The pattern of alcohol use among suicidents.

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.

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