Substance misuse in life and death in a 2-year cohort of suicides

Impulsivity, aggression, and suicidality relationship in adults: A systematic review and meta-analysis

BACKGROUND

The aim of the study was to crystallize the nature of relationships between impulsivity, aggression, and suicidality. We reviewed studies of adults with published, psychometric measures of impulsivity and aggression, and measures of suicidality.

METHODS

Our primary data source was Web of Science (from inception to 31st December 2021). Quality of articles was assessed using a Joanna Briggs Appraisal Tool and publication bias using Trim and Fill. We synthesised results using random effects meta-analyses and explored moderation by measure of impulsivity, aggression, and suicidality, and population.

FINDINGS

77 studies were included in our analysis. We found weak positive relationships between impulsivity (r = 0·19 [95% CI: 0·15-0·22]), aggression (0·23 ([0·17, 0·29]), and impulsive aggression (0·16 [0·1, 0·22]) with suicidality. Heterogeneity was significant and only partially explained by moderators. Limitations included the lack of studies which assess impulsivity or aggression proximal to suicidality.

INTERPRETATION

Given small effect sizes and significant heterogeneity, the study suggests that additional studies are needed in the field to analyze the relation between impulsivity and aggression with suicidality.

FUNDING

None.

Substance use-related suicide after release from correctional, behavioral health, and healthcare facilities using national violent death reporting system data

INTRODUCTION

Suicide and substance use are prevalent problems among persons discharged from facilities. This study (1) articulated rates of substance-related suicide deaths among those discharged correctional, behavioral health, and healthcare facilities, and (2) identified factors associated with substance-related suicide deaths unique to, or generalizing across, facility discharge.

METHODS

We used data from the National Violent Death Reporting System. Suicide deaths (N = 105,968) were aggregated from 2003 to 2017. Chi-square and independent samples t-tests were used to examine associations between drug/alcohol-related deaths and each correlate. Logistic regression was employed to identify the most robust substance-related suicide death-related factors.

RESULTS

Suicide deaths were commonly marked as being substance-related: 69% from correctional institutions, 54% from behavioral health facilities, 45% from those not released from a facility, and 39% from healthcare facilities. Regression models indicated housing interruptions and interpersonal stressors increased odds of the suicide death being marked as substance-related across discharge categories. Each discharge category also had unique predictors, underscoring the need for tailored prevention.

CONCLUSIONS

Substance-related suicide deaths are particularly common among adults discharged from correctional and behavioral health facilities. Findings are discussed with respect to community-focused, discharge planning, and clinical care suicide prevention strategies.

Alcohol and cocaine use prior to suspected suicide: Insights from toxicology

INTRODUCTION

This study investigates whether there is a relationship between alcohol and cocaine use in deaths where suicide by self-injury is the suspected cause of death.

METHODS

Adults referred by coroners to the Imperial College London Toxicology Unit for toxicological analysis between 2012 and 2016 were reviewed for inclusion criteria. Those who died by self-injury reasoned to be deliberate were included in the analysis. Femoral blood alcohol concentration (BAC) and presence of cocaine or benzoylecognine (a metabolite of cocaine) in blood and/or urine were tabulated and odds ratios calculated.

RESULTS

A total of 1722 decedents met inclusion criteria. BAC was ≥50 mg/dL in 29% of decedents. Cocaine was detected in 8.4% of cases. The likelihood of testing positive for cocaine increased with BAC and was most frequent between 100 and 199 mg/dL, consistent with moderate to severe intoxication (odds ratio 5.88, 95% confidence interval 3.80, 9.09; P ≤ 0.001) compared to those with BAC <10 mg/dL.

DISCUSSION AND CONCLUSIONS

This study demonstrates a correlation between increasing BAC and likelihood of cocaine use prior to suspected suicide, up to a level consistent with severe intoxication. Cocaine use was found in a high proportion of cases relative to the general population reporting regular use. This pattern of drug and alcohol use has previously been given little attention in suicide prevention strategies and clinical prioritisation.

Individual, Family, and School Correlates across Patterns of High School Poly-substance Use

Background: Recent popularity in e-cigarette use among high school students and the legalization of marijuana across many states resulted in new patterns of poly-substance use (PSU). Objective: The purpose of this study is to understand contemporary patterns of PSU and their associations with individual social-emotional characteristics (sensation seeking, perceived harm, life satisfaction) and social-contextual factors (parental involvement, school norms, academics, and behaviors). Methods: Latent class analysis (LCA) was used to identify patterns of PSU among 12th-grade students (n = 8417) from the 2016 Monitoring the Future project. Multinomial logistic regression was used to understand the relationship among individual characteristics, social-contextual factors, and patterns of PSU. Results: From the LCA, three patterns of PSU were identified: (1) low-use (72.2%); (2) pre-dominantly marijuana use with some co-occurring substance use (23.8%); and (3) high PSU (4.0%). Results indicate that students with pre-dominant marijuana use were differentiated from those with PSU by having higher perceived harm of electronic and regular cigarette, heavy alcohol use, and better academic grades. Furthermore, students with both polysubstance and pre-dominant marijuana use, when compared to those with low-use, had lower life satisfaction, higher sensation seeking, lower perceived harm of substance use, poorer grades, and more disciplinary problems. Conclusion/Importance: Findings draw attention to the importance of understanding levels of life satisfaction, sensation seeking, perceived harm, academic grades, and disciplinary problems as they pertain to contemporary patterns of PSU. Schools should consider a tailored and multi-tiered approach to addressing students' substance use.

Biological bases of suicidal behaviours: A narrative review

Suicidal behaviour is a multifaceted phenomenon that concerns all human populations. It has been suggested that a complex interaction between the individual genetic profile and environmental factors throughout life underlies the pathophysiology of suicidal behaviour. Although epidemiological and genetic studies suggest the existence of a genetic component, exposure to biological and psychosocial adversities, especially during critical developmental periods, also contributes to altering the biological responses to threat and pleasure. This results in amplified maladaptive cognitive and behavioural traits and states associated with suicidal behaviours. Alterations in the cognitive inhibition and decision-making capacity have been implicated in suicidal behaviours. Structural and functional changes in key brain regions and networks, such as prefrontal cortex, insula and default mode network, may underlie this relationship. Furthermore, the shift from health to suicidal behaviour incorporates complex and dynamic changes in the immune and stress responses, monoaminergic system, gonadal system and neuroplasticity. In this review, we describe the major findings of epidemiological, genetic, neuroanatomical, neuropsychological, immunological and neuroendocrinological studies on suicide behaviours to provide a solid background for future research in this field. This broad overview of the biological bases of suicide should promote neuroscience research on suicidal behaviours. This might lead to improved biological models and to the identification of evidence-based biomarkers, treatment options and preventive strategies.

From Substance Use Disorders in Life to Autopsy Findings: A Combined Case-Record and Medico-Legal Study

Objectives: Several studies have shown mortality and suicide risk in substance use disorders, and autopsy findings with respect to the used substances. However, there seems to be a gap in the knowledge about substances misused in life and at death at the within-person level. Methods: All consecutive, autopsied patients during 1993 to 1997, who had been in contact with the Addiction Centre in Malmö from 1968, were investigated (365 subjects). Drug misuse in the long-term course noted in case records was related to autopsy findings. Self-inflicted death (suicide/undetermined suicide/accidental overdose) was compared with natural death. Results: Benzodiazepine misuse was associated with a high risk of autopsy findings of the substance in suicide and death of undetermined intent. It was also associated among non-misusers, but less so. An alcohol level above 1‰ was found more often in self-inflicted death. Prescription opioids at autopsy were mainly found in self-inflicted death among non-misusers. Heroin misuse was related to overdose. Central nervous system stimulants (CNS-S) and cannabis were rarely found in self-inflicted death among previous misusers. The overlap between depression in life and antidepressants at death was low. Conclusions: Benzodiazepines and alcohol seem to disinhibit suicidal tendencies. Suicide risk among users of cannabis and CNS-S may be related to other risk factors than acute use. Implications for suicide prevention are discussed.

Forensic Toxicology Perspectives of Methadone-associated Deaths in Tehran, Iran, a 7-year Overview

Methadone has a long history of pain relief and successful substitute for maintenance treatment in heroin and narcotic addiction. The aim of the study was to assess the trends of methadone-associated deaths in Tehran, Iran, in 2009-2015, from a forensic toxicology point of view. All methadone-associated deaths during this 7-year study period were evaluated according to demographic parameters and forensic toxicology analysis results. Results showed that 1274 cases of methadone-associated deaths were investigated during the study period. The incidence rate of methadone-associated deaths had risen 7.7 times in 2015 in comparison with 2009 (p < 0.05). The majority of cases were men (90.35%), aged from 20 to 40 years. About 80% of cases had shown positive results for other drugs and poisons in combination with methadone. Methamphetamine and tramadol were the most drugs detected in post-mortem samples. Death rates among methadone users in Tehran, Iran, increased year by year during 2009-2015. These findings raise the attention to the concomitant use of drugs with the need for changes in regulation and regulatory policy to restrict access and use of controlled drugs.

Acute and chronic alcohol use correlated with methods of suicide in a Swiss national sample

OBJECTIVES

Chronic and acute alcohol use are highly associated risk factors for suicides worldwide. Therefore, we examined suicide cases with and without alcohol use disorder (AUD) using data from the SNSF project "Suicide in Switzerland: A detailed national survey". Our investigations focus on correlations between acute and chronic alcohol use with reference to suicide and potential interactions with the methods of suicide.

METHODS

We used data from the SNSF project in which all cases of registered completed suicide in Switzerland reported to any of the seven Swiss institutes of legal and forensic medicine between 2000 and 2010 were collected. We extracted cases that were tested for blood alcohol to use in our analysis. We compared clinical characteristics, blood alcohol concentrations, and methods of suicide in cases with and without AUD.

RESULTS

Out of 6497 cases, 2946 subjects were tested for acute alcohol use and included in our analysis. Of the latter, 366 (12.4%) persons had a medical history of AUD. Subjects with AUD significantly had higher blood alcohol concentrations and were more often in medical treatment before suicide. Drug intoxication as method of suicide was more frequent in cases with AUD compared to NAUD.

CONCLUSION

Overall, we found a high incidence of acute alcohol use at the time of death in chronic alcohol misusers (AUD). The five methods of suicide most commonly used in Switzerland differed considerably between individuals with and without AUD. Blood alcohol concentrations varied across different methods of suicide independently from the medical history in both groups.

Forensic toxicology analysis of self-poisoning suicidal deaths in Tehran, Iran; trends between 2011-2015

BACKGROUND

Suicide ranks among the top ten causes of death in all age groups all over the world. There are many methods for committing suicide including self-poisoning, firearm and hanging. The aim of the present study was to provide an overview of self-poisoning related suicidal deaths with special focus on forensic toxicology analysis results in Tehran, Iran from 2011 to 2015.

METHODS

All suspicious cases with the the history of self-poisoning were investigated to define the cause and manner of death under the supervision of forensic medicine practitioners. Postmortem samples were analysed in forensic toxicology laboratory to confirm the presence of drugs in cadaver of suicidal cases. Drugs and poisons were analysed using thin layer chromatography, high performance liquid chromatography, gas chromatography/mass spectrometry, headspace gas chromatography and gas chromatography equipped with nitrogen phosphorus detector. Demographic data were collected from autopsy reports of all cases with confirmed self-poisoning suicidal cause of death.

RESULTS

Results showed that 674 cases of self-poisoning deaths were investigated during a five-year study period, of which 68.55% were male. The most often used suicide method was self-poisoning in young population. Phosphine gas liberated from aluminum phosphide tablets was the most toxic substance detected in postmortem samples (619 cases) followed by opioids, methamphetamine, organophosphates, cyanide and strychnine.

CONCLUSION

In conclusion self-poisoning suicidal death was predominant in young male population in Tehran, Iran. It seems that free access to suicide means such as drugs and poisons should be restricted by national and health authorities.

TRIAL REGISTRATION

Not applicable.

An exploration of integrated data on the social dynamics of suicide among women

The gender-based nature of suicide-related behaviour is largely accepted. However, studies that report exclusively on female suicides are rare. Here we demonstrate how female suicide has effectively been 'othered' and appears incidental in studies which compare female and male behaviour. We highlight how recent studies of suicide have tended to be dominated by male-only approaches, which increasingly link issues of masculinity with male death by suicide. Drawing on data collected from the general practitioner and coroner's office, we then apply the sociological autopsy approach to a cohort of 78 deaths recorded as suicides in the UK between 2007 and 2009. By focusing on females in isolation from males, we demonstrate that, as in male-only suicide studies, it is similarly possible to draw out issues associated with the feminine identity, which can be linked to death by suicide. We find that bereavement, sexual violence and motherhood could all be linked to the lives and help-seeking of the females who died. In closing, we suggest that a reorientation towards sociological analytic approaches of female suicide may help to produce further reductions in the rate of female death by suicide. A Virtual Abstract of this paper can be found at: https://www.youtube.com/watch?v=a0w9KKMFdIQ.