Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Dying for a drink: Aboriginal perspectives
- Subas C Pradhan (16 October 2001)
-
Dying for a drink. Global suicide prevention.
- Fabio Levi (16 October 2001)
-
Dying for a drink: The role of the Accident and Emergency Department
- Robert Patton (7 November 2001)
-
Alcohol use, seasonal depression, and suicidal behavior
- Leo Sher (18 November 2001)
-
Decapitating the Hydra: alcohol dependent approaches to suicide and suicidal ideation.
- Odivad A Llennod (2 December 2006)
|
|
|||
|
Subas C Pradhan, Director of Mental Health Mount Isa, Queensland
Send response to journal:
|
Dying for a drink: Aboriginal perspectives Editors- Tom Foster privides an excellent and evidence based appeal for reduction of drinking practices as a prime requirement for suicide prevention [1]. It is infact heartening to appreciate that the common sense approach of reducing the grog to feel good has a scientific basis. I wish to discuss the above points from an Australian aboriginal perspective. Suicide among the aboriginal people is a matter of national and international concern for most of the countries. In Queensland, an Australian state the suicide rates for Aboriginal and Torres Strait Islanders, especially the young, are disproportionately high than other areas [2], a large part of which could be attributed to the life style and a pattern of higher alcohol and drug abuse among these groups. It is quite interesting to note that although fewer aboriginals than non- aboriginal Australians drink alcohol, those who drink do so excessively [3]. This is also coupled with the fact that in many an aboriginal communities, help seeking especially from the health system run by a different ethnic group is not viewed with respect. It is a complex situation, involving binge drinking, social isolation and abnormal illness behaviour, which might explain the higher rates of suicide among aboriginal people. So far as the management is concerned there is no straight-line answer. The universal realization that an anti-alcohol campaign might be helpful in reducing suicide could be difficult to practice. The perestroika approaches may have to be modified before being applied (among Australian aborigines), where infact for various socio political reasons the government sponsored licensed clubs promote drinking among the Australian aboriginal communities. Although it was supposed to encourage a healthy drinking pattern without creating much fuss, the above approach has been criticised for it’s inherent fallacy [4]. Hence although supply reduction is an essential component of curtailing alcohol consupmtion the high suicide and self-harm among alcohol abusing aboriginal communities could have many alternate explanations. References: 1. Foster T. Dying for a drink: Global suicide prevention should focus more on alcohol use disorders BMJ 2001;323:817-818. 2. Cantor CH, Slater PJ. A regional profile of suicide in Queensland. Aust N Z J Public Health 1997 Apr;21(2):181-6. 3. Gray D, Saggers S, Sputore B, Bourbon D. What works? A review of evaluated alcohol misuse interventions among aboriginal Australians. Addiction 2000 Jan;95(1):11-22. 4. d’Abbs PHN. Out of sight, out of mind? Licenced clubs in remote aboriginal communities. Aust N Z J Psychiatry 1998; 22:679-84. Subas C Pradhan, |
|||
|
|
|||
|
Fabio Levi, ass. professor of epidemiology, Head University Social and Preventive Medicine, University of Lausanne, Bugnon 17, CH-1005 Lausanne
Send response to journal:
|
EDITOR - Foster (1) critically reviews the importance of alcohol drinking on national suicide rates. We updated trends in age-standardized mortality from suicide over the period 1965-98 in the European Union (EU), selected eastern European countries, the Russian Federation, the USA and Japan using the World Health Organization (WHO) database (Figure 1) (2). In the EU, overall age-standardized suicide mortality peaked at 16.1/100,000 men in 1980-84, and declined thereafter to 14.4/100,000 in 1995-98. In females, the fall was 29%, to reach 4.6/100,000 in 1995-98. Although mortality values were substantially higher than in the EU, a similar pattern of trends was observed in eastern European countries providing long term data (i.e., Bulgaria, the Czech Republic, Hungary, Poland, Romania, and Slovakia). In contrast, mortality from suicide rose substantially in the Russian Federation, from 37.7/100,000 males in 1985- 89 to 58.3 in 1995-98 (+55%), and from 8.5 to 9.5 (+12%) in females – as well as in most other countries of the former Soviet Union. In the USA and most other American countries, no consistent pattern was evident for males, but appreciable falls were observed in females (-25%). Downward trends were registered for Japan, until the early 1990’s (-15% for men, - 25% for women). Although psychiatric conditions - mainly depression and its management - may have had some influence on several favourable trends in suicide rates, the major determinants of the substantial variation in suicide rates across geographic areas and calendar periods should be related to economic, socio-cultural features and characteristics (including deprivation and unemployment, but also alcohol abuse) of various populations (1-4). A role may also have been played by reduced availability of methods of suicide, including gas detoxification and catalytic converters. In Russia and other countries of the former Soviet Union, substantial rises were observed in suicide mortality particularly for young males, whose rates reached 66/100,000 men aged 15 to 34 in the late 1990’s. Suicide was therefore the major cause of death in young males (5). The reasons for these rises are likely to be complex, but are likely to include widespread alcohol abuse (1,5). More important, recent trends in the Russian Federation contrast with the relatively favourable pattern of suicide mortality worldwide, and indicate the importance and urgency of integrated medical, but mainly social, interventions – including control of alcohol abuse - in the prevention of suicide in those areas of the world. Fabio Levi, associate professor of epidemiology
Franca Lucchini, staff scientist
Eva Negri, head, Unit of Epidemiological Methods
Carlo La Vecchia, associate professor of epidemiology
REFERENCES 1. Foster T. Dying for a drink. Global suicide prevention should focus more on alcohol use disorders. Br Med J 2001; 323:817-808. 2. La Vecchia C, Lucchini F, Levi F. Worldwide trends in suicide mortality, 1955-1989. Acta Psychiatr Scand 1994 ;90 :53-64. 3. Hawton K. A national target for reducing suicide. Br Med J 1998;317:156-157. 4. Davies S, Naik PC, Lee AS. Depression, suicide, and the national service framework. Br Med J 2001;322:1500-1501. 5. Shkolnikov V, McKee M, Leon DA. Changes in life expectancy in Russia in the mid-1990s. Lancet 2001; 357: 917-921. |
|||
|
|
|||
|
Robert Patton, Research Associate Imperial College
Send response to journal:
|
We agree with Foster that greater attention must be paid to alcohol use disorders if national and international targets for suicide reduction are to be met 1. In addition to primary care based initiatives advocated in his editorial, we believe that the accident and emergency department (AED) also has a central role to play in tackling the link between alcohol misuse and suicidal behaviour as the majority of patients with deliberate self harm (DSH) present here. Previous research has indicated that over half of men who present to hospital following an episode of DSH have consumed alcohol in the few hours preceding the attempt, 50% regularly drink excessive amounts of alcohol and 23% are alcohol dependent 2. Despite this strong association there is clear evidence that many patients who present to hospital following DSH receive no assessment of their alcohol use 3. At the AED at St Mary’s Hospital, in Paddington in inner London, the proportion of patients whose alcohol consumption is assessed has been greatly increased by the introduction of a brief questionnaire, the Paddington Alcohol Test 4. The Paddington Alcohol Test takes less than a minute to complete and provides a reliable indication of the presence of alcohol use disorders. Those who test ‘positive’ are offered brief intervention from staff working in the AED which may include literature about safer drinking or an appointment with an alcohol health worker. Providing assessment and treatment for people who attend AED following deliberate self harm is complicated because many people are reluctant to take up offers of help 5. However a recent audit of the management of alcohol problems in St Mary’s AED revealed that of 34 patients who presented following DSH and were test positive, 24 (71%) were prepared to take up an offer of further advice about their alcohol consumption. We are currently in the process of examining the effects that this advice has on the likelihood of further suicidal behaviour. Meanwhile, this evidence suggests that people who present to AED following deliberate self harm and are drinking excessively are willing to accept offers of help and emphasises the importance of identifying alcohol misuse problems in patients in the AED. 1. Foster T. Dying for a drink: Global suicide prevention should focus more on alcohol use disorders. BMJ 2001; 323:817-818 2. Merrill J, Milner G, Owens J, Vale A. Alcohol and attempted suicide. British Journal of Addiction 1992; 87:83-89 3. Shepherd R, Dent THS, Alexander GJM, London M. Prevalence of alcohol histories in medical and nursing notes of patients admitted with self poisoning. BMJ 1995; 311:847 4. Huntley JS, Blain C, Hood S, Touquet R. Improving detection of alcohol misuse in patients presenting to an accident and emergency department. Emergency Medicine Journal 2001; 18(2):99-104 5. Crawford MJ, Wessely S. Does initial management affect the rate of repetition of deliberate self harm? Cohort study. BMJ 1998; 317:985 Robert Patton, Research Associate Department of Public Mental Health, Imperial College, London Dr. Mike Crawford, Senior Lecturer Department of Public Mental Health, Imperial College, London Robin Touquet, Director of Accident and Emergency Services St Mary’s Hospital, London |
|||
|
|
|||
|
Leo Sher, Assistant Clinical Professor Division of Neuroscience, Department of Psychiatry, Columbia University, New York, NY 10032, USA
Send response to journal:
|
Foster1 suggests that "global suicide prevention strategies should include a focus on alcohol use disorders in terms of … aggressive treatment of comorbid depression." Seasonal affective disorder (SAD), a condition where depressions in fall and winter alternate with nondepressed periods in the spring and summer, is one of the most treatable causes of suicidal behavior. Recent data suggest that seasonal depression is closely related to alcoholism.2 Some patients with alcoholism have a seasonal pattern to their alcohol abuse. Patients with alcoholism may be self-medicating SAD with alcohol or manifesting a seasonal pattern to alcohol-induced depression. Family studies also suggest that there is a relationship between alcoholism and SAD. It has been proposed that if some patients with alcoholism attempt to self-medicate SAD with alcohol, or if SAD predisposes this population to alcohol relapse, then treatment of SAD with light therapy may be beneficial in preventing relapse into alcoholism in this population.3 Suicidal ideation occurs less frequently in patients with SAD than in those with nonseasonal depression.4 However, suicidal ideas are commonly found in SAD.4 SAD can be effectively treated with light therapy that relieves suicidal ideation in patients with SAD consistent with overall clinical improvement. Thus, light therapy might both decrease suicidal ideation and prevent relapse into alcoholism in patients with SAD. Worsening suicidal ideation is uncommon in patients treated with morning light therapy. However, clinicians should always be vigilant of suicidality. Pharmacological and psychological treatments can also help patients with SAD who abuse alcohol. Contemporary treatment may prevent suicidal behavior in patients with comorbid SAD and alcoholism. 1. Foster T. Dying for a drink. Global suicide prevention should focus more on alcohol use disorders. BMJ 2001; 323: 817-818. 2. Sher L. Relationships between seasonality and alcohol use: A genetic hypothesis. Med Hypotheses, 2002, in press. 3. Avery DH, Bolte MA, Ries R. Dawn simulation treatment of abstinent alcoholics with winter depression. J Clin Psychiatry 1998; 59: 36-42. 4. Lam RW, Tam EM, Shiah IS, Yatham LN, Zis AP. Effects of light therapy on suicidal ideation in patients with winter depression. J Clin Psychiatry 2000; 61: 30-32. |
|||
|
|
|||
|
Odivad A Llennod, Cultural Theorist Queen's University, Belfast, BT7
Send response to journal:
|
Editors the case, which is presented by Tom Foster (1), underlines something of an epistemological malaise afflicting the field of psychiatry. Whilst it is undisputed that a correlation between alcohol dependence and suicide exists it is certainly less clear whether this implies a causal correlation. The statistics presented in Dr Foster’s article also demonstrate (in a staggering 89% of cases) the existence of at least one comorbid mental disorder in cases of suicide with alcohol dependence. I will attempt to argue, in this brief rejoinder, that the success of any global anti-suicide strategy will be based on not viewing alcoholism (abuse and dependency) in abstraction but rather locating it firmly within the comorbidity complex. The proclivity of alcoholism towards suicidal ideation should be viewed as concomitant with such ideations rather than a contributing factor towards such ideations. A more powerful contributor towards suicidal ideation is demonstrated by the role of alienation, which, incidentally, is a vital root cause of the alcoholism itself. Much respected work has been done in this field, notably by Callichia JP and Barresi RM, who demonstrated (using Dean’s alienation scale) that alcoholics displayed a greater overall alienation than a control sample and specifically in terms of social isolation, powerlessness and normlessness (2). Problems of alienation strike at the very idea of our own identity and it is salient that problems of alcohol abuse are prevalent in areas where identity is in question. One example is that of ethnic identity: Tom Foster, whilst adopting a global strategy, writes, primarily, from the Northern Irish perspective; Subas C Pradhan (3), who responded to Foster’s article addresses the case of the Aboriginal and Torres Strait Islanders; another respondent to this article is Fabio Levi (4) who raises similar conflict of identity issues from the eastern European perspective. To be sure, conflicts of identity are not restricted to issues of ethnicity; it is suggested here that mental disorders display similar identity conflicts. It would not be controversial to suggest that individuals experiencing a mental disorder, of various kinds, will also experience significant alienation as a result. It has already been recognised that the deep and intractable comorbidity of alcoholism and mental disorder is present in a significant number of suicides. It is the contention here that attempts to delineate the alcoholism component may be, at best unsuccessful, and at worst counterproductive. A robust primary care response is essential in managing clients who present with comorbidity. The Mental Health Council of Australia (MHCA) is currently adopting such an approach in what it terms ‘Managing the Mix’, by essentially grouping together the problems of alcoholism, depression and anxiety. The refusal to demarcate alcoholism from its related mental disorders or vice versa has the advantage of maintaining an open minded and therefore more flexible approach to comorbid clients and one that can be adapted to respond to comorbid clients presenting suicidal ideations. Much can be learned from the Australian experience which would include enhanced training and information for those involved in general practice (5). Statistics presented may make treating clients with alcohol problems in isolation more seductive, however, if this treatment is not matched by an equally voracious approach to attendant mental disorders then its efficacy will be dissipated. Any global strategy, or national strategy for that matter, designed to tackle the widespread abuse of alcohol must recognise that comorbid mental disorders, if present, are indeed significant. To simply quote statistics that demonstrate that alcoholism is evident in a significant number of suicide cases does not confirm that alcoholism is the root cause. Such equivocation is epistemologically weak and requires the real insight and analysis which only the Australian approach seems to embody. Further, the reliance on a thinly conceived statistic will, at a diagnostic level, lead to thinly conceived diagnoses where the actual content of a problem is mistaken for the form it takes: the Hydra will simply grow another head. Finally, it is wryly observed in statistics that the blind use of statistics is not unlike the inebriate who uses the lamppost: more for support than illumination, this is surely what we wish to avoid. (1) 1. Foster T. Dying for a drink: Global suicide prevention should focus more on alcohol use disorders BMJ 2001;323:817-818. (2) Callichia JP and Barresi RM, The Journal of Clinical Psychology, 1975 October 31 (4) 770-5 (3) Subas C Pradhan, Dying for a drink: Aboriginal perspectives (4) Fabio Levi,Dying for a drink. Global suicide prevention. [A RESPONSE] (5) For a good overview on the Australian model visit http://www.primarymentalhealth.com.au/site/index.cfm Competing interests: Cultural theory, alienation, alcoholism and subcultures. |
|||