Psychoactive substances in suicides. Comparison of toxicologic findings in two samples.

The goal in this study was to assess if there is any constancy in detections of psychoactive substances in consecutive suicides. Toxicologic findings in 179 suicides in San Diego County, California, between 1981 and 1982, and 333 suicides in Mobile County, Alabama, between 1990 and 1998, were compared. Alcohol was detected in about 30% of suicides in both samples. Abusable prescription psychoactive substances, i.e., benzodiazepines and opiates, were detected in one fifth of cases in both locations. Nonabusable prescription psychoactive substances, mainly antidepressants, were found in more suicides in Mobile than in San Diego. Detection rates of different classes of psychoactive substances have not changed much in the past decade. Detection of alcohol, cocaine, or cannabis in about 40% of suicides supports the clinical practice of discouraging consumption of these substances in depressed patients. Another challenge is the low rate of detection of antidepressants in suicide, which suggests undertreatment of depression in suicides. Continued reporting of routine, comprehensive, toxicologic findings in suicides is useful to monitor patterns of use of psychoactive substances in this group and to guide suicide prevention in clinical practice and public health policy.

Patterns of psychoactive substance detection from routine toxicology of suicides in Mobile, Alabama, between 1990 and 1998.

BACKGROUND: Postmortem toxicology can be useful for reconstructing some clinically important events occurring before a suicide. Its utility may be improved by examining patterns of detected substances in a population over time. METHODS: Toxicology was performed for 333 (96%) of the 346 suicides occurring in Mobile County, Alabama, between October 1990 and September 1998. Detected psychoactive substances were grouped in three categories: alcohol, cocaine, and cannabis; abusable prescription medications; and non-abused psychotropic medications. The overlap between these three categories was assessed. RESULTS: Psychoactive substances were detected in 227 (68%) of 333 suicides. Of the cases positive for any prescription psychoactive medication, 2/3 were positive for an abusable medication. An abusable substance was found in 56% of cases positive for non-abused psychotropic medication. Alcohol, cocaine and/or cannabis were found in 34% of cases with abusable prescription medications and in 33% with non-abused psychotropics. LIMITATIONS: Clinicians must be aware of a number of methodological realities when interpreting routine postmortem toxicology results. CONCLUSIONS: Routine surveillance of psychoactive substances among suicides can provide useful data for directing and monitoring strategies for suicide prevention in clinical practice.

The evaluation of a sexual assault risk reduction program: a multisite investigation.

This article summarizes the results of the Ohio University Sexual Assault Risk Reduction Project, which is a program designed to reduce college women's risk for sexual assault. The program was evaluated at 2 separate universities with 762 women. Participants were randomly assigned either to the program or to the no-treatment comparison group, and they completed measures that assessed sexual victimization, dating behaviors, sexual communication, and rape empathy at the pretest and at the 2-month and 6-month follow-ups. At the 2-month follow-up, there were no differences between the groups on any of the outcome measures. However, those women who were moderately victimized during the 2-month follow-up were significantly less likely to be revictimized during the 6-month follow-up period if they participated in the program.

Suicide methods and presence of intoxicating abusable substances: some clinical and public health implications.

Toxicological studies have reported the presence of alcohol in about a third of suicides. Some have suggested that the presence of alcohol might predispose suicidal people to use particular methods, e.g., guns, although, in general, this does not appear to be the case. More recently, comprehensive toxicological studies have provided data on the detection of all intoxicating abusable substances (IAS) among suicides. The purpose of this report is to examine the presence of two samples of suicides to see if any relationships between presence of IAS at post mortem toxicology and any specific suicide method. The samples included 179 suicides from San Diego, California (1981-1982), and 225 suicides from Mobile, Alabama (1990-1995) for which comprehensive toxicological examination had been conducted. Methods were grouped into more immediately fatal (MIF) and less immediately fatal (LIF) categories. The most common method in each category (guns and overdoses respectively) were examined separately as well. The same proportions of men (51%) and women (65%) were positive for any IAS in both locations. There were no significant differences in the proportions of suicides that were positive for IAS between the sample totals or by gender or age groups (under age 30 and age 30 and over) for any of the methods or categories examined. Significantly more of the Mobile suicides were by MIF methods than in San Diego for both genders, almost totally attributable to the use of guns. The use of guns for suicide in Mobile (and the state of Alabama) was also significantly higher than the rest of the U.S. in the early 1990's. Nonetheless, the suicide rates for men and women in Mobile (and Alabama) were no higher than for the overall U.S. rates. We conclude that potentially suicidal people should be advised to avoid intoxicating abusable substances of any kind. We also suggest that physicians should avoid prescribing such substances to depressed or suicidal patients.

Suicide and antidepressants in south Alabama: evidence for improved treatment of depression.

The purpose of this study was to investigate the occurrence of antidepressants among suicides in the era since the introduction of newer less toxic antidepressants. Comprehensive post mortem toxicological examinations were performed on 94% of certain and uncertain suicides in Mobile County, Alabama, between October 1, 1990 and September 30, 1995. Comparisons were made between current data from Mobile and data from the San Diego study in 1981-83. About twice as many suicides in Mobile were positive for antidepressants than in San Diego (15% vs. 8%). The proportions of antidepressant overdose deaths were the same (5%), however. Antidepressants were found in significantly fewer males than females and blacks than whites in Mobile. Although antidepressants were found in a greater proportion of people who committed suicide in Mobile, they were not used more frequently as a means of suicide. The authors conclude that this may represent improvement in care received by people with depression. It remains to be determined what suicide preventive effects individual antidepressants or groups of antidepressants may have.

Epidemiological data suggest antidepressants reduce suicide risk among depressives.

In spite of the availability of antidepressant medication for several decades, it has not been shown that such medication lowers the risk for suicide in depressed patients. This report explores this apparent paradox by means of pharmacoepidemiological methods. Data on the prevalence of depression in the population and among suicides as well as data on the prevalence of antidepressant medication in depressed suicides were obtained from a review of the literature. Data on the prevalence of antidepressant medication in the population in 1990-1991 were obtained from the statistics of the Swedish National Corporation of Pharmacies. It was found that only one in five depressed individuals with major depression were treated with antidepressants in Sweden. The calculated risk for suicide among depressed patients who were treated with antidepressants was 141 per 100,000 person years and, among the untreated, 259 per 100,000 person years (i.e., 1.8 times higher among the untreated). This supports the hypothesis that antidepressant medication decreases the risk for suicide in depressed patients. The reason this has not been obvious in the general suicide statistics seems to be that so few depressed people are treated with antidepressants. Effective suicide prevention strategies should include intensive efforts to recognize and treat more depressed people.

Antidepressants, depression and suicide: an analysis of the San Diego study.

Depression has been consistently reported in 40-50% of suicides. Previous toxicologic studies of suicides have not included diagnostic information, however. This report includes 247 (87%) of 283 suicides in whom it was possible to perform toxicological analyses for tricyclic antidepressants. We wanted to see if any relationships existed among the presence of antidepressants at autopsy, diagnosis of Depression, recent contact with physicians and prescription of antidepressant medication. Toxicology was positive in 19 (8%) subjects. Only 12% of the subjects with a DSM-III diagnosis of Major or Atypical Depression were positive. Lethal blood levels of antidepressants were found in only 4% of all subjects and most of those involved multiple drugs. Also, most of those subjects had co-morbid Depression and Substance Abuse. More than half of the Depressed subjects had seen a physician within 90 days from suicide but less than half of these were prescribed antidepressants and only one-third of the latter were positive for antidepressants in toxicology. These data suggest that more suicides might be averted by decisively treating Depressed patients with ADs, including strict monitoring of dosage and compliance, than by not treating them to avoid AD overdoses. Diagnostic caution should be observed to identify co-morbid Substance Abuse when treating patients with Depression and suicidal ideation.

Rates and correlates of suicide attempts in first-admission psychotic patients.

The relationship of attempted suicide to demographic characteristics, current and lifetime psychiatric diagnoses, clinical history, and current symptoms was assessed in a sample of 184 recently hospitalized psychotic patients. Forty-three patients (23%) had an attempt history, and 28 (15% of sample; 65% of attempters) made an attempt during the episode for which they were hospitalized. Demographic characteristics did not distinguish attempters from nonattempters. Variables significantly associated with having ever attempted suicide were current diagnosis of unipolar major depressive disorder but not bipolar; lifetime major depressive episode; a history characterized by a less acute onset, lower pre-admission psychosocial functioning, and episodes of physical violence; and a symptom picture characterized by greater depression, hopelessness, negative symptoms, hallucinations and less thought disorder. Those with a current attempt had significantly higher rates of lifetime history of major depression and less physical violence than those with past attempts only. The potential importance of the data for predicting future suicidal acts is discussed.

Diagnostic and statistical manual of mental disorders, 3rd ed. (DSM-III), adaptive functioning in young Swedish suicides.

Fifty-eight consecutive suicides between 15 and 29 years of age occurring in Göteborg, Sweden, were assessed in accordance with DSM-III Axis V (highest level of adaptive functioning in the past year). The levels of adaptive functioning were compared to principal Axes I and II disorders. Subjects with a borderline personality or schizophrenic disorder as the principal disorder tended to have poor to very poor adaptive functioning and were frequently associated with substance abuse (19 of 24 subjects). Subjects with adjustment disorder or major depressive disorder as the principal disorder generally had very good to fair adaptive functioning. Clinicians are reminded that apparently higher functioning as defined by DSM-III Axis V is no insurance against suicide.

Suicide over 60: the San Diego study.

OBJECTIVES: To see if selected clinical factors characterize suicides over the age of 60 differently from younger suicides and to ascertain if those factors characterize female and male suicides over the age of 60 differently. DESIGN: A group of consecutive suicides aged 60-88 was compared with groups of consecutive suicides aged 31-59 and 16-30. The female suicides aged 60-88 were also compared with the male suicides in that age group. Data were gathered from a variety of informants using a structured interview format. SETTING: The sample was gathered in San Diego County, California, between November, 1981 and September 1982. PARTICIPANTS: The sample consisted of 204 consecutive suicides. These included 49 cases aged 60-88, 94 cases aged 31-59, and 61 cases aged 16-30. The older group consisted of 20 females and 29 males. MEASUREMENTS: Comparisons were made in demographic, diagnostic, and other clinical characteristics. RESULTS: There were no significant differences between female and male suicides over age 60 on any of the variables examined. Only minor differences were found among the groups in patterns of mental disorders diagnosed. Older suicides were significantly more likely to be married or, if not married, widowed than either of the two younger groups. They were also significantly more likely to be stressed by medical illness. They were significantly less likely to have financial problems as stressors. They were significantly less likely to have talked about suicide or made prior suicide attempts than either of the two younger groups. CONCLUSIONS: Patterns of certain characteristics of suicides are very similar regardless of age. However, specific age-related differences occur that need to be considered when assessing suicide risk. Older suicides may be harder for clinicians to predict and, therefore, prevent.

Sedatives and suicide: the San Diego study.

Although clinical experience points to the frequent use of sedatives and hypnotics in suicide, remarkably few data are available to characterize the demographics of the population involved. The San Diego study, in which toxicological examinations were performed in over 90% of 204 consecutive suicides seen by the San Diego County Coroner during 1981-1982, provides an opportunity to examine suicide victims who were taking various medicines and drugs of abuse. Drugs were detected in 68% of tested subjects. Anxiolytics and hypnotics were found in 10.7% and 12.3% of the cases respectively. Women were more than 4 times as likely as men to have tested positive for an anxiolytic or hypnotic. Antidepressants were found in 5.9%. Alcohol had been ingested by 28.3% of subjects. Barbiturates and benzodiazepines were found in approximately equal proportions, although nationally the number of barbiturate prescriptions filled in drugstores was only one-sixth that of benzodiazepines. Major depression was found in 22.5%; among cases with positive histories of major depression, only a small proportion ranging from 4-10% were positive for antidepressants, anxiolytics or hypnotics. Interestingly, approximately equal proportions (4.8% and 6.2%) of depressed and non-depressed patients were positive for antidepressants. Among subjects whose deaths were attributed to drug ingestion, benzodiazepines, barbiturates and antidepressants were found in approximately one-third each, with little overlap. Although benzodiazepines were found in less than 10% of the group as a whole, they were found in one-third of subjects who committed suicide by overdose.(ABSTRACT TRUNCATED AT 250 WORDS)

Similarities in diagnostic comorbidity between suicide among young people in Sweden and the United States.

A significant difference in the prevalence of personality disorders was reported between similar studies of suicide among young people (under age 30) performed in San Diego, California (10% of 133 cases), and Göteborg, Sweden (34% of 58 cases). The difference was due entirely to the absence of borderline personality disorder (BPD) reported in the San Diego sample. In this study, we used preselected variables to reassess the suicides from the San Diego study for criteria consistent with BPD. We found that 41% met the criteria, which was now not significantly different from the Göteborg sample. Comparisons among a number of other demographic, social, and diagnostic variables revealed many similarities in the two samples, particularly Axis I comorbidity with depression and/or substance abuse and Axis II comorbidity with antisocial personality disorder. We conclude that the characteristics associated with BPD identify similar young persons who committed suicide in Sweden and the United States. Questions remain as to whether or not Axis I and II disorders are independent in relation to suicide. The comorbidity pattern described here must be considered seriously in the clinical setting for its fatal implications.

Suicide, stressors, and the life cycle.

OBJECTIVE: Relationships between stressors and suicide might be expected to vary with stages of the life cycle. The purpose of this study was to examine this possibility. METHOD: The authors examined the first 204 consecutive cases from the San Diego Suicide Study, a federally funded investigation of 283 suicides, for possible relationships between suicide and age and the frequency of specific stressors. Information was gathered from family members, spouses, acquaintances, employers, other witnesses, physicians, and other professionals by trained interviewers using a structured format. Hospital, physician, therapist, school, and police records were also included when available. DSM-III diagnoses were made by consensus of two investigators. Life events information was also reviewed independently by the investigators to determine stressors (if any) for each case. RESULTS: Of the 202 subjects for whom data were available, 195 (97%) had one or more stressors; 137 male subjects had a total of 272 stressors, and 58 female subjects had a total of 115 stressors. The authors found predictable patterns of the three most common stressor groups--conflict-separation-rejection, economic problems, and medical illness. The majority of the stressors among subjects 80 years old or older were illnesses. The only significant difference between the sexes was that more men than women had economic problems as a stressor. CONCLUSIONS: The variations in the patterns of stressors found in this study of suicides coincide with adult development theory. The lack of population comparison subjects and stressor scoring validation, however, limits the predictive value of these data in assessing suicidal persons.