Research Paper (APA STYLE) as soon as possible
osita92
10.10072fs00406-012-0292-0.pdf
O R I G I N A L P A P E R
Substance abuse and suicide risk among adolescents
Maurizio Pompili • Gianluca Serafini • Marco Innamorati • Massimo Biondi •
Alberto Siracusano • Massimo Di Giannantonio • Giancarlo Giupponi •
Mario Amore • David Lester • Paolo Girardi • Anne Maria Möller-Leimkühler
Received: 9 August 2011 / Accepted: 10 January 2012 / Published online: 31 January 2012
� Springer-Verlag 2012
Abstract The aim of this paper was to review the liter-
ature concerning the relationship between suicide and
substance abuse behaviours among adolescents, focusing
on epidemiology, comorbidity and preventive programmes.
We performed a Pubmed/Medline, Scopus, PsycLit and
PsycInfo search to identify all papers and book chapters
during the period between 1980 and 2011. Adolescents
with substance abuse disorder who attempt or complete
suicide can be characterized as having mood disorders,
stressful life events, interpersonal problems, poor social
support, lonely lives and feelings of hopelessness. The
research supports the existence of a strong relationship
between suicide and substance abuse. Preventive pro-
grammes should be based on the detection of risk factors
associated with both suicide and substance abuse disorder.
Management programmes should combine different
therapeutic strategies such as peer-to-peer education,
school-based programmes, psychotherapy and pharmaco-
logical treatment. Evidence suggests that targeted suicide
prevention programmes can be delivered which reduce the
burden associated with substance abuse and suicide in
youths.
Keywords Drug abuse � Alcohol abuse � Suicide � Youths � Prevention
Introduction
Adolescence is a challenging period of cognitive, biologi-
cal, physiological and psychological transition, occurring
between 10 and 19 years of age [22]. The transition to
M. Pompili � G. Serafini � M. Innamorati � P. Girardi Department of Neurosciences, Mental Health and Sensory
Functions, Suicide Prevention Center, Sant’Andrea Hospital,
Sapienza University of Rome, Rome, Italy
M. Pompili
McLean Hospital, Harvard Medical School, Belmont, MA, USA
M. Pompili (&) Department of Neuroscience, Mental Health and Sensory
Organs—Sant’Andrea Hospital, Sapienza University of Rome,
1035-1039 Via di Grottarossa, 00189 Rome, Italy
e-mail: [email protected]
M. Biondi
Department of Psychiatry and Psychological Medicine,
Sapienza Università di Roma, Rome, Italy
A. Siracusano
Department of Neuroscience, Division of Psychiatry,
University of Rome ‘‘Tor Vergata’’, Rome, Italy
M. Di Giannantonio
Neuroscience and Imaging Department, University of Chieti,
Chieti, Italy
G. Giupponi
Department of Psychiatry, Bolzano, Italy
M. Amore
Department of Neurosciences, Division of Psychiatry, University
of Parma, Parma, Italy
D. Lester
The Richard Stockton College of New Jersey, Pomona, NJ, USA
A. M. Möller-Leimkühler
Department of Psychiatry, Ludwig-Maximilians-University
of Munich, Munich, Germany
123
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
DOI 10.1007/s00406-012-0292-0
adolescence leads to needs for independence, identity for-
mation and acceptance by peers. All of these contribute to
risk-taking behaviours, suicidal ideation and suicidal
behaviour.
According to the World Health Organization [115],
suicide is the third leading cause of death among those
aged 15–24, after car accidents and cancer. Additionally,
suicide attempts represent the main reason for referral to
child and adolescent psychiatric emergency services [77].
Despite the fact that suicide mortality in middle-aged
and older persons has recently decreased in several Euro-
pean and North American countries, suicides among youths
have risen dramatically in recent decades [76], and
researchers have associated this increase in youth suicide
with the widespread use of alcohol and other drugs among
adolescents [7, 47, 112].
Both cross-sectional and retrospective evidence in ado-
lescent and adult populations have reported an association
between suicidal behaviours and substance use. Goldsmith
et al. [35] reported a rapid increase in drug abuse in the
USA in the years after 1960 especially in adolescents.
Adolescent suicidal behaviour also increased by about
300%. Substance using in adolescence has been proposed
as a relevant risk factor for suicidal behaviours [97]. Wines
et al. [114] found that 28% of inpatients in drug abuse
treatment centres had histories of suicidal ideation and 21%
had attempted suicide. Additionally, after 2 years of sub-
stance abuse treatment, 19% continued to have suicidal
ideation and 7% had made suicide attempts. It was also
suggested that the estimated risk for suicide in the presence
of alcohol-related disorders was about four times greater in
men and five times greater in women than in its absence
[100]. Shneider et al. [101] reported that alcohol-related
disorders (DSM-IV alcohol dependence) were more often
diagnosed in suicide victims than in controls (OR = 8.8,
95% CI 4.4–17.7).
Based on the existing literature, this systematic review
first aimed to investigate whether there is an association
between the substance use/abuse/dependence and suicidal
behaviour in clinical and non-clinical samples. Our second
aim was to ascertain whether substance use/abuse/depen-
dence may be considered as a specific risk factor for sui-
cide after controlling for a number of potentially
confounding factors.
Materials and methods
To achieve a high standard of reporting, we have adopted
‘Preferred Reporting Items for Systematic Reviews and
Meta-Analyses’ (PRISMA) guidelines [69]. In order to
provide a new and timely systematic review of substance
abuse and suicidal behaviour, we performed a Pubmed/
Medline, Scopus, PsycLit and PsycInfo search to identify
all papers and book chapters during the period between
1980 and 2010. The search used the following terms:
(suicide OR suicide attempt OR ideation OR suicidal
behaviour) AND (epidemiology OR rates OR trends OR
incidence) AND (drug OR substance abuse OR drug abuse
OR substance disease OR comorbidity) AND (‘prevention’
OR ‘intervention’ OR ‘future implications’). Specifically,
in order to adequately focus on the specific field of interest,
the following search query was used in Pubmed: (suicid*
[TI] AND substanc* [TI]). This search in Medline gener-
ated 182 articles. The same search strategy was used in
Scopus rendering 4 additional articles and in PsycLit/Psy-
cInfo (specifying ‘suicide AND substance abuse’ and
deleting ‘[TI]’) providing 43 further articles. The reference
lists of the articles included in the review were manually
checked yielding 27 additional articles that might be
potentially considered for screening. The Pubmed, Scopus
and PsycLit/PsycInfo databases revealed a total of 151
potentially relevant articles after the removal of duplicates.
Figure 1 summarizes the search strategy used for selecting
studies (identification, screening, eligibility, inclusion
process).
Data collection
Only those articles published in peer-reviewed journals
were included. Where a title or abstract seemed to
describe a study eligible for inclusion, the full article was
obtained and examined to assess its relevance based on
the inclusion criteria. Two independent researchers con-
ducted a two-step literature search. Any discrepancies
between the two reviewers who, blind to each other,
examined the studies for the possible inclusion were
resolved by consultations with a senior author. Included
were all contributions that explicitly mention the associ-
ation between substance use and suicidal behaviour in
clinical and non-clinical (healthy) samples. Exclusion
criteria are the following: (1) studies including samples
with mean age [18 were excluded years; (2) studies published before 1980; (3) articles without abstracts or
abstracts that did not explicitly mention suicidal behav-
iour, substance use, abuse and dependence; (4) articles not
published in English language; and (5) articles having low
relevance to the main theme. Included papers were
restricted to those in English with the exception of one
Norwegian study [75] included in Table 1 because it was
considered to be of particular interest. All 151 articles
were critically evaluated: 24 of these were excluded
because they were not published in peer-reviewed jour-
nals, were without abstracts, had abstracts that did not
explicitly mention suicidal behaviour (suicidal attempts
and ideation) and substance abuse, and are articles with a
470 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
publication date before 1980. This left 127 full-text arti-
cles of which 110 articles were excluded because they
were not published in English language, had low rele-
vance to the main theme, included unclear data regarding
materials and method and number of patients analyzed.
Thus, 17 articles meeting our inclusion criteria were
included in the present review.
Data extraction
Data were independently collected by the two reviewers.
The following characteristics were extracted from the 17
included articles in Table 1: author/s and publication year,
study design, sample size, eventual follow-up, conclusions
and main risk factors.
The principal reviewer (MP) inspected all reports. Then,
three reviewers (MP, PG and GS) independently inspected
all citations of studies identified by the search and grouped
them according to the topic of the papers. Reviewers
acquired the full article for all papers located. Where dis-
agreement occurred, this was resolved by discussion with
MA who also with double-blind features inspected all
articles located and grouped them following the major
areas of interest identified by all authors. If doubt
remained, the study was put on the list of those awaiting
assessment, pending acquisition of more information. We
excluded from our analysis any studies vaguely reporting
on substance abuse in adolescence or using inadequate or
unclear diagnostic criteria for such disorders or those
inappropriately assessing the impact of substance abuse on
suicide risk. Results of this search are presented in the
paragraphs regarding the role of substance abuse in the
precipitation of suicide risk.
Summary measures
Studies were rated for quality using the following eligi-
bility criteria: (i) the representativeness of the sample
from the general population (0–2 points), (ii) the presence
of a control group (1 or 2 points), (iii) presence of follow-
up [1 year (1 or 2 points), (iv) evidence-based measures of assessment (e.g. the use of the SCID-I for the diagnosis
of the substance abuse/dependence or other psychometric
evaluation) (1 or 2 points), (v) the presence of two
independent raters who blindly diagnosed the substance
abuse/dependence (1 or 2 points), (vi) a statistical eval-
uation of the interrater reliability (1 or 2 points) and (vii)
evidence-based measures for assessing suicide or suicide
attempts (1 or 2 points). Quality ratings had 14 as the
maximum score.
Studies were differentiated in the following way: good
quality ([11 points)—most or all criteria being fulfilled, and where they were not met, the study conclusions were
thought very unlikely to alter; moderate quality (6–11
Fig. 1 Search strategy used for selecting studies (identification,
screening, eligibility, inclusion
in the systematic review)
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 471
123
T a
b le
1 R
e le
v a n
t st
u d
ie s
a b
o u
t su
b st
a n
c e
a b
u se
a n
d su
ic id
e ri
sk in
a d
o le
sc e n
ts a n
d y
o u
n g
a d
u lt
s
S tu
d y
D e si
g n
S a m
p le
si z e
E v
e n
tu a l
fo ll
o w
-u p
C o
n c lu
si o
n s
M a in
ri sk
fa c to
rs Q
u a li
ty
sc o
re
Q u
a li
ty
d if
fe re
n ti
a ti
o n
D a rk
e a n
d
R o
ss [2
4 ]
R e v
ie w
a rt
ic le
o n
su ic
id e
ra te
s,
su ic
id e
ri sk
fa c to
rs a n
d m
e th
o d
s
e m
p lo
y e d
fo r
su ic
id e
a m
o n
g
h e ro
in u
se rs
N o
t re
p o
rt e d
N o
H e ro
in u
se rs
a re
1 4
ti m
e s
m o
re li
k e ly
th a n
p e e rs
to d
ie fr
o m
su ic
id e .
T h
e y
a ls
o a tt
e m
p te
d su
ic id
e m
o re
fr e q
u e n
tl y
th a n
th a t
o f
c o
m m
u n
it y
sa m
p le
s. R
is k
fa c to
rs fo
r su
ic id
e w
e re
p sy
c h
o p
a th
o lo
g y
, fa
m il
y d
y sf
u n
c ti
o n
a n
d so
c ia
l is
o la
ti o
n a s
w e ll
a s
p o
ly -
d ru
g u
se .
D ru
g s
b u
t n
o t
h e ro
in a s
a
m e th
o d
o f
su ic
id e
a p
p e a r
to p
la y
a
re le
v a n
t ro
le in
su ic
id e
a m
o n
g th
is
g ro
u p
1 .
P sy
c h
o p
a th
o lo
g y
2 .
F a m
il y
d y
sf u
n c ti
o n
3 .
S o
c ia
l is
o la
ti o
n
4 .
P o
ly -d
ru g
u se
I =
2
II =
2
II I
= 0
IV =
1
V =
2
V I
= 2
V II
= 2
T o
ta l
sc o
re =
1 1
M o
d e ra
te
q u
a li
ty
R o
y [9
4 ]
C a se
– c o
n tr
o l
st u
d y
c o
m p
a ri
n g
o p
ia te
-d e p
e n
d e n
t p
a ti
e n
ts w
h o
h a d
a n
d h
a d
n o
t a tt
e m
p te
d su
ic id
e
2 4
6 o
p ia
te -
d e p
e n
d e n
t
p a ti
e n
ts
N o
O n
e h
u n
d re
d o
f th
e 2
4 6
o p
ia te
-d e p
e n
d e n
t
p a ti
e n
ts h
a d
a tt
e m
p te
d su
ic id
e ,
a n
d
si g
n ifi
c a n
tl y
m o
re o
f th
e o
p ia
te -
d e p
e n
d e n
t p
a ti
e n
ts w
h o
h a d
a tt
e m
p te
d
su ic
id e
h a d
a fa
m il
y h
is to
ry o
f b
o th
c o
m p
le te
d a n
d a tt
e m
p te
d su
ic id
e .
O p
ia te
-d e p
e n
d e n
t p
a ti
e n
ts w
h o
h a d
a tt
e m
p te
d su
ic id
e re
p o
rt e d
si g
n ifi
c a n
tl y
m o
re c h
il d
h o
o d
e m
o ti
o n
a l
a b
u se
,
p h
y si
c a l
a b
u se
, se
x u
a l
a b
u se
a n
d
e m
o ti
o n
a l
a n
d p
h y
si c a l
n e g
le c t.
M o
re o
v e r,
o p
ia te
-d e p
e n
d e n
t p
a ti
e n
ts
w h
o h
a d
a tt
e m
p te
d su
ic id
e w
e re
fo u
n d
to b
e si
g n
ifi c a n
tl y
m o
re in
tr o
v e rt
e d
,
h o
st il
e a n
d n
e u
ro ti
c .
F in
a ll
y ,
si g
n ifi
c a n
tl y
m o
re o
f th
e p
a ti
e n
ts w
h o
h a d
a tt
e m
p te
d su
ic id
e w
e re
fe m
a le
a n
d
u n
e m
p lo
y e d
1 .
F a m
il y
h is
to ry
o f
b o
th c o
m p
le te
d a n
d
a tt
e m
p te
d su
ic id
e
2 .
C h
il d
h o
o d
e m
o ti
o n
a l
a b
u se
3 .
C h
il d
h o
o d
p h
y si
c a l
a b
u se
4 .
C h
il d
h o
o d
se x
u a l
a b
u se
5 .
E m
o ti
o n
a l
a n
d
p h
y si
c a l
n e g
le c t
6 .
In tr
o v
e rs
io n
, h
o st
il it
y
a n
d n
e u
ro ti
c is
m .
7 .
B e in
g fe
m a le
a n
d
u n
e m
p lo
y e d
I =
2
II =
2
II I
= 0
IV =
1
V =
2
V I
= 2
V II
= 2
T o
ta l
sc o
re =
1 1
G o
o d
q u
a li
ty
H a v
e n
s
e t
a l.
[4 2 ]
C ro
ss -s
e c ti
o n
a l
st u
d y
in v
e st
ig a ti
n g
th e
re la
ti o
n sh
ip b
e tw
e e n
su ic
id a l
id e a ti
o n
w it
h in
je c ti
o n
d ru
g u
se rs
(I D
U s)
a n
d n
o n
-i n
je c ti
o n
d ru
g
u se
rs (N
ID U
s)
2 4
4 in
je c ti
o n
d ru
g u
se rs
a n
d 7
3 n
o n
-
in je
c ti
o n
d ru
g u
se rs
N o
S u
ic id
a l
id e a ti
o n
w a s
p re
se n
t in
2 7
% o
f
th e
ID U
p a ti
e n
ts v
s. 1
4 %
a m
o n
g th
e
N ID
U p
a ti
e n
ts ,
p =
0 .0
0 3
. A
ft e r
c o
n tr
o ll
in g
fo r
c o
n fo
u n
d in
g li
fe st
y le
fa c to
rs ,
in c lu
d in
g h
o m
e le
ss n
e ss
,
d e p
re ss
iv e
sy m
p to
m s
a n
d g
a y
/l e sb
ia n
/
b is
e x
u a l
id e n
ti ty
, th
e a ss
o c ia
ti o
n w
a s
n o
lo n
g e r
si g
n ifi
c a n
t. T
h e
p o
o r
so c io
p sy
c h
o lo
g ic
a l
b a c k
g ro
u n
d
(p sy
c h
ia tr
ic d
is o
rd e rs
, se
x u
a l
o ri
e n
ta ti
o n
, is
o la
ti o
n ),
w h
ic h
is
fr e q
u e n
t a m
o n
g in
je c ti
o n
d ru
g u
se rs
m a y
b e
re sp
o n
si b
le fo
r th
e in
c re
a se
d
su ic
id a l
id e a ti
o n
fo u
n d
in ID
U s
1 .
P sy
c h
ia tr
ic d
is o
rd e rs
2 .
S e x
u a l
o ri
e n
ta ti
o n
3 .
Is o
la ti
o n
I =
2
II =
2
II I
= 0
IV =
1
V =
0
V I
= 1
V II
= 0
T o
ta l
sc o
re =
6
M o
d e ra
te
q u
a li
ty
472 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
T a
b le
1 c o
n ti
n u
e d
S tu
d y
D e si
g n
S a m
p le
si z e
E v
e n
tu a l
fo ll
o w
-u p
C o
n c lu
si o
n s
M a in
ri sk
fa c to
rs Q
u a li
ty
sc o
re
Q u
a li
ty
d if
fe re
n ti
a ti
o n
K a ly
o n
c u
e t
a l.
[5 0 ]
C ro
ss -s
e c ti
o n
a l
e x
a m
in a ti
o n
o f
th e
so c io
-d e m
o g
ra p
h ic
a n
d c li
n ic
a l
c h
a ra
c te
ri st
ic s
1 0
8 y
o u
n g
a d
u lt
h e ro
in -
d e p
e n
d e n
t
in p
a ti
e n
ts
N o
B o
th th
e fe
m a le
a n
d m
a le
su ic
id e
a tt
e m
p te
rs w
e re
si g
n ifi
c a n
tl y
y o
u n
g e r
a t
th e
o n
se t
o f
h e ro
in u
se th
a n
th o
se
w h
o h
a d
n o
t a tt
e m
p te
d su
ic id
e .
T h
e
st a rt
in g
a g
e o
f h
e ro
in u
se m
a y
b e
a ri
sk
fa c to
r fo
r su
ic id
e a tt
e m
p ts
. T
h e
su ic
id e
a tt
e m
p te
rs h
a d
e x
p e ri
e n
c e d
g re
a te
r
fa m
il y
p sy
c h
o p
a th
o lo
g y
a n
d
d y
sf u
n c ti
o n
th a n
th e
n o
n -a
tt e m
p te
rs
a n
d h
a d
si g
n ifi
c a n
tl y
h ig
h e r
sc o
re s
o n
th e
C h
il d
h o
o d
T ra
u m
a Q
u e st
io n
n a ir
e .
P re
v io
u s
tr a u
m a ti
c e x
p e ri
e n
c e s
a re
st ro
n g
ly a ss
o c ia
te d
w it
h su
ic id
e
a tt
e m
p ts
in y
o u
n g
a d
u lt
h e ro
in -
d e p
e n
d e n
t p
a ti
e n
ts .
In p
a rt
ic u
la r,
th e
m a le
su ic
id e
a tt
e m
p te
rs m
o re
o ft
e n
m e t
th e
c ri
te ri
a fo
r d
e p
re ss
iv e ,
a n
x ie
ty a n
d
a n
ti so
c ia
l p
e rs
o n
a li
ty d
is o
rd e rs
1 .
Y o
u n
g e r
a g
e
2 .
T h
e st
a rt
in g
a g
e o
f
h e ro
in u
se
3 .
F a m
il y
p sy
c h
o p
a th
o lo
g y
a n
d
d y
sf u
n c ti
o n
4 .
C h
il d
h o
o d
tr a u
m a ti
c
e x
p e ri
e n
c e s
5 .
D e p
re ss
iv e
d is
o rd
e r
6 .
A n
x ie
ty d
is o
rd e r
7 .
A n
ti so
c ia
l
p e rs
o n
a li
ty d
is o
rd e r
I =
2
II =
0
II I
= 0
IV =
2
V =
1
V I
= 2
V II
= 0
T o
ta l
sc o
re =
7
M o
d e ra
te
q u
a li
ty
M a rz
u k
e t
a l.
[6 3 ]
In d
iv id
u a l
re v
ie w
o f
a u
to p
sy a n
d
to x
ic o
lo g
ic a l
re c o
rd s
N o
t re
p o
rt e d
N o
T h
e p
re v
a le
n c e
o f
c o
c a in
e u
se a m
o n
g
y o
u n
g H
is p
a n
ic m
a le
s w
h o
c o
m m
it te
d
su ic
id e
w a s
4 5
% .
P e rs
o n
s w
h o
w e re
y o
u n
g ,
b la
c k
o r
H is
p a n
ic a n
d w
h o
h a d
u se
d a lc
o h
o l
im m
e d
ia te
ly b
e fo
re th
e
fa ta
l in
ju ry
w e re
m o
st li
k e ly
to h
a v
e
b e e n
re c e n
t c o
c a in
e u
se rs
. A
ft e r
c o
n tr
o ll
in g
fo r
d e m
o g
ra p
h ic
v a ri
a b
le s
a n
d a lc
o h
o l
u se
, su
b je
c ts
w h
o
c o
m m
it te
d su
ic id
e w
it h
fi re
a rm
s w
e re
tw ic
e a s
li k
e ly
to h
a v
e u
se d
c o
c a in
e a s
th o
se w
h o
u se
d o
th e r
m e th
o d
s
1 .
C o
c a in
e u
se
2 .
Y o
u n
g e r
a g
e
3 .
B la
c k
o r
H is
p a n
ic
ra c e
4 .
A lc
o h
o l
c o
n su
m p
ti o
n
im m
e d
ia te
ly b
e fo
re
th e
fa ta
l in
ju ry
I =
2
II =
0
II I
= 0
IV =
0
V =
2
V I
= 2
V II
= 0
T o
ta l
sc o
re =
6
M o
d e ra
te
q u
a li
ty
R o
y [9
3 ]
C a se
– c o
n tr
o l
st u
d y
2 1
4 c o
c a in
e -
d e p
e n
d e n
t
p a ti
e n
ts
N o
3 9
% o
f th
e c o
c a in
e -d
e p
e n
d e n
t p
a ti
e n
ts
h a d
a tt
e m
p te
d su
ic id
e a t
so m
e ti
m e
in
th e ir
li v
e s,
m o
re o
ft e n
h a d
a fa
m il
y
h is
to ry
o f
su ic
id a l
b e h
a v
io u
r a n
d
re p
o rt
e d
si g
n ifi
c a n
tl y
m o
re c h
il d
h o
o d
tr a u
m a .
T h
e y
a ls
o h
a d
h ig
h e r
p e rs
o n
a li
ty sc
o re
s fo
r in
tr o
v e rs
io n
,
n e u
ro ti
c is
m a n
d h
o st
il it
y ;
th e y
h a d
si g
n ifi
c a n
tl y
m o
re c o
m o
rb id
it y
w it
h th
e
u se
o f
o th
e r
su b
st a n
c e s,
a s
w e ll
a s
p sy
c h
ia tr
ic a n
d p
h y
si c a l
d is
o rd
e rs
1 .
F a m
il y
h is
to ry
o f
su ic
id a l
b e h
a v
io u
r
2 .
C h
il d
h o
o d
tr a u
m a
3 .
In tr
o v
e rs
io n
,
n e u
ro ti
c is
m a n
d
h o
st il
it y
4 .
P sy
c h
ia tr
ic d
is o
rd e rs
5 .
P h
y si
c a l
d is
o rd
e rs
I =
2
II =
2
II I
= 0
IV =
2
V =
0
V I
= 2
V II
= 0
T o
ta l
sc o
re =
8
M o
d e ra
te
q u
a li
ty
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 473
123
T a
b le
1 c o
n ti
n u
e d
S tu
d y
D e si
g n
S a m
p le
si z e
E v
e n
tu a l
fo ll
o w
-u p
C o
n c lu
si o
n s
M a in
ri sk
fa c to
rs Q
u a li
ty
sc o
re
Q u
a li
ty
d if
fe re
n ti
a ti
o n
W a ld
ro p
e t
a l.
[1 1
1 ]
N a ti
o n
a l
c ro
ss -s
e c ti
o n
a l
S u
rv e y
o f
A d
o le
sc e n
ts
2 0
0 2
a d
o le
sc e n
ts
(a g
e d
1 2
– 1
7 )
N o
S a m
p le
p re
v a le
n c e s
o f
su ic
id a l
id e a ti
o n
a n
d a tt
e m
p ts
w e re
2 4
.3 a n
d 3
.3 %
,
re sp
e c ti
v e ly
, y
ie ld
in g
w e ig
h te
d
p o
p u
la ti
o n
p re
v a le
n c e
e st
im a te
s o
f 2
3 .3
a n
d 3
.1 %
. S
u ic
id a l
id e a ti
o n
w a s
p o
si ti
v e ly
a ss
o c ia
te d
w it
h fe
m a le
g e n
d e r,
a g
e ,
fa m
il y
, a lc
o h
o l
a n
d d
ru g
p ro
b le
m s,
v io
le n
c e
e x
p o
su re
, li
fe ti
m e
d e p
re ss
io n
a n
d P
T S
D .
S u
ic id
e a tt
e m
p ts
w e re
a ss
o c ia
te d
w it
h fe
m a le
g e n
d e r,
a g
e ,
se x
u a l
a n
d p
h y
si c a l
a ss
a u
lt ,
li fe
ti m
e su
b st
a n
c e
a b
u se
o r
d e p
e n
d e n
c e ,
P T
S D
a n
d d
e p
re ss
io n
1 .
P sy
c h
o p
a th
o lo
g y
2 .
F e m
a le
g e n
d e r
3 .
A g
e
4 .
S e x
u a l
a n
d p
h y
si c a l
a ss
a u
lt s
I =
2
II =
0
II I
= 0
IV =
0
V =
1
V I
= 2
V II
= 1
T o
ta l
sc o
re =
6
M o
d e ra
te
q u
a li
ty
G a rl
o w
[3 3 ];
G a rl
o w
e t
a l.
[3 4 ]
R e tr
o sp
e c ti
v e
a n
a ly
si s
o f
re c o
rd s
o f
th e
O ffi
c e
o f
th e
M e d
ic a l
E x
a m
in e r
o f
a ll
c o
m p
le te
d
su ic
id e s
4 1
6 c o
c a in
e
u se
rs
N o
A lm
o st
a ll
(9 4
.6 %
) o
f th
e su
ic id
e s
in
w h
o m
c o
c a in
e w
a s
d e te
c te
d w
e re
m a le
, 5
1 .4
% o
f th
e c o
c a in
e -p
o si
ti v
e
su ic
id e s
w e re
A fr
ic a n
A m
e ri
c a n
m e n
a n
d 4
3 .2
% w
e re
w h
it e
m e n
. M
o st
(8 6
.7 %
) o
f A
fr ic
a n
A m
e ri
c a n
te e n
a g
e rs
d id
n o
t u
se su
b st
a n
c e s
b e fo
re c o
m m
it ti
n g
su ic
id e ,
w h
e re
a s
5 0
.0 %
o f
th e
w h
it e
te e n
a g
e
v ic
ti m
s h
a d
u se
d o
n e
o r
b o
th
su b
st a n
c e s,
w it
h 4
1 .7
% o
f th
e w
h it
e
te e n
a g
e rs
h a v
in g
u se
d e th
a n
o l.
E th
a n
o l
u se
w a s
m u
c h
m o
re
c o
m m
o n
a m
o n
g w
h it
e v
ic ti
m s
o f
a ll
a g
e g
ro u
p s
1 .
B e in
g m
a le
2 .
Y o
u n
g e r
a g
e
3 .
B e in
g w
h it
e o
r
A fr
ic a n
A m
e ri
c a n
4 .
C o
c a in
e o
r e th
a n
o l
d e te
c te
d a t
a u
to p
sy
I =
2
II =
0
II I
= 0
IV =
0
V =
2
V I
= 0
V II
= 0
T o
ta l
sc o
re =
4
L o
w q
u a li
ty
In n
a m
o ra
ti
e t
a l.
[4 8 ]
C ro
ss -s
e c ti
o n
a l
st u
d y
3 4
0 y
o u
n g
a d
u lt
s
N o
1 4
.7 %
w e re
d ru
g u
se rs
a n
d 2
4 .1
%
d ri
n k
e rs
. A
lc o
h o
l a n
d d
ru g
m is
u se
w a s
si g
n ifi
c a n
tl y
a ss
o c ia
te d
w it
h re
a so
n s
fo r
li v
in g
, h
o p
e le
ss n
e ss
, su
ic id
a l
a tt
it u
d e s
a n
d d
e p
re ss
io n
. A
ft e r
m u
lt ip
le
re g
re ss
io n
a n
a ly
si s,
th e
D ru
g A
b u
se
S c re
e n
in g
T e st
, th
e Z
u n
g D
e p
re ss
io n
S c a le
a n
d L
o ss
o f
M o
ti v
a ti
o n
w e re
p o
si ti
v e
p re
d ic
to rs
o f
su ic
id e
ri sk
w it
h S
u rv
iv a l
a n
d C
o p
in g
B e li
e fs
a s
n e g
a ti
v e
p re
d ic
to rs
. C
a n
n a b
is
m a y
b e
a ss
o c ia
te d
w it
h ri
sk y
h e a lt
h b
e h
a v
io u
r
1 .
A lc
o h
o l
a n
d d
ru g
m is
u se
2 .
H ig
h e r
sc o
re s
o n
th e
Z u
n g
D e p
re ss
io n
S c a le
3 .
L o
ss o
f m
o ti
v a ti
o n
I =
2
II =
0
II I
= 0
IV =
2
V =
2
V I
= 2
V II
= 2
T o
ta l
sc o
re =
1 0
M o
d e ra
te
q u
a li
ty
474 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
T a
b le
1 c o
n ti
n u
e d
S tu
d y
D e si
g n
S a m
p le
si z e
E v
e n
tu a l
fo ll
o w
-u p
C o
n c lu
si o
n s
M a in
ri sk
fa c to
rs Q
u a li
ty
sc o
re
Q u
a li
ty
d if
fe re
n ti
a ti
o n
B e a u
tr a is
e t
a l.
[2 ]
C a se
– c o
n tr
o l
st u
d y
3 0
2 c a se
s v
s.
1 ,0
2 8
c o
n tr
o ls
N o
S u
b je
c ts
w h
o h
a d
m a d
e se
ri o
u s
su ic
id e
a tt
e m
p ts
h a d
si g
n ifi
c a n
tl y
h ig
h e r
ra te
s
o f
c a n
n a b
is a b
u se
/d e p
e n
d e n
c e
th a n
c o
m p
a ri
so n
su b
je c ts
p re
su m
a b
ly
re la
te d
to th
e so
c io
-d e m
o g
ra p
h ic
d is
a d
v a n
ta g
e s
a n
d d
is a d
v a n
ta g
e d
c h
il d
h o
o d
fa m
il y
c ir
c u
m st
a n
c e s.
A ft
e r
c o
n tr
o ll
in g
fo r
c o
n fo
u n
d in
g fa
c to
rs a n
d
c o
m o
rb id
p sy
c h
ia tr
ic d
is o
rd e r,
th e
o d
d s
ra ti
o b
e tw
e e n
c a n
n a b
is a b
u se
/
d e p
e n
d e n
c e
a n
d m
a k
in g
a se
ri o
u s
su ic
id e
a tt
e m
p t
w a s
2 .0
a n
d o
n ly
m a rg
in a ll
y st
a ti
st ic
a ll
y si
g n
ifi c a n
t
1 .
C a n
n a b
is a b
u se
/
d e p
e n
d e n
c e
2 .
S o
c io
-d e m
o g
ra p
h ic
d is
a d
v a n
ta g
e d
c h
il d
h o
o d
fa m
il y
c ir
c u
m st
a n
c e s
3 .
C o
m o
rb id
m o
o d
d is
o rd
e r,
o th
e r
su b
st a n
c e
u se
d is
o rd
e r
a n
d a n
ti so
c ia
l
p e rs
o n
a li
ty d
is o
rd e r
I =
2
II =
2
II I
= 0
IV =
2
V =
1
V I
= 2
V II
= 1
T o
ta l
sc o
re =
1 0
M o
d e ra
te
q u
a li
ty
F e rg
u ss
o n
e t
a l.
[3 2 ]
2 1
-y e a r
lo n
g it
u d
in a l
st u
d y
1 ,2
6 5
a d
o le
sc e n
c e /
y o
u n
g a d
u lt
s
F ir
st
e v
a lu
a ti
o n
= a t
b ir
th
T 1
= 4
m o
n th
s
T 2
= 1
y e a r
T 3
= a n
n u
a l
in te
rv a ls
u p
to
a g
e 1
6 y
e a rs
T 4
= a t
a g
e
1 8
y e a rs
T 5
= a t
2 1
y e a rs
R e g
u la
r c a n
n a b
is u
se w
a s
a ss
o c ia
te d
w it
h
a d
ra m
a ti
c in
c re
a se
in th
e ri
sk o
f o
th e r
il li
c it
d ru
g u
se ,
e v
e n
w h
e n
c o
n fo
u n
d in
g
v a ri
a b
le s
w e re
ta k
e n
in to
a c c o
u n
t. In
a d
d it
io n
, re
g u
la r
c a n
n a b
is a b
u se
w a s
a ss
o c ia
te d
w it
h in
c re
a se
s in
d e li
n q
u e n
c y
, d
e p
re ss
io n
a n
d su
ic id
a l
b e h
a v
io u
r. T
h e
a d
v e rs
e e ff
e c ts
o f
c a n
n a b
is o
n a d
ju st
m e n
t se
e m
e d
to b
e
m o
st p
ro n
o u
n c e d
fo r
y o
u n
g e r
u se
rs a n
d
d e c li
n e d
w it
h in
c re
a si
n g
a g
e
1 .
C a n
n a b
is u
se
2 .
Y o
u n
g e r
a g
e
3 .
D e li
n q
u e n
c y
in
c a n
n a b
is u
se rs
4 .
D e p
re ss
io n
in
c a n
n a b
is u
se rs
I =
2
II =
0
II I
= 2
IV =
2
V =
2
V I
= 2
V II
= 2
T o
ta l
sc o
re =
1 2
G o
o d
q u
a li
ty
R e y
e t
a l.
[8 9 ]
C ro
ss -s
e c ti
o n
a l
st u
d y
1 ,2
6 1
a d
o le
sc e n
ts
u si
n g
c a n
n a b
is
N o
1 /4
o f
th e
sa m
p le
re p
o rt
e d
h a v
in g
u se
d
c a n
n a b
is a n
d m
a le
s w
e re
tw ic
e a s
li k
e ly
a s
fe m
a le
s to
h a v
e u
se d
c a n
n a b
is b
e fo
re
th e
a g
e o
f 1
3 .
A n
a ss
o c ia
ti o
n b
e tw
e e n
d e p
re ss
io n
a n
d c a n
n a b
is u
se w
a s
fo u
n d
.
C a n
n a b
is u
se in
c re
a se
d th
e in
c id
e n
c e
o f
d is
ru p
ti v
e b
e h
a v
io u
rs su
c h
a s
c o
n d
u c t
p ro
b le
m s,
to b
a c c o
sm o
k in
g ,
e x
c e ss
iv e
d ri
n k
in g
a n
d th
e u
se o
f il
li c it
d ru
g s
1 .
B e in
g m
a le
2 .
D e p
re ss
io n
3 .
C o
n d
u c t
p ro
b le
m s,
to b
a c c o
sm o
k in
g ,
e x
c e ss
iv e
d ri
n k
in g
a n
d e x
c e ss
iv e
u se
o f
il li
c it
d ru
g s
in
c a n
n a b
is u
se rs
I =
2
II =
0
II I
= 0
IV =
2
V =
2
V I
= 2
V II
= 0
T o
ta l
sc o
re =
8
M o
d e ra
te
q u
a li
ty
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 475
123
T a
b le
1 c o
n ti
n u
e d
S tu
d y
D e si
g n
S a m
p le
si z e
E v
e n
tu a l
fo ll
o w
-u p
C o
n c lu
si o
n s
M a in
ri sk
fa c to
rs Q
u a li
ty
sc o
re
Q u
a li
ty
d if
fe re
n ti
a ti
o n
C h
a b
ro l
e t
a l.
[1 8 ]
C ro
ss -s
e c ti
o n
a l
st u
d y
2 4
8 h
ig h
sc h
o o
l
st u
d e n
ts
N o
T h
o se
w h
o h
a d
u se
d c a n
n a b
is a t
le a st
o n
c e
in th
e la
st si
x m
o n
th s
h a d
si g
n ifi
c a n
tl y
h ig
h e r
ra te
s o
f su
ic id
a l
b e h
a v
io u
r, d
e p
re ss
io n
sy m
p to
m s
a n
d
a n
x ie
ty sy
m p
to m
s c o
m p
a re
d to
n o
n -
u se
rs .
C a n
n a b
is u
se a p
p e a re
d to
b e
a n
in d
e p
e n
d e n
t p
re d
ic to
r o
f su
ic id
a l
b e h
a v
io u
r a ft
e r
c o
n tr
o ll
in g
fo r
d e p
re ss
io n
a n
d a n
x ie
ty sy
m p
to m
s
1 .
C a n
n a b
is u
se
2 .
D e p
re ss
io n
sy m
p to
m s
a n
d a n
x ie
ty
sy m
p to
m s
in c a n
n a b
is
u se
rs
I =
2
II =
0
II I
= 0
IV =
1
V =
0
V I
= 0
V II
= 2
T o
ta l
sc o
re =
5
L o
w q
u a li
ty
E p
st e in
a n
d
S p
ir it
o
[3 0 ]
C ro
ss -s
e c ti
o n
a l
st u
d y
1 3
,9 1
7 h
ig h
sc h
o o
l
st u
d e n
ts
N o
E a rl
y a lc
o h
o l
o n
se t,
h a v
in g
h a d
se x
b e fo
re a g
e 1
3 ,
in je
c ti
o n
d ru
g u
se a n
d
b e in
g fo
rc e d
to h
a v
e se
x w
e re
a ss
o c ia
te d
w it
h su
ic id
a li
ty a c ro
ss
g e n
d e r.
S m
o k
in g
in g
ir ls
w a s
a ss
o c ia
te d
w it
h m
a k
in g
a p
la n
to
a tt
e m
p t
su ic
id e
a n
d a c tu
a l
su ic
id e
a tt
e m
p ts
. F
ig h
ti n
g w
a s
re la
te d
to
su ic
id a li
ty fo
r g
ir ls
, w
h il
e fi
g h
ti n
g in
sc h
o o
l w
a s
re la
te d
to su
ic id
a li
ty fo
r
b o
y s
1 .
E a rl
y a lc
o h
o l
o n
se t
2 .
H a v
in g
h a d
se x
b e fo
re a g
e 1
3
3 .
In je
c ti
o n
d ru
g u
se
4 .
B e in
g fo
rc e d
to h
a v
e
se x
5 .
S m
o k
in g
in g
ir ls
6 .
F ig
h ti
n g
fo r
g ir
ls a n
d
fi g
h ti
n g
in sc
h o
o l
fo r
b o
y s
I =
2
II =
0
II I
= 0
IV =
1
V =
0
V I
= 2
V II
= 0
T o
ta l
sc o
re =
5
L o
w q
u a li
ty
P ri
c e
e t
a l.
[8 6 ]
L o
n g
it u
d in
a l
st u
d y
to g
e th
e r
w it
h a
c ro
ss -s
e c ti
o n
a l
in v
e st
ig a ti
o n
u si
n g
th e
N a ti
o n
a l
C a u
se o
f D
e a th
R e g
is te
r to
c o
rr e c tl
y id
e n
ti fy
6 0
0
su ic
id e s
a n
d u
n d
e te
rm in
e d
d e a th
s
5 0
,0 8
7 m
a le
m il
it a ry
c o
n sc
ri p
ts
3 3
-y e a r
fo ll
o w
-u p
5 ,3
8 0
(1 0
.7 %
) o
f su
b je
c ts
a d
m it
te d
to
h a v
in g
u se
d c a n
n a b
is w
h il
e 4
1 ,3
9 4
(8 2
.6 %
) h
a d
n o
t. T
h e
a ss
o c ia
ti o
n
b e tw
e e n
c a n
n a b
is u
se a n
d ri
sk fo
r
su ic
id e
w a s
p re
se n
t u
si n
g a
c ru
d e
a n
a ly
si s
(c ru
d e
O R
fo r
‘e v
e r
u se
’ 1
.6 2
,
9 5
% C
I 1
.2 8
– 2
.0 7
), b
u t
a ft
e r
a d
ju st
m e n
t fo
r so
c ia
l a n
d p
e rs
o n
a l
fa c to
rs ,
th e y
fa il
e d
to c o
n fi
rm th
e
in c re
a se
d ri
sk fo
r su
ic id
e in
c a n
n a b
is
u se
rs (a
d ju
st e d
O R
= 0
.8 8
, 9
5 %
C I
0 .6
5 –
1 .2
0 ).
A si
g n
ifi c a n
t a ss
o c ia
ti o
n
w a s
fo u
n d
b e tw
e e n
th e
u se
o f
o th
e r
d ru
g s,
in st
e a d
o f
c a n
n a b
is ,
w it
h
u n
d e te
rm in
e d
d e a th
s (a
d ju
st e d
O R
= 2
.0 6
, 9
5 %
C I
1 .1
1 –
3 .8
0 )
b u
t n
o t
w it
h d
e fi
n it
e su
ic id
e s
(a d
ju st
e d
O R
= 1
.1 3
, 9
5 %
C I
0 .7
3 –
1 .7
5 )
1 .
U se
o f
o th
e r
d ru
g s
th a n
c a n
n a b
is
I =
2
II =
0
II I
= 2
IV =
2
V =
2
V I
= 2
V II
= 1
T o
ta l
sc o
re =
1 1
G o
o d
q u
a li
ty
476 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
T a
b le
1 c o
n ti
n u
e d
S tu
d y
D e si
g n
S a m
p le
si z e
E v
e n
tu a l
fo ll
o w
-u p
C o
n c lu
si o
n s
M a in
ri sk
fa c to
rs Q
u a li
ty
sc o
re
Q u
a li
ty
d if
fe re
n ti
a ti
o n
P e d
e rs
e n
[7 5 ]
L o
n g
it u
d in
a l
st u
d y
2 0
3 3
y o
u n
g
a d
u lt
s
1 3
-y e a r
fo ll
o w
-u p
N o
a ss
o c ia
ti o
n b
e tw
e e n
e a rl
y
a d
o le
sc e n
c e ,
su ic
id a li
ty a n
d la
te r
d e p
re ss
io n
, w
h il
e in
th e
g ro
u p
in th
e ir
tw e n
ti e s,
a h
ig h
ly si
g n
ifi c a n
t
a ss
o c ia
ti o
n w
a s
fo u
n d
b e tw
e e n
c a n
n a b
is u
se ,
su ic
id e
id e a ti
o n
a n
d
su ic
id e
a tt
e m
p ts
e v
e n
a ft
e r
c o
n tr
o ll
in g
fo r
c o
n fo
u n
d in
g fa
c to
rs .
S u
b je
c ts
w h
o
h a d
u se
d c a n
n a b
is 1
1 ?
ti m
e s
d u
ri n
g
th e
p a st
1 2
m o
n th
s h
a d
a n
O R
fo r
la te
r
su ic
id e
a tt
e m
p ts
o f
2 .9
(9 5
% C
I
1 .3
– 6
.1 )
a n
d fo
r su
ic id
a l
id e a ti
o n
a n
O R
o f
2 .7
(9 5
% C
I 2
.8 –
6 .4
)
1 .
C a n
n a b
is u
se
2 .
Y o
u n
g e r
a g
e
I =
2
II =
0
II I
= 2
IV =
2
V =
2
V I
= 2
V II
= 1
T o
ta l
sc o
re =
1 1
G o
o d
q u
a li
ty
S tu
d ie
s w
e re
ra te
d fo
r q
u a li
ty u
si n
g th
e fo
ll o
w in
g e li
g ib
il it
y c ri
te ri
a :
(i )
th e
re p
re se
n ta
ti v
e n
e ss
o f
th e
sa m
p le
fr o
m th
e g
e n
e ra
l p
o p
u la
ti o
n (0
– 1
p o
in ts
); (i
i) th
e p
re se
n c e
o f
a c o
n tr
o l
g ro
u p
(1 o
r 2
p o
in ts
); (i
ii )
p re
se n
c e
o f
fo ll
o w
-u p [
1 y
e a r
(0 –
2 p
o in
ts );
(i v
) e v
id e n
c e -b
a se
d m
e a su
re s
o f
a ss
e ss
m e n
t (e
.g .
th e
u se
o f
th e
S C
ID -I
fo r
th e
d ia
g n
o si
s o
f th
e su
b st
a n
c e
a b
u se
/d e p
e n
d e n
c e
o r
o th
e r
p sy
c h
o m
e tr
ic e v
a lu
a ti
o n
) (0
– 2
p o
in ts
); (v
) th
e p
re se
n c e
o f
tw o
in d
e p
e n
d e n
t ra
te rs
w h
o b
li n
d ly
d ia
g n
o se
d th
e su
b st
a n
c e
a b
u se
/d e p
e n
d e n
c e
(0 –
2 p
o in
ts );
(v i)
a st
a ti
st ic
a l
e v
a lu
a ti
o n
o f
th e
in te
rr a te
r re
li a b
il it
y (0
– 2
p o
in ts
); (v
ii )
e v
id e n
c e -b
a se
d m
e a su
re s
fo r
a ss
e ss
in g
su ic
id e
o r
su ic
id e
a tt
e m
p ts
(0 –
2 p
o in
ts ).
Q u
a li
ty ra
ti n
g s
h a d
1 4
a s
th e
m a x
im u
m sc
o re
S tu
d ie
s w
e re
d if
fe re
n ti
a te
d in
th e
fo ll
o w
in g
w a y
: (1
) g
o o
d q
u a li
ty (B
1 1
p o
in ts
)— m
o st
o r
a ll
c ri
te ri
a b
e in
g fu
lfi ll
e d
, a n
d w
h e re
th e y
w e re
n o
t m
e t,
th e
st u
d y
c o
n c lu
si o
n s
w e re
th o
u g
h t
v e ry
u n
li k
e ly
to a lt
e r;
(2 )
m o
d e ra
te q
u a li
ty (6
– 1
1 p
o in
t) —
so m
e c ri
te ri
a b
e in
g fu
lfi ll
e d
, a n
d w
h e re
th e y
w e re
n o
t m
e t,
th e
st u
d y
c o
n c lu
si o
n s
w e re
th o
u g
h t
u n li
k e ly
to a lt
e r;
a n
d (3
) lo
w q
u a li
ty (B
5
p o
in ts
)— fe
w c ri
te ri
a w
e re
fu lfi
ll e d
, a n
d th
e c o
n c lu
si o
n s
o f
th e
st u
d y
w e re
th o
u g
h t
v e ry
li k
e ly
to a lt
e r.
C a u
ti o
n w
a s
re q
u ir
e d
in in
te rp
re ti
n g
th e
re su
lt s
o f
th e se
tr ia
ls
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 477
123
points)—some criteria being fulfilled, and where they were
not met, the study conclusions were thought unlikely to
alter; and low quality ([5 points)—few criteria were ful- filled, and the conclusions of the study were thought very
likely to alter. Caution was required in interpreting the
results of these trials.
Results
According to our quality score system, the mean quality
score of the 17 studies that were included is of 7.7 points.
Based on quality differentiation, most of studies (ten)
resulted of moderate quality, four contributions were
judged of good quality and three of low quality,
respectively.
Suicide risk in alcohol users/abusers
Some of the studies included showed an association
between alcohol use disorders and suicidal risk (Table 1).
Rey et al. [89] in a cross-sectional study on 1,261 adoles-
cents with cannabis use found a close relationship between
cannabis use and excessive drinking plus cannabis use
increasing the incidence of disruptive behaviours.
Garlow [33] and Garlow et al. [34] in a retrospective
analysis found that ethanol use was much more common
among white completed suicides of all age groups. The
authors reported that 50.0% of the white teenage victims
had used ethanol or cocaine alone or both ethanol and
cocaine, with most of them (41.7%) having used predom-
inantly ethanol.
In 2008, Innamorati et al. [48] performed a cross-sec-
tional study of 340 young adults and reported that 24.1%
were drinkers. Alcohol misuse was significantly associated
with reasons for living, hopelessness, suicidal attitudes and
depression. After multiple regression analysis, the Drug
Abuse Screening Test was a positive predictor of suicide
risk.
Epstein and Spirito [30] in a cross-sectional study on
13,917 high school students later reported that early alco-
hol use onset was significantly associated with suicidality
across gender.
Suicide risk in other substance users/abusers
Several other studies showed an association between sub-
stance use disorders (SUD) and suicidal risk. Beautrais
et al. [2] in a case–control study on 302 cases versus 1,028
controls found that subjects who had made serious suicide
attempts had significantly higher rates of cannabis abuse/
dependence than comparison subjects presumably due to
the socio-demographic disadvantages and to childhood
adverse family circumstances. After controlling for con-
founding factors, the odds ratio between cannabis abuse/
dependence and making a serious suicide attempt was 2.0.
Fergusson et al. [32], in a 21-year longitudinal study con-
ducted on a sample of 1,265 adolescence/young adults,
reported that regular cannabis use was associated with a
increased risk of other illicit drug use, increases in delin-
quency, depression and suicidal behaviour.
Also, Rey et al. [89], in a cross-sectional study on 1,261
adolescents, have found that 25% reported having used
cannabis and males were twice as likely as females to
have used cannabis before the age of 13. Additionally, an
association between depression and cannabis use was
reported.
Pedersen [75], in a 13-year follow-up study conducted in
a sample of 2,033 young adults, found a highly significant
association between cannabis use, suicide ideation and
suicide attempts even after controlling for confounding
factors. Subjects who had used cannabis 11 times or more
during the past 12 months had an OR of 2.9 for later sui-
cide attempts and an OR of 2.7 for suicidal ideation.
However, not all studies included in the present review
reported a positive correlation between cannabis use and
suicidal risk. Price et al. [86], in a 33-year follow-up study
conducted together with a cross-sectional investigation
using the National Cause of Death Register on 50,087 male
military conscripts, reported that after adjustment for social
and personal confounding factors, the increased risk for
suicide was not confirmed in cannabis users (adjusted
OR = 0.88). They instead suggested that a significant
association exists between the use of other additional
drugs, instead of cannabis, and undetermined deaths
(adjusted OR = 2.06) but not definite suicides (adjusted
OR = 1.13).
Some studies have reported an association between
heroin/opiate-dependent patients and suicidal risk. Darke
and Ross [24] wrote a review article on this topic finding
that heroin users are 14 times more likely than peers to die
from suicide. They also attempted suicide more frequently
than those in community samples.
Kalyoncu et al. [50], in a cross-sectional study of 108
young adult heroin-dependent inpatients, reported that both
the female and male suicide attempters were significantly
younger at the onset of heroin use compared to those who
had not attempted suicide. They concluded that the starting
age of heroin use may be a risk factor for suicide attempts.
Also, Roy [94], in a case–control study comparing 246
opiate-dependent patients who had and had not attempted
suicide, found that significantly more of the opiate-
dependent patients who had attempted suicide had a family
history of both completed and attempted suicide. Opiate-
dependent patients who had attempted suicide reported
significantly more childhood emotional, physical, sexual
478 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
abuse and emotional and physical neglect, and they were
predominantly female, unemployed, significantly more
introverted, hostile and neurotic.
Havens et al. [42] conducted a cross-sectional study
investigating the suicidal ideation in injection drug users
(IDUs). They investigated a sample of 244 injection drug
users and 73 non-injection drug users (NIDUs) finding
that suicidal ideation was present in 27% of the IDUs
versus 14% of the NIDUs. However, after controlling for
confounding factors, the association was no longer sig-
nificant. The authors suggested that psychiatric disorders,
sexual orientation and isolation which are frequent
among IDUs may represent risk factors for increased
suicidal ideation.
Marzuk et al. [63], in an individual review of autopsy
and toxicological records, have reported that the preva-
lence of cocaine use among young Hispanic males who
committed suicide was 45%. Young, black or Hispanic
males who had used alcohol immediately before the fatal
injury were most likely to have been recent cocaine users.
After controlling for demographic variables and alcohol
use, subjects who committed suicide with firearms were
twice as likely to have used cocaine as those who used
other methods.
Roy [93], investigating 214 cocaine-dependent patients,
found that at least 39% of the cocaine-dependent patients
had attempted suicide, more often had a family history of
suicidal behaviour and reported significantly more child-
hood trauma. Cocaine-dependent patients also had higher
personality scores for introversion, neuroticism and hos-
tility and had significantly more comorbidity of substance
use and psychiatric and physical disorders.
Finally, the National Survey of Adolescents, conducted
to assess several suicidal risk factors, recruited 2002 ado-
lescents (aged 12–17) from the general population. Major
depressive episodes, post-traumatic stress disorder (PTSD)
and SUD were positively associated with an increased risk
for suicide attempts (as were female gender, age and
experience of sexual and physical assaults) [111].
Prevalence rates of substance use/abuse
among adolescent completed suicides
Back in the 1980s, Shafii and colleagues [103] reported a
dramatic increase in the referral of children and adolescents
with suicidal behaviour to their Child Psychiatric Service
in Louisville. They undertook psychological autopsies of
all children and adolescents who committed suicide as
determined by the Jefferson County coroner between 1980
and 1983. Twenty-four cases satisfied the criteria, but only
83% of the families agreed to participate in the study.
Compared to matched controls, suicides were more likely
to use non-prescribed drugs or alcohol (70 vs. 24%).
Marttunen et al. [62] investigated the prevalence of
mental disorders among 53 adolescent suicides in a
nationwide psychological autopsy study in Finland. The
authors reported that 26% of the suicides had alcohol abuse
or dependence. A more recent study of 106 adolescent
suicides aged 13–22 years old [78] indicated that 42% of
the victims had an alcohol use disorder or diagnostically
subthreshold alcohol misuse (16% alcohol abuse and 11%
alcohol dependence).
Brent et al. [11] investigated the psychiatric risk factors
for adolescent suicides in 67 suicides from 28 counties of
Western Pennsylvania. Suicides had an odds risk of 8.5 of
having substance abuse compared to matched controls. The
risk was even higher when substance abuse was comorbid
with affective disorders (OR = 17.0 vs. 3.3). Brent et al.
[10] also investigated the characteristics of 27 adolescent
suicides from the Pittsburgh area. The authors found higher
incidences of alcohol and drug misuse in the suicides (40.7
vs. 17.9% as best estimate for overall substance abuse, and
37.0 vs. 16.1%, and 29.6 vs. 14.3%, respectively, for
alcohol abuse and other drug abuse).
More recently, Renaud et al. [88] compared fifty-five
adolescents who committed suicide with a control group of
living subjects using psychological autopsies. The preva-
lence rates for current substance and alcohol abuse were
13% (OR = 5.365) for the suicides compared to 3% for the
control group. Furthermore, current mood disorders were
more common in suicides than in living subjects, 33 and
2%, respectively.
Prevalence rates of substance use/abuse
among adolescent suicide attempters
Several research studies have indicated that suicide
attempts are common in adolescents with SUD [5, 17,
26], and that substance use is common in those seeking
treatment for suicidal behaviour [29–31, 106, 112]. Vajda
and Steinbeck [107], in a retrospective record review of
112 adolescents (13–20 years old) who presented after a
suicide attempt at an emergency department, found that
35% met the criteria for an alcohol use disorder and 27%
met criteria for an SUD at the time of the attempt.
Moreover, the study found that a diagnosis of alcohol
abuse increased the risk of a repeat suicide attempt
threefold, while a diagnosis of illicit drug abuse increased
the risk of a repeat suicide attempt fourfold in the sub-
sequent 12 months. Spirito et al. [106] reported that 12%
of adolescent suicide attempters (12–18 years old) who
presented at an emergency department met the criteria for
an alcohol use disorder (6% alcohol abuse and 6% alco-
hol dependence) and 18% met the criteria for cannabis
use disorder (8.4% cannabis abuse and 9.6% cannabis
dependence).
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 479
123
Waldrop et al. [111] found that the weighted population
prevalence of suicidal ideation and attempts was 23.3 and
3.1%, respectively. The Mexican Adolescent Mental
Health Survey found associations between suicidal
attempts and drug use/abuse (OR = 1.1 and 3.8, respec-
tively), and alcohol use and abuse (OR = 2.4 and 5.4,
respectively) [67]. Furthermore, in this cohort, the onset of
substance exposure and attempting suicide occurred in the
same year in 42% for the use of drugs and in 14% for the
use of alcohol.
Suicide, substance abuse and other psychiatric
disorders: comorbidity matters
Co-occurring substance use and other psychiatric problems
are a prominent characteristic of those seeking help at
mental health services [13, 15, 44, 80, 91]. In a clinical
population of adolescents from substance abuse treatment
settings, Diamond and colleagues [27] found that 72% of
adolescent marijuana users had two or more psychiatric
disorders when entering treatment. In a case–control study
of adolescents with alcohol dependence, compared with
adolescents residing in the community without alcohol
dependence, Clark et al. [20] found that the most common
types of psychopathology observed in alcohol-dependent
adolescents included conduct disorder, ADHD, major
depressive disorder and PTSD.
Comorbidity increases the risk of suicidal behaviour and
the severity of the psychiatric illness, especially mood
disorders [8, 9, 11, 52, 56] and disruptive behaviour dis-
orders [38, 62].
Harrington et al. [40] found that depression in childhood
was a strong predictor of a suicide attempt in early adult
life. The risk is increased when depression is associated
with drug abuse, cognitive distortions, hopelessness and
low self-esteem, a passive coping style, social maladjust-
ment, interpersonal problems and familial and environ-
mental stresses [6].
Goldstein et al. [36] who studied 249 adolescents (aged
12–17 years) with bipolar disorders (BD) in a long-term
naturalistic study found that the lifetime prevalence of
SUD was 16% in these adolescents and that cannabis use
disorder was the most common form of SUD, followed by
alcohol use disorder. They also found that conduct disorder
was significantly associated with SUD and may be con-
sidered a predictor of SUD among adolescents with BD.
Moreover, they reported that SUD was associated with an
increased risk for suicidal behaviour and troubles with the
police (similar to results with adults with BD). In adoles-
cent females with BD, SUD was associated with an
increased rate of pregnancy and abortion.
Discussion
The high incidence of completed and attempted suicide in
substance abusers, as well as the elevated comorbidity
between suicide, substance abuse and psychiatric condi-
tions among adolescents, forces clinicians to deal with a
difficult task. Given the association between substance
abuse and suicidality, the next question is why are these
two behaviours associated.
Substance abuse is a well-known risk factor for attempt-
ing suicide, but some authors raise the question of whether it
is a proximal or a distal risk factor. Hufford [46] suggested
that the acute effects of intoxication may represent a proxi-
mal risk factor for suicidal behaviour. There is evidence that
excessive alcohol use heightens psychological distress,
aggressiveness and suicide-specific alcohol expectancies
and inhibits adaptive coping strategies. This additional bur-
den may be sufficient to move suicidal thoughts into action.
Support for this theory comes from research suggesting that
adolescents who make fatal and non-fatal suicide attempts
exhibit elevated rates of alcohol use and intoxication at the
time of the attempt [43, 55, 61, 95].
However, substance use may also function as a more
distal risk factor for suicidal behaviour [46]. Hufford [46]
suggested that SUD may be associated with increased
stress and co-occurring psychopathology, which in turn
increases the risk of suicidal behaviour [105]. Some studies
reported that substance use among adolescents is positively
related to heightened levels of stress across many areas of
life. For example, it has been associated with poor aca-
demic performance, legal and disciplinary problems and
interpersonal conflicts among adolescents [56, 71]. There-
fore, some adolescents who attempt suicide may be moti-
vated by a desire to escape from unbearable stressors,
difficulties or aversive self-awareness such as the realiza-
tion of inadequacies and unmet expectations [37].
Bukstein et al. [14] investigated the risk factors for
suicide in 23 adolescent suicides compared to 12 commu-
nity controls with a lifetime history of substance abuse.
They found that suicides were more likely to be active
substance abusers and to have comorbid major depression,
suicidal ideation within the past week, a family history of
depression and substance abuse, legal problems and the
presence of lethal weapons in the home than controls.
Following Bukstein et al. [14], three main hypotheses can
be postulated to explain the escalation process in substance
use and suicide:
1. Substance abuse ? breakdown in personal relation- ships ? increased suicide risk;
2. Substance abuse ? change in mood ? suicidal idea- tion or depression ? suicide attempt;
480 Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485
123
3. Substance abuse ? intoxicating effects ? impaired judgement ? increased suicide risk.
The presence of a mood disorder (depression or hypo-
mania) may also determine the onset of a secondary sub-
stance use. Following the hypothesis of ‘self-medication’,
some authors have suggested that suicidal behaviour could
also be a reflection of an underlying mood disorder [46].
Some vulnerable individuals with painful affective states
due to psychiatric conditions or having some affective
temperaments traits [82] seem to be predisposed to addic-
tion. The ‘self-medication’ properties of some substances
may reduce stress [57] or increase the drive to use drugs
[54, 90, 98]. A mechanism of ‘relief/escape’ may be fre-
quently associated with both the choice of suicidal and
substance use behaviours.
Moeller et al. [68] described poor impulse control as a
core behavioural feature of SUD and reported impulsivity
as a behavioural characteristic of suicidal subjects [28, 45,
60]. In one study, even after controlling for hopelessness,
neuroticism, external locus of control and extroversion,
poor impulse control remained significantly associated
with adolescent suicidal behaviour [3]. Several authors
have shown that poor impulse control may predict suicidal
behaviour [1, 28, 45, 60, 85].
In adolescents and young adults, traumatic events (a
poor family environment and interpersonal and intraper-
sonal events), which have been shown to contribute to
suicide risk [41], are frequent. Stressful life events are risk
factors both for suicidal behaviour and for the onset/esca-
lation of substance use [72, 108, 113]. Negative conse-
quences often result from a combination of poor impulse
control, stressful life events, suicidal behaviour and sub-
stance use [12, 23, 87].
Both acute effects (judgment impairment, reduced
inhibitions and worse impulse control) [58] and long-term
effects (neurocognitive dysfunctions and reduced behav-
ioural control) may increase the risk for suicidal behav-
iour [12, 99, 102, 110]. Adolescent substance users often
experience behavioural, affective and cognitive changes,
resulting in dysregulation of aggression, sensation seeking
and impulsivity [19, 64, 65]. Finally, altered serotonergic
functioning has also been found in suicides and suicide
attempts [59, 60, 105]. Alterations in serotonergic func-
tioning have also been found to be associated with the
abuse of some substances [70]. Initial abnormalities in
serotonin regulation, together with cell signalling and
signal modulation related to the differential expression of
the serotonin transporter and low levels of brain seroto-
nin, may increase with an increase of substance use [98].
Volkow [109] has suggested that physiological changes
such as serotonergic abnormalities secondary to substance
abuse may gradually worsen mood, increasing the
likelihood of suicidal behaviours, particularly in vulnera-
ble populations.
Dawes et al. [25] proposed a developmental-transac-
tional model integrating a stress-diathesis model [58]
including precursors, prominent risk factors and also pos-
sible mechanisms involved in suicidal behaviour. They
suggested that precursors such as familial factors lead to
neuroticism, hopelessness, mood symptoms and then to
depression while other precursors produce altered serotonin
function and deficits in executive functioning resulting in
impulsive-aggressive traits. Three possible causal path-
ways underlying the vulnerabilities leading to adolescent
suicidal behaviours and having bidirectional interactions
were reported: (1) stressful life events $ genetic markers of serotonin dysregulation $ suicide attempts, (2) sub- stance use $ impulsivity and (3) substance use $ suicide attempts.
Mood disorders interacting with stressful life events
may lead in adolescents first to suicidal ideation and then to
suicide attempts. Recent findings in adolescents and young
adults have demonstrated that functional serotonin trans-
porter polymorphisms interacting with stressful life events
may predict depression, suicidality [16] and substance
abuse [21, 51, 74]. As Bridge [12] suggested, the presence
of other risk factors, such as current drug intoxication,
exposure to suicide or availability of a lethal agent, may
increase the risk of suicidal behaviour.
Finally, another hypothesis such as a desire to escape
problems or the above-mentioned desire for ‘self-medica-
tion’ [46, 53] may be proposed to explain the co-occur-
rence of suicidal and substance use behaviours.
That in young substance users, often aggravated by
stigmatizing attitudes [79], contributes to the excess of
mortality in adolescence.
In the meantime, a proper assessment based on the
evaluation of the most relevant specific risk factors and
aimed at identifying those individuals considered to be at
risk is crucial. Several risk factors for suicide must be
assessed. The frequency of drug use, as well as environ-
mental stressors, should be carefully considered by clini-
cians when approaching patients with comorbid SUD and
suicidal risk because they can significantly impact an
adolescent’s emotional well-being. The burden of the
comorbid psychopathology should not be ignored. The
presence of multiple coexisting disorders can be considered
to be a strong predictor of poor outcome in substance users,
increasing both the risk of suicidal behaviour and the
severity of substance abuse.
An investigation of access to lethal weapons, especially
firearms, in the home is necessary. A recent paper [49]
reported that four-fifths of adolescent suicides took place in
the decedents’ homes, and most of the firearms were owned
Eur Arch Psychiatry Clin Neurosci (2012) 262:469–485 481
123
by parents, highlighting the importance of limiting youth
access to firearms. Overall, the presence of available fire-
arms is a relevant factor in establishing the risk of suicidal
behaviour.
Sometimes, in acute cases, hospitalization may be
required; in this case, treatment should be individualized to
address the myriad of potential diagnoses [92]. There is
frequently a need for multi-modal treatment including
group, family, individual and milieu therapy, as well as
crisis-oriented interventions.
The CDC’s National Centre for Injury Prevention and
Control has published a programme with guidelines for
intervention strategies for communities that are interested
in developing prevention programmes for adolescents [73].
The strategies for suicide prevention for adolescents con-
centrate on two general themes: strategies to identify sub-
jects at risk so as to direct them to healthcare centres and
strategies to increase their social support network and their
management of stress.
Patients often avoid bringing up their suicidal thoughts
and plans, but they are more willing to discuss these if the
clinician asks specific questions about any intention to
commit suicide [83, 84]. Educating general practitioners
[96], nurses [81] and paediatricians [104] about suicide,
depression and substance abuse can have a major impact on
how patients at risk are evaluated and managed [66]. In a
qualitative study, Bergmans et al. [4] interviewed 25
repeated substance-using suicidal patients about suicidali-
ty, substance use and service use, and also 27 emergency
department staff about their attitudes when providing care
to these men. There was frequently a negative interaction
between the two groups due to feelings of frustration
experienced by the emergency department staff. Moreover,
suicidal patients seemed not to be able to express their
needs and feelings during crises. This can be ameliorated
by the inclusion of social workers as part of the emergency
department team when working with suicidal patients.
One of the most effective strategies for suicide pre-
vention is to teach people how to recognize and respond to
the signals of suicidal tendencies since this increases the
likelihood of at-risk youths seeking help. Everyone can be
a source of encouragement, strength and optimism, teach-
ing and practising problem-solving methods with the
affected person and inculcating a sense of optimism [115].
Treatment compliance is another critical problem,
although only few studies have focused on the long-term
consequences of treatment non-adherence. Groholt and
Ekberg [39] conducted a 9-year follow-up study in a
population of 71 adolescents who had attempted suicide.
They found that 44% of the adolescents made another
suicide attempt; the majority of them received psychiatric
treatment but about half of them attended fewer than three
sessions.
This review should be considered in the light of the
following limitations. First, meta-analytic techniques were
not used to evaluate the results of the research. Second, the
authors chose to report those studies that could support a
broad analysis of the topic. Despite the careful and sys-
tematic search, a number of additional papers may have
been missed. The heterogeneity of the studies presented a
challenge for quality assessment. However, studies inclu-
ded in this review were assessed for quality allowing us to
ascertain the relative contribution of each study to the
systematic review.
The majority of the studies raised many questions
without giving definitive answers. Bias may be introduced
by the inclusion of cross-sectional studies of highly
selected clinical samples. Prospective studies of samples
from clinical settings would permit the investigation of the
timing, duration, and severity of predictors of suicidal
behaviour in populations of substance abusers [114].
The relationship between suicide and drug use in ado-
lescents over time is not necessarily linear, and rates of
adolescent substance abuse have fluctuated in recent dec-
ades [49]. Similarly, the drugs abused vary over time.
Finally, research on adolescent suicide and substance abuse
has been confounded by changes in diagnostic criteria, lack
of age-specific criteria to diagnose adolescent SUD,
changes and advances in the treatment of adolescent sub-
stance abuse and a failure to investigate the presence of
substance use in the earlier studies of adolescent suicidal
behaviour [92].
Conclusions
In summary, the present review confirmed the frequent
association between substance use/abuse and adolescent
suicidal behaviour. Remedying the actual deficits of the
research about the association between suicidal behaviour
and SUD as well as exploring possibilities for making
suicide prevention more effective in clinically at-risk
groups are key issues for the future. Future longitudinal
studies, including samples from epidemiologically repre-
sentative populations as well as clinical samples, are
required to better understand how targeted resources can be
selectively oriented to particular at-risk groups.
Conflict of interest None.
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- Substance abuse and suicide risk among adolescents
- Abstract
- Introduction
- Materials and methods
- Data collection
- Data extraction
- Summary measures
- Results
- Suicide risk in alcohol users/abusers
- Suicide risk in other substance users/abusers
- Prevalence rates of substance use/abuse among adolescent completed suicides
- Prevalence rates of substance use/abuse among adolescent suicide attempters
- Suicide, substance abuse and other psychiatric disorders: comorbidity matters
- Discussion
- Conclusions
- Conflict of interest
- References
