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

EDITORIAL

Alcohol and suicide^beyond the link at the individual level

Both suicide and alcohol abuse represent areas of great concern with respea to health and welfare as well as social and economical costs. TTie degree to which these two are interrelated has been subject to scientific interest for more than a century. Scientific efforts in this area have so far brought us knowledge of significant relevance, for clinical and political purposes beyond the potential of generating knowledge per se. But we are still in need of, and in search for, more knowledge. I will in the following briefly sketch out some of the proposed mechanisms of association between alcohol and completed suicide, some of the consistencies and inconsistencies in empirical findings, and some of the future challenges for research in this area. Although attempted and completed suicide may overlap and share characteristics and predictors in some respects the focus here will be limited to that of completed suicide.

escape in the bottle as the first choice, and in suicide next. At the aggregate level social changes may increase the level offi:aistrationor degree of anomie, causing some people to respond with suicide whereas others respond with drinking. On the other hand, by comparing regions with the same level of frustration, one may find that in some regions there are cultural "prescriptions" to choose suicide as a response to fiTistration whereas in other regions (wetter cultures, presumably) alcohol will be the choice of preference, and in the latter case fewer lives are lost in suicide. These kinds of mechanisms are only in part well documented and empirically supported through various studies. It also remains to assess the relative importance of these mechanisms in various cultures and under various conditions. By leaning on both individual data studies and on aggregate data studies the potential for further finitful elaboration in this direction is probably enhanced.

Mechanisms The role of alcohol in suicide covers various mechanisms.'"* Suicide may be the end point of a long tenn drinking career with gradual social isolation and depression as intermediate factors, but it may also be the solution to the child or the wife of an alcohol abuser seeing no other way to escape &om insecurity, isolation, neglect, and violence. To some people getting into a state of intoxication may be like pulling the triggerbarriers to hurting oneself are removed, and depression, self pity and suicidal thoughts fioat overpaving the ground for the final act. Others again are probably suicidally inclined &om an early point in life, but seek comfort, relief, or

Empirical studies
Indimdual level studies

Most studies in the area of alcohol and suicide are on the individual level, and they can to a i a i ^ extent be divided into two groups; studies of suicide in alcohol abusers or heavy drinkers, and studies of alcohol use and alcohol abuse in suicides. There has been found a significMit excess mortality by suicide in samples of alcohol abusers in treatment, ranging from 2 to 25,' with the majority of studies arriving at estimates of excess suicide mortality in the range from 5 to 10 for males.'"'' Furthermore, the life time risk of

0965-2140/96/101413-04 t8.00 Society for the Study of Addiction to Alcohol and Other Drags Carfax Publishing Company

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Editorial

suicide in alcohol abusers has been estimated to some 2-5%. "'^'* The proportion of suicides with a history of alcohol abuse or heavy drinking has been reported to vary as much as in the range from ia-54%.'-'*-" Thus, on the basis of individual level studies the findings are quite consistent with respect to an excess mortality by suicide in alcohol abusers, and an elevated proportion of alcohol abusers and alcohol intoxicated persons in samples of suicides. The degree, however, to which alcohol abusers are more prone to suicide, and the degree to which alcohol abusers are overrepresented in samples of suicides vary largely. One may, probably to a significant extent, ascribe these variations to random variations in time and space and to methodological inconsistencies. For instance the criteria for alcohol abuse differ significantly between studies, which accordingly implies a variation in the proportion of alcohol abusers in samples of suicides. Furthermore, the increased suicide risk in alcohol abusers with psychiatric co-morbidity"''^'" may also account for some of the variation in excess suicide mortality, as the samples probably vary with respect to prevalence of mental illness. Yet, on the other hand the idea that the relationship between alcohol and suicide also would be subject to actual cultural and social variations that are observable, seems plausible and worth pursuing.

Aggregate level studies

Although suicide appears to be an individualistic phenomenon related to characteristics of the individual, one may also, as Durkheim" regard the suicide rates in a society as a response to social phenomenas and social changes at the macro level. Norstrom' assumed that genetic fectors and personality traits may predispose some individuals for suicide, whereas social or environmental factors may be the mgger of suicide in predisposed individuals. An empirical approach to the association between alcohol and suicide at the macro level may serve several purposes. So far individual level studies have given sparse if any basis for determining the degree to which the observed associations between alcohol and suicide reflect selection mechanisms or a causal relationship. Whereas time series studies at the aggregate level have provided a basis for assessment of the pro-

portion of suicides that are attributable to the direct and indirect effects of alcohol consumption.^ Ecological analyses at the macro level have also hitherto been the only empirical approach to test the hypothesis of alcohol and suicide as alternative strategies. Hence, this may illustrate the importance of supplementing individual level studies and aggregate level studiesapproachii^ the issue from difEerent empirical angles." Furthermore, from an alcohol policy point of view it is also of importance and relevance to have a well founded idea about the magnitude of social costs, in terms of alcohol related suicides and other deaths, that can be expected to follow a given increase in total alcohol consumption. Until recently the number of studies on alcohol and suicide at the aggregate level were few. Indeed Durkheim already a century ago tested the possible association between suicide rates and rates of alcoholism and alcohol consumption levels.'* Although on failing methodological grounds,^ he concluded that no such association could be detected. In more recent years a growing number of studies on alcohol and suicide at the aggregate level have been undertaken. These studies comprise analyses of temporal variations, of spatial variations, and of both combined. They have demonstrated a positive and significant association between per capita alcohol consumption and male suicide rates in a number of coimtries.'' But even the estimates derived from comparable time series analyses vrith standardized methodology vary significantly. Hence, it has heen reponed an increase in male suicide rates with around 2-3% given a I liter increase in per capita alcohol consumpdon,^""^^ but also a 1015% increase in suicide rates^^"^' given the same increase in alcohol consumption. Thus, results derived from aggregate level studies lend support to what might be inferred also on the basis of individual level studiesnamely that there may be social and cultural factors influencing the association between alcohol and suicide. But, if this is the case, the question inevitably ariseswhat are these faaors and how do they work?

Discrepancies, questions and challenges From documentation of both alcohol consumption and of suicide rates as separate phenomena we know that they are both behaviors into which

Editorial people engage differently, depending on factors like ailtural climate and gender, amongst others. A rather striking observation when results from time series analyses are compared between various countries, is that in dry drinidng cultures like Norway and Sweden the estimated effects of an increase in alcohol consumption on suicide rates tend to be of a larger magnitude than in wet drinking cultures like Portugal and France. NorstrSm" has argued that this can be explained by less self-selection to alcohol abuse and suicide and less marginalization and stigmatization of alcohol abusers in wet drinking cultures. A broader empirical basis for comparisons between wet and dry drinking cultures is, however, warranted in order to substantiate the validity of these cross-cultural differences. Furthermore, it may also be questioned whether differences in the alcoholsuicide association across drinking cultures only are attributable to differences in prevalence of heavy drinkers, or whether cross-cultural variation to some degree also reflect differences in drinking patterns and the effects of acute intoxication. TTiis issue has been brought up by Makela^' who related the stronger association between per capita consumption and male suicide rates in younger age groups as compared to older age groups, to a heavier alcohol consumption and more frequent alcohol intoxication in the younger age groups. More systematic approaches to this issue, both in terms of individual level studies and aggregate level studies should be welcomed. Besides the potential to explain crosscultural variations more thoroughly, this is also of relevance to alcohol policy with respect to curbing the extent of acute intoxication. When results from time series analyses and ecological analyses within the same country are compared, findings from some studies indicate that time series analyses yield a higher estimate of the alcohol-suicide association than ecological analyses do.^''""^' Such findings do, if they can be validated, imply aspects of theoretical and methodological interest. The findings can be interpreted as an indication of two mechanisms operating at the same timeboth a causal mechanism and a mechanism of alternative solutions.^''^' The findii^ also indicate that one may not assume that the parameter estimate over time is of the same magnitude as the estimate between regions, as may be the case in pooled cross-sectional time series analyses.^

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Gender differences in suicide risk in alcohol abusers have been brought up in some reviews on alcohol and suicide.'"' A gender ratio in the magnitude of 9 men to 1 woman in alcoholic suicide victims has been interpreted as a higher suicide risk in male alcohol abusers as compared to female alcohol abusers.' More recent studies have, however, demonstrated that the incidence of suicide in male and female alcohol abusers is of the same magnitude.'"" It has been demonstrated that the prevalence of antisocial personality, of phobic disorder and of major depression was more elevated in female alcohol dependents as compared to male alcohol dependents.^* As alcohol abuse is less prevalent among women, it thus appears that the degree of self selection to alcohol abuse is larger among women, and one might therefore on these grounds assume a higher suicide risk among female alcohol abusers. One might also assume that the disruptive effects of alcohol abuse on social integration may effect women to the same extent as men and thus just as prone to suicide. Little seems to serve as a sufficient basis for fiirther speculations in this area now, and thus further studies should be most welcomed. At the aggregate level the number of studies are still sparse, but so far it seems as if temporal analyses of per capita consumption yield higher effect estimates on male suicide rates than on female suicide rates,^''^' whereas this has not been found in spatial analyses.^' Further studies in this direction are warranted and may be helpful to assess the relative impact of various mechanisms for men and women. A final point that deserves attention is the rather one-sided focus on the intra-individual association, on suicide in the drinker himself in the scientific literature. Norstrom' suggested, however, that alcohol abuse may not only be deteriorating for the drinker himself but it may also cause isolation, insecurity, fhistration and helplessness in his closest dependents. Hence, alcohol abuse may not only increase the risk of suicide in the drinker, but also increase the risk of suicide in his spouse or children. There are case reports of parental alcohol abuse in youth suicides,^' but there seems to be few studies to support that victims of other's alcohol abuse are at an increased risk of suicide. The potential and challenges that lie in further studies in this area, are not only relevant for establishing knowledge per se, but also relevant for alcohol policy in

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