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199406, Санкт-Петербург, ул.Гаванская, д. 49, корп.2

ISSN 1999-6314

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ТОМ 4, СТ. X (сc. X) // Апрель, 2003 г.

THE PATTERN OF ALCOHOL USE AMONG SUICIDENTS

A. Värnik
Estonian-Swedish Institute of Suicidology, Tallinn; Tartu University; Estonia
M. Väli,
Tartu University, Estonia
K. Kõlves,
Estonian-Swedish Institute of Suicidology, Tallinn
Abstact



  << Contents

 

The aim of the study was to clear out the proportion of alcohol dependence among suicide victims in Estonia. On individual level suicidents for the year 1999 (427 cases) were examined. The diagnosis of alcohol abuse or dependence was set up by clinical diagnosis during the lifetime from medical documentation and diagnosis post mortem at psychological autopsy study run by psychiatrists.

The result of the study was that proportion of suicide victims involved in alcohol abuse or dependence was very high. Obviously alcoholism, one of the suicide risk factors, was hypo-diagnosed at lifetime, particularly with men.

Introduction

Alcohol is known from clinical studies to be an important factor in suicidal behaviour (1-7). Various studies have shown substantial proportions of alcoholics among completed suicides. Substance abuse is also commonly reported in retrospective investigations of suicide (8-10), in which 15-50% of unselected suicides were found to be alcoholics (11,12). The relation between alcohol and suicide is weaker for females than for males (13). The proportion of women alcoholics among completed suicides found in the study by Robins et al (8) was 13%, while Barraclough et al (9) reported 6% and Åsgård 7% (14). Alcohol problems are more often observed among young and middle-aged male suicidents than in other agegroups (12).

It is known, that Estonia is the country with high suicide risk and also use of alcohol in litres per capita is very high.

The aim of the study was to clear out the proportion of alcohol dependence among suicide victims in Estonia. On the assumption of previous studies we raised hypotheses that male suicidents are more frequently alcohol misusers than female suicidents; middle-aged males are the biggest alcohol and suicide riskgroup. We examined also hypothesis that condition of hepatis at autopsy can use as an additional possibility for diagnosing alcoholism and tried to find correlation between habits of alcohol use among suicidents and condition of hepatis.

Methods

Subjects

On the assumption of the data of Estonian Statistical Office there was 469 suicides in Estonia in 1999. Psychological autopsy was available for 427 cases which constitute 91% of suicides in this time period. 343 (80%) from suicidents were male and 84 (20%) female. Estonian constituted 57% and non-Estonian 43%.

Alcohol diagnosis

We started our diagnostic procedure by examining medical documentation of suicidents. First we excluded suicidents who suffered at their life time from hard mental disease like schizophrenia, organic psychoses etc to detach secondary alcoholism, so 6.3% from suicidents dropped out. Hard mental disease was diagnosed more frequently among female suicidents compared to male (3.5% among males, 17.9% among females).

Secondly, we fixed the clinical diagnosis of alcohol dependence. Later we looked through all the material for every individual case and concluded post mortem status concerning pattern of alcohol use as follows:

F1x.2. Alcohol dependence

F1x.1 Alcohol abuse

Moderate use of alcohol

Abstinence

Drug abuse

Indistinct

Missing

Diagnosis for alcohol dependence and alcohol abuse was classified on the basis of ICD-10 as follows, if during last year three or more following symptoms occurred:

  1. obsession to use alcohol;

  2. inability to control behaviour or amount of alcohol while drinking;

  3. withdrawal syndrome when decreasing the use of alcohol or quitting;

  4. decrease of tolerance;

  5. the progressing lose of interests, the increased amount of time necessary for recovering from the consumed alcohol;

  6. somatic and psychological disorder (liver, depression, impediment of cognitive functions).

Diagnostical difficulties

Post mortem diagnosis is problematic because many alcoholics and alcohol abusers have not reached for help, therefore diagnosing according to medical documentation would demonstrate that the number of alcoholics is significantly smaller than in reality, as also revealed by the present study. Posthumous diagnosis using the data of a close relative is rather subjective because it is influnced by:

  1. an interviewee;

  2. an interviewer;

  3. the quality of a questionnaire.

We tried to guarantee objectivity by the following aspects:

  1. Interviewers were experienced psychiatrists who in every case expressed and added their opinion of alcohol use.

  2. One of the authors (AV) made a separate posthumous diagnosis about every subject to be studied on the basis of the material gathered. Diagnosis was carried out with blind method twice.

  3. The condition of liver as reported in autopsy was used as a crucial objective symptom.

  4. The questionnaire of psychological autopsy used for interviewing has been worked out in Finland and is internationally approved, whereas ICD-10 standards were used as the basis for the posthumous diagnosis.

Results

From total population of suicidents a half were alcoholics and 6% alcohol abusers by ICD-10 (Table 1). A quarter from suicidents used alcohol in moderate level and 11% did not use alcohol at all (at least in last 12 months). Drug abusers constituted 5% from suicidents, and 15 cases stay indistinct.

Table 1. Suicidents of the year 1999 in Estonia (No 427) devided by pattern of alcohol use

Groups by pattern of alcohol use

total

male

female

No

%

No

%

No

%

Alcohol dependence (F1x.2 by ICD-10):

199

49.8

186

56.2

13

18.8

clinical diagnosis

65

16.3

65

19.6

0

0

diagnosis post mortem

134

33.5

121

36.6

13

18.8

Alcohol abuse (F1x.1 by ICD-10)

23

5.8

20

6.0

3

4.3

Moderate use of alcohol

98

24.5

73

22.1

25

36.2

Abstinence

43

10.9

22

6.6

21

30.4

Drug abuse

22

5.5

19

5.7

3

4.3

Indistinct

15

3.8

11

3.3

4

5.8

Total

400

100

331

100

69

100

Missing (severe mental illness)

27

6.3

12

3.5

15

17.9

Differences between gender

Male suicidents were alcoholics significantly more frequently than females as well as alcohol abusers were found more commonly among male suicidents (Fig. 1). Among female suicidents was the proportion of moderate users of alcohol or non-alcohol users noticeably bigger than among males.

Figure 1. Pattern of alcohol use among male and female suicidents. Estonia, 1999.

Differences between age groups among males

We compared the pattern of alcohol use among male suicidents at the age of 35-59 with younger and older male suicidents. 3% from male suicidents in age group 35-59 dropped out from analysis because of hard mental illness, 1% dropped out from younger and 7% from the older age group. Almost three-quarters of middle-aged (35-59) male suicidents were alcoholics and 5% alcohol abusers. Only 2% did not use alcohol (at least in last 12 months) in this group and 13% used alcohol at the moderate level. If we compare these results with groups of younger and older males are differences remarkable. Table 2 shows also that alcohol dependence is very high among older males (older than 59) and drug users are mostly male suicidents in younger agegroup.

Table 2. Male suicidents, devided by pattern of alcohol use and age, Estonia

Groups by pattern of

males aged
> 35

males aged 35-59

males aged <59

alcohol use

abs.

%

abs.

%

abs.

%

Alcohol dependence (F1x.2 by ICD-10):

26

26.8

118

74.2

42

56.0

clinical diagnosis

7

7.2

45

28.3

13

17.3

diagnosis post mortem

19

19.6

73

45.9

29

38.7

Alcohol abuse (F1x.1 by ICD-10)

8

8.2

8

5.0

4

5.3

Moderate use of alcohol

35

36.1

21

13.2

17

22.7

Abstinence

8

8.2

3

1.9

11

14.7

Drug abuse

15

15.5

4

2.5

0

0.0

Indistinct

5

5.2

5

3.1

1

1.3

Total

97

100

159

100

75

100

Missing (severe mental illness)

1

1.0

4

2.5

7

8.5

Condition of hepatis

Almost a fifth (19% - 81) from suicidents had dystrophia or cirrhosis hepatis, 10% of them (8) had hard mental illness and dropped out from analysis. Among suicidents with pathology of hepatis proportion of alcoholics was remarkably higher than among suicidents without hepatis damage (Table 3). Alcohol non-users and users in moderate level had affected hepatis more seldom.

Table 3. Cirrhosis or dystrophia hepatis. Suicidents for year 1999 in Estonia (No 427) devided by pattern of alcohol use

Groups by pattern of alcohol use

liver damage

non liver damage

abs.

%

abs.

%

Alcohol dependence (F1x.2 by ICD-10):

52

71.2

147

45.0

clinical diagnosis

16

21.9

49

15.0

diagnosis post mortem

36

49.3

98

30.0

Alcohol abuse (F1x.1 by ICD-10)

4

5.5

19

5.8

Moderate use of alcohol

7

9.6

91

27.8

Abstinence

3

4.1

40

12.2

Drug abuse

5

6.8

17

5.2

Indistinct

2

2.7

13

4.0

Total

73

100

327

100

Missing (severe mental illness)

8

9.9

19

5.5

Discussion

The results show that proportion of alcoholics and alcohol abusers is very high among suicidents in Estonia in 1999: more than half of cases. In accordance with other studies, are alcohol misusers more frequently males: alcohol dependence is three times higher among male suicidents compared to females. Female suicidents are mostly alcohol non-users or users in moderate level.

Alcohol is especially important suicide riskfactor among males at the age of 35-59, but also among older male suicidents. Younger suicide victims are more frequently drug users compared with other age groups.

We tried also find relationship between alcohol using habits and damage of hepatis. Results showed that suicidents with damage of hepatis were more frequently alcoholics than suicidents without damage of hepatis, but as a additional possibility for diagnosing alcoholism is this not 100% secure.

References

  1. Beskow J. (1979) Suicide and mental disorder in Swedish men. Acta Psychiatrica Scandinavica, Suppl. 227, 1979

  2. Murphy GE. (1992) Suicide in alcoholism. New York, Oxford University Press, 1992

  3. Frances RJ, Franklin J, Flavin DK. (1987) Suicide and alcoholism. American Journal of Drug and Alcohol Abuse 1987: 13: 327-341

  4. Wasserman D, Värnik A, Eklund G. (1994) Male suicides and alcohol consumption in the former USSR. Acta Psychiatrica Scandinavica 89: (5): 306-313

  5. Lester D. (1995) The association between alcohol consumption and suicide and homicide rates: a study of 13 nations. Alcohol & Alcoholism 30: 4: 465-468

  6. Värnik A. Suicide in the Baltic countries and in former republics of the USSR. Stockholm 1997

  7. Wasserman D, Värnik A, Dankowicz M, Eklund G. (1999) Suicide Preventive Effects of Perestroika in the former USSR. Acta Psychiatrica Scandinavica, Suppl. 394

  8. Robins E, Murphy GE, Wikonson RH, Gassner S, Kayes J. (1959) Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. American Publ. of Health 1959: 49: 888-889

  9. Barralough B, Bunch J, Nelson B, Sainsbury P. (1974) A hundred cases of suicide. British Journal of Psychiatry 1974: 125: 355-373

  10. Vijayakumar L, Rajkumar S. (1999) Are risk factors for suicide universal? A case-sontrol study in India. Acta Psychiatrica Scandinavica 1999: 99: 407-411

  11. Wasserman D. (2001) Suicide - An unnecessary death. Martin Dunitz 2001

  12. Murphy GE. (2000) Psychiatric Aspects of Suicidal Behaviour: Substance Abuse. In Hawton K, van Heeringen K. (Eds.) The International Handbook on Suicide and Attempted Suicide. John Wiley & Sons, Ltd. 2000: 135-146

  13. Pirkola SP, Isometsä ET, Heikkinen ME, Lönnqvist JK. (2000) Suicides of alcohol misusers and non-misusers in a nationwide population. Alcohol & Alcoholism 2000: 35: 1: 70-75

  14. Åsgård U. (1990) Suicide among Swedish women: A psychiatric and epidemiologic study. Stockholm, Karolinska Institute 1990



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