Clinical features of alcoholic suicide attempters / non-attempters

differences between those who had/had not attempted suicide, and investigates their relationships to current suicidal ideation. Thesuicide attempters were significantly younger, separated and unemployed. They began regular drinking earlier, were more severely dependent and had a higher proportion of major depression, antisocial personality disorder and another drug abuse. The results suggest a high incidence of suicidal behaviour in alcoholics and high psychiatric comorbidity in alcoholics who attempt suicide.

Alcoholic patients who attempt suicide form an important clinical group because of their utilisa tion of emergency medical services and subse quent risk of completed suicide (Roy & Linnoila, 1986: Roy et al 1990), but the nature of association between alcoholism and attempted suicide has been less researched (Black et al, 1986;Hawton et al 1989;Roy et al 1990;Platt & Robinson, 1991).Clinical utility of a study of alcoholics who attempt suicide lies in identifica tion and treatment of high risk groups.
Previous research suggested that, compared with non-attempters, the alcoholic suicide at tempters were younger, began to drink earlier, were excessive, problem and more severely dependent drinkers, reported increased family histories of alcoholism and affective disorder and more often had additional lifetime psychiatric diagnoses (Black et al 1986;Hesselbrock et al 1988: Roy et al 1990).
While most American researchers have studied the connection between suicidal behaviour and alcoholism in populations of alcoholics, British researchers have studied this association in populations of suicide attempters.We conducted a study of alcoholics admitted to a subregional alcohol treatment unit, with and without previous suicide attempt(s).We believe that our study is the first report from a British alcohol treatment unit describing clinical features of alcoholics who had/had not attempted suicide.We designed a cross-sectional study measuring these patients' severity of alcohol dependence, depression and current suicidal ideation.We also measured the intercorrelations among variables related to suicidal tendencies.
Our aim was to compare suicide attempters and non-attempters in order to gain a wider understanding of the differences in their sociodemographic variables, drinking history, psychia tric diagnoses and suicidal ideation.We also aimed to study the nature and patterns of reported suicide attempts.We hypothesised that alcoholic suicide attempters will have more profound psychopathology than non-attempters, and their severity of alcohol dependence, depres sion and number of previous suicide attempts will be correlated with suicidal ideation.

The study
The individuals in this study were referred to a subregional alcohol treatment unit in the north west of England.The accepted referrals were made by local general practitioners, consultant psychiatrists and physicians, and the community drug and alcohol teams.Tertiary referrals from other districts in the region, were also accepted as this unit is a subregional specialist service.
We included 74 consecutive patients admitted for in-patient treatment between 1 August 1993 and 31 January 1994.All patients met DSM-III-R (American Psychiatric Association, 1987) criteria for alcohol dependence and gave informed con sent for participation in the study.We divided them into two groups according to the presence or absence of history of previous suicide attempt(s).Suicide attempt was defined as an attempt at selfharm (Roy et al 1990) by an individual at some Urne in his/her life.This included deliberate selfpoisoning and injury, when an individual delib erately causes self-injury and/or takes a sub stance in excess of any prescribed or generally recognised dosage (Kreitman, 1977).
Careful psychiatric histories, including social and personal history, drug and alcohol history, history of psychiatric illness and nature and pattern of suicide attempts, were taken in a semistructured clinical interview.Questions based on DSM-III-R criteria were used for the assessment and diagnosis of antisocial person ality disorder and another drug abuse.History of drug abuse included past and current drug abuse as reported by the patients and their referrers.Current mental state and physical examinations were carried out on admission and blood samples were taken to check mean corpuscular volume (MCV) and gammaglutamyl transpeptldase (GGT).We also used the following measurement instruments: Short Alcohol Dependence Data (SADD) to measure the severity of alcohol dependence (Raistrick et al 1983;Davidson & Raistrick, 1986).It is a 15-item, forced choice, self-report scale designed to measure the range of present state alcohol dependence (total maximum score=45).
Beck's Depression Inventory (BDI; Beck et al. 1961) to measure the severity of depression.It is a 21-item self-report inventory covering a wide range of symptoms associated with depression (total maximum score=63).
Beck's Scale for Suicidal Ideation (SSI; Beck et al, 1979) to quantify the intensity of current suicidal thoughts of suicide attempters.This is a 19-item scale with each item worth 0-2 points generating a total score of 0-38.

Statistical analysis
We used x2 test for categorical variables and twotailed Student's 't'-test for the comparison of means of continuous variables.Pearson correlation coeffi cients (r)were calculated to investigate the relation ships of alcohol dependence, depression and previous suicide attempts to current suicidal ideation and their significance was tested using the two-tailed t'-test.
A higher proportion of attempters than nonattempters reported family histories of alcoholism and depression fTable 1).They began regular drinking at an earlier age, had longer duration of problematic drinking, had been drinking exces sively and had higher SADD scores, MCVs and GGT (Table 2).A significantly higher proportion of attempters than non-attempters had alcohol related problems, including drink related offences such as drink-driving convictions, and physical problems (Table 1).The significant physical problems included history of treatment for peptic ulcer (P< 0.025).
Significantly more attempters than non-at tempters met DSM-III-R criteria for lifetime psychiatric diagnoses of major depression, anti social personality disorder and drug abuse (Table 1).The most frequently used drugs were canna bis, stimulants, hallucinogens and benzodiazepines.Significantly more attempters than nonattempters gave a history of previous in-patient alcohol treatment and past treatment with antidepressants (Table 1).
On index admission, the attempters had sig nificantly higher BDI scores than non-attempters   (P< 0.002) and a higher proportion reported feeling hopeless (Table 1).Thirty per cent of the attempters, as compared to none of the nonattempters, reported suicidal ideation on BDI.

Clinicalfeatures of alcoholic suicide attempters/non-attempters
The mean SSI score of the attempters was 10.93 (s.d.=4.82).Twelve of the 44 (27%) attempters had made single attempts and 32 (73%) were repeated attempters.The mean number of their previous attempts was 3.43 (s.d.=2.49).The significant positive correlates of SSI were the number of past attempts, SADD scores and BDI scores (Table 3).The most frequently used method of suicide attempt was self-poisoning (90%); 45% used self-cutting of which 7% used self-cutting alone and the remainder (38%) used it in combination with other methods, most frequently overdose.Other methods involved self-stabbing by one patient, self-shooting by one and attempted drowning by another.The most frequently used drug for overdose was paracetamol.Seventythree per cent of the attempters reported hospitalisation following suicide attempts.How ever, only two of the 44 attempters reported treatment in intensive care following an over dose.Ninety-seven per cent of the attempters reported alcohol consumption just before or at the time of attempting suicide.The most frequently reported precipitant was arguing with spouse/partners.
Seventy-two per cent of the attempters reported making impulsive attempts.

Comments
The present study replicates the findings of previous studies of alcoholics entering treatment (Hesselbrock et al 1988;Roy et al 1990).Similar to Berglund's study (1984) of suicidal alcoholics, we also found that a higher proportion of attempters than non-attempters had a history of peptic ulcer.Our results were similar to Beck et at s (1982) findings of strong correlations between depression, past suicide attempts and current suicidal ideation.However, we found that scores for alcohol dependence were also significantly correlated to current suicidal ideation, and there was a significant correlation between BDI and SADD scores.This may suggest that severely dependent alcoholics may also have had second ary/coexistent depression.The presence of cur rent suicidal ideation reemphasises Beck's (1982) comment: "the finding that alcoholic suicide attempters were also currently thinking about suicide, cautions that the alcoholics entering treatment should be closely observed for suicide risk."However, the most striking finding was a much higher rate of attempted suicide among alcoholics than reported in previous studies (17% to 29.2%, Hesselbrock et al 1988;Roy et al 1990).A number of factors may have operated to account for this.The unit's admission policies and the referral patterns may have an influence on characteristics of the sample population.Our subjects were the most severely dependent and problem drinkers, referred to a specialist treat ment facility.It is also recognised that the people in the northwest are amongst the heaviest drinkers in England with higher than national average rates for psychiatric admissions and have increased morbidity (North Western Regional Health Authority, 1990).Our definition of at tempted suicide led us to include patients with varying degrees of suicidal intent.However, the majority of the attempters (36 of the 44) reported a moderately high suicidal intent while making previous attempts and only eight patients denied any serious intent.
The reported patterns of suicide attempts were similar to previous studies, in terms of selfpoisoning being the most frequent method {Hawton et al 1989), increased utilisation of medical services (Roy et al 1990) and the attempts generally being not too serious (Black et al 1986).However, we found that the most frequently used drug for overdose was paraceta mol, whereas in his study of suicide attempters with a history of alcoholism Hawton et al (1989) reported most frequent use of tranquillisers and sedatives.An explanation for our finding of most frequent use of paracetamol for overdose could be its easy availability, without the need for a prescription.Our attempters also used sedatives and hypnotics but less frequently than paraceta mol.This could also be explained in terms of a ready availability, as a high proportion of our attempters were misusing benzodiazepines.Although a high proportion of attempters were treated with antidepressants in the past, the use of antidepressants for overdose was less fre quently reported.This could result from a policy of prescribing short supplies at any one time to prevent suicide, and the problem of availability of antidepressants due to the need for a prescrip tion.Similar to Hawton et als report (1989) a very high proportion of our attempters reported drinking alcohol just prior to or at the time of making attempts, possibly to enhance courage and reduce pain.Black et al (1986) suggested that alcoholism, depression and antisocial personality disorder may predispose to suicide attempts and the interaction of the three is particularly dangerous.This model could be applied to our patients as we also found that a high proportion of our attempters were severely dependent and chronic drinkers, had major depression and antisocial personality disorder and a high incidence of suicidal behaviour.We also found that a high proportion were misusing another drug, which may be an additional risk factor for suicide attempts.
Despite methodological limitations, for example a small size and selective nature of the study sample, our results confirm the findings of previous investigators including a high incidence of suicidal behaviour among alcoholics entering treatment, and the high psychiatric comorbidity and current suicidal ideation in alcoholic suicide attempters.Clinicians should be aware of high risk factors for suicide attempts in alcoholics admitted for in-patient treatment.Treatment and prevention programmes should include early interventions and treatment of alcohol problems, post treatment relapse prevention strategies and maintenance of abstinence, vigorous treatment of depression and treatment and rehabilitation of drug misusers.

Table 1 .
Significant differences between attempters and non-attempters

Table 2 .
Alcohol history: continuous variables