Alcohol and Suicide

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Addiction (1996) 91(10), 1413-1416

EDITORIAL

Alcohol and suicide—^beyond the link at theindividual level

Both suicide and alcohol abuse represent areas of

great concern with respea to health and welfareas well as social and economical costs. TTie de-gree to which these two are interrelated has beensubject to scientific interest for more than acentury. Scientific efforts in this area have so farbrought us knowledge of significant relevance,for clinical and political purposes beyond thepotential of generating knowledge per se. But weare still in need of, and in search for, moreknowledge. I will in the following briefly sketchout some of the proposed mechanisms of associ-ation between alcohol and completed suicide,some of the consistencies and inconsistencies inempirical findings, and some of the future chal-lenges for research in this area. Although at-tempted and completed suicide may overlap andshare characteristics and predictors in some re-spects the focus here will be limited to that ofcompleted suicide.

MechanismsThe role of alcohol in suicide covers variousmechanisms.'"* Suicide may be the end point ofa long tenn drinking career with gradual socialisolation and depression as intermediate factors,but it may also be the solution to the child or thewife of an alcohol abuser seeing no other way toescape &om insecurity, isolation, neglect, andviolence. To some people getting into a state of

intoxication may be like pulling the trigger—bar-riers to hurting oneself are removed, and de-pression, self pity and suicidal thoughts fioat

escape in the bottle as the first choice, and

suicide next. At the aggregate level socchanges may increase the level of fi:aistration odegree of anomie, causing some people to spond with suicide whereas others respond wdrinking. On the other hand, by comparing gions with the same level of frustration , one mfind that in some regions there are cultu"prescriptions" to choose suicide as a responto fiTist ration whereas in other regions (wetcultures, presumably) alcohol will be the choof preference, and in the latter case fewer livare lost in suicide.

These kinds of mechanisms are only in pwell documented and empirically supportthrough various studies. It also remains to assthe relative importance of these mechanisms various cultures and under various conditionBy leaning on both individual data studies aon aggregate data studies the potential for fther finitful elaboration in this direction is proably enhanced.

Empirical studiesIndimdual level studiesMost studies in the area of alcohol and suiciare on the individual level, and they can toi a i ^ extent be divided into two groups; studiof suicide in alcohol abusers or heavy drinkeand studies of alcohol use and alcohol abuse suicides. There has been found a significMit ecess mortality by suicide in samples of alcohabusers in treatment, ranging from 2 to 2 5 ,' w





Editorial 14

people engage differently, depending on factorslike ailtural climate and gender, amongst others.

A rather striking observation when resultsfrom time series analyses are compared betweenvarious countries, is that in dry drinidng cultureslike Norway and Sweden the estimated effects ofan increase in alcohol consumption on suiciderates tend to be of a larger magnitude than in wetdrinking cultures like Portugal and France.NorstrSm" has argued that this can be explainedby less self-selection to alcohol abuse and suicideand less marginalization and stigmatization ofalcohol abusers in wet drinking cultures. Abroader empirical basis for comparisons betweenwet and dry drinking cultures is, however, war-ranted in order to substantiate the validity ofthese cross-cultural differences.

Furthermore, it may also be questionedwhether differences in the alcohol—suicide associ-ation across drinking cultures only are attribu-table to differences in prevalence of heavydrinkers, or whether cross-cultural variation tosome degree also reflect differences in drinkingpatterns and the effects of acute intoxication.TTiis issue has been brought up by Makela^' whorelated the stronger association between per cap-ita consumption and male suicide rates inyounger age groups as compared to older agegroups, to a heavier alcohol consumption andmore frequent alcohol intoxication in theyounger age groups. M ore systematic approachesto this issue, both in terms of individual levelstudies and aggregate level studies should bewelcomed. Besides the potential to explain cross-cultural variations more thoroughly, this is alsoof relevance to alcohol policy with respect tocurbing the extent of acute intoxication.

When results from time series analyses andecological analyses within the same country arecompared, findings from some studies indicatethat time series analyses yield a higher estimateof the alcohol-suicide association than ecologicalanalyses do.^''""^' Such findings do, if they canbe validated, imply aspects of theoretical andmethodological interest. The findings can be in-terpreted as an indication of two mechanismsoperating at the same time—both a causal mech-anism and a mechanism of alternative solu-tions.^''^' The findii^ also indicate that one

h h i

Gender differences in suicide risk in alcoabusers have been brought up in some revieon alcohol and suicide.'"' A gender ratio in magnitude of 9 men to 1 woman in alcohsuicide victims has been interpreted as a higsuicide risk in male alcohol abusers as compato female alcohol abusers.' More recent studhave, however, demonstrated that the incideof suicide in male and female alcohol abuserof the same magnitude.'"•" It has been demstrated that the prevalence of antisocial persoity, of phobic disorder and of major depresswas more elevated in female alcohol dependas compared to male alcohol dependents.^*alcohol abuse is less prevalent among womenthus appears that the degree of self selectionalcohol abuse is larger among women, and

might therefore on these grounds assumehigher suicide risk among female alcoabusers. One might also assume that the disrtive effects of alcohol abuse on social integramay effect women to the same extent as men thus just as prone to suicide. Little seemsserve as a sufficient basis for fiirther speculatiin this area now, and thus further studies shobe most welcomed.

At the aggregate level the number of studare still sparse, but so far it seems as if tempanalyses of per capita consumption yield higeffect estimates on male suicide rates than female suicide rates,^''^' whereas this has been found in spatial analyses.^' Further studin this direction are warranted and may be heful to assess the relative impact of various meanisms for men and women.

A final point that deserves attention is rather one-sided focus on the intra-individassociation, on suicide in the drinker himselfthe scientific literature. Norstrom' suggesthowever, that alcohol abuse may not only deteriorating for the drinker himself but it malso cause isolation, insecurity, fhistration ahelplessness in his closest dependents. Henalcohol abuse may not only increase the risksuicide in the drinker, but also increase the rof suicide in his spouse or children. There case reports of parental alcohol abuse in yo

suicides,^' but there seems to be few studiessupport that victims of other's alcohol abuse at an increased risk of suicide The potential a



1416 Ediumal

assessing some of the enemal costs of alcoholabuse.

tojGEBORG ROSSOW

National Institute for Alcohol and Drug Research,Damtevigsveien 10,

0463 Oslo,Ncnvay

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