberate self-poisoning (via toxicology services and Poison Information Centres), tells us this is not the case in Australia. Indeed the Australian study conducted by the authors themselves shows that over 90% of the time overdoses with unknown intent as attended by paramedics are transported to hospital3. Thus the rational for adjusting for medical severity is not clear to us in this context, however we do agree that engaging a breadth of services for a holistic response to self-harm is essential, especially drug and alcohol services when alcohol may be a driving factor.

1.Chitty KM, Dobbins T, Dawson AH, Isbister GK, Buckley NA. Relationship between prescribed psychotropic medications and co-ingested alcohol in intentional self-poisonings. The British journal of psychiatry : the journal of mental science 2017.

2.Bagge CL, Conner KR, Reed L, Dawkins M, Murray K. Alcohol use to facilitate a suicide attempt: an event-based examination. Journal of studies on alcohol and drugs 2015; 76(3): 474-81.

3.Lloyd B, Gao CX, Heilbronn C, DI L. Self Harm and Mental Health-Related Ambulance Attendances in Australia: 2013 Data. Fitzroy, VIC: Turning Point, 2015.
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Conflict of interest: None Declared

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Does prescribing psychiatric medication really make it less likely that alcohol is involved in a self-poisoning?

Jonathan Chick, Medical Director, Castle Craig Hospital; Visiting Professor, School of Health and Social Care, Napier University, Edinburgh
Colin Drummond, Professor of Addiction Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College, London
Julia Sinclair, Senior Lecturer, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton
13 March 2017

It is risky to make causal assertions from complex cross-sectional data. It may lead to erroneous clinical advice.

Although a negative association has been revealed between alcohol ingestion in self-poisoning and taking psychiatric medications (particularly a tricyclic or a typical antipsychotic)1, persons who are prescribed those medications may be different people than those who are not, even after adjusting in covariate analysis for a generic category ‘psychiatric diagnosis’. This association even led Chitty et al to speculate that D2 antagonists might reduce the use of alcohol. However, there is evidence to the contrary: flupenthixol led to more drinking when tested in randomised controlled trials (RCTS) 2, and olanzapine caused a similar trend3. In the remaining 10 of 13 RCTs found in a systematic review, antipsychotics did not reduce drinking4.

Clearly, there are various interpretations of the association they found. For example, perhaps people who have access to highly sedating and potentially lethal drugs such as tricyclics and antipsychotics can self-poison seriously without recourse to added alcohol.

While Chitty et al raise some interesting questions, we are concerned lest those reading the Abstract alone might misperceive a role for antipsychotics in drinkers. Suicide rates in people who drink heavily might be best prevented by improving treatment and access to treatment for alcohol use disorders.

1.Chitty KM, Dobbins T, Dawson AH, Isbister GK and Buckley NA. Relationship between prescribed psychotropic medications and co-ingested alcohol in intentional self-poisonings. B J Psychiat 2017; 210: 203-8

2.Wiesbeck GA, Weijers HG, Lesch OM, Glaser T, Toennes PJ, Boening J. Flupenthixol decanoate and relapse prevention in alcoholics: results from a placebo-controlled study. Alcohol Alcohol. 2001; 36:329-34.

3.Guardia J, Segura L, Gonzalvo B, Iglesias L, Roncero C, Cardús M, Casas M. A double-blind, placebo-controlled study of olanzapine in the treatment of alcohol-dependence disorder Alcohol Clin Exp Res 2004; 28:736-45

4.Kishi T, Sevy S, Chekuri R, Correll CU. Antipsychotics for primary alcohol dependence: a systematic review and meta-analysis of placebo-controlled trials J Clin Psychiat 2013;74:642-54

Jonathan Chick, Medical Director, Castle Craig Hospital; Visiting Professor, School of Health and Social Care, Napier University, Edinburgh

email @ prof.j.chick@castlecraig.co.uk

Colin Drummond, Professor of Addiction Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College, London

Julia Sinclair, Senior Lecturer, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK.

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Conflict of interest: None Declared

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Co-consumption of alcohol and psychotropic medications in episodes of non-fatal self-poisoning attended by ambulance services in Victoria, Australia: Evidence of potential modification by medical severity

Katrina Witt, Post-Doctoral Research Fellow, Turning Point, Eastern Health Clinical School, Monash University
Dan Lubman, Professor of Addiction Studies and Services, Turning Point, Eastern Health Clinical School, Monash University
Belinda Lloyd, Associate Professor of Addiction Studies and Services, Turning Point, Eastern Health Clinical School, Monash University
Karen Smith, Manager, Research and Evaluation and Adjunct Professor, Ambulance Victoria and the Department of Epidemiology and Preventive Medicine, Monash University
09 March 2017

To the editor,

Chitty and colleagues’ recent investigation into the association between psychotropic medication use and alcohol co-consumption during emergency department presentations for self-poisoning raises an interesting perspective on the putative role of psychopharmacology in reducing risky alcohol use among those at risk of self-harm and suicide [1].

Episodes of attempted suicide resulting in hospital presentation may underestimate the true extent of psychotropic medication and alcohol co-ingestion across the community, given recent findings suggesting just over one half of patients treated by ambulance paramedics following an episode of self-harm and/or attempted suicide are transported to hospital [2].

Using data from our ongoing study of mental health presentations to ambulance services [3], we extracted information on all episodes of non-fatal self-poisoning in the state of Victoria, Australia from January 2012 to December 2016 (N=24,726). In contrast to Chitty and colleagues, we found that, overall, use of psychotropic medications was associated with an increased, not decreased, risk of alcohol co-consumption at the self-poisoning episode (odds ratio [OR] 1.35; 95% confidence interval [CI] 1.28 to 1.42).

Whilst anticonvulsants (0.74; 0.65 to 0.84), antipsychotics (0.81; 0.75 to 0.86), and psychostimulants (0.52; 0.32 to 0.85) were associated with a decreased risk of alcohol co-consumption, in contrast to Chitty and colleagues, we found that benzodiazepines (1.60; 1.52 to 1.69) were associated with an increased risk of alcohol co-consumption. Additionally, we found no significant association between antidepressant use and risk of alcohol co-consumption for these presentations (1.04; 0.97 to 1.11).

Importantly, however, we found medical severity may modify these associations. Specifically, most associations were reduced to non-significance when considering those not requiring hospital treatment following the self-poisoning episode: all psychotropic medication classes (1.12; 0.76 to 1.65), anticonvulsants (0.39; 0.09 to 1.80), antidepressants (1.05; 0.63 to 1.77), antipsychotics (0.81; 0.48 to 1.36), benzodiazepines (1.40; 0.94 to 2.07), and psychostimulants (0.44; 0.02 to 9.21).

This highlights the importance of considering the breadth of services people who engage in self-harm come into contact with so as to provide a fuller picture of treatment needs for this population and how these may vary as a consequence of medical severity.

References:

[1] Chitty KM, Dobbins T, Dawson AH, Isbister GK, Buckley A. Relationship between prescribed psychotropic medications and co-ingested alcohol in intentional self-poisonings. Br J Psychiatry. 2017; 210: 203-8.

[2] Matsuyama T, Kitamura T, Kiyohara K, Hayashida S, Kawamura T, Iwami T, Ohta B. Characteristics and outcomes of emergency patients with self-inflicted injuries: A report from ambulance records in Osaka City, Japan. Scand J Trauma Resusc Emerg Med. 2016; 24: 68.

[3] Lloyd B, Gao CX, Heilbronn C, Lubman DI. Self Harm and Mental Health-Related Ambulance Attendances in Australia: 2013 Data. 2015. Fitzroy, VIC: Turning Point. ISBN: 978-1-74001-014-6.
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Conflict of interest: None Declared

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