Journal of Epidemiology and Community Health 1992; 46: 256-260

Blood alcohol levels in suicide cases

Linda Hayward, Stephen R Zubrick, Sven Silburn

AbstractStudy objective-The aim was to investi-

gate the relationship between alcohol con-sumption prior to suicide and the act ofsuicide.Design-This was a retrospective total

ascertainment survey ofa three year cohortof suicides in Western Australia.Setting-Coroner's records of suicide in

Western Australia between 1986 and 1988inclusive.Participants-The study involved 515

consecutive suicides: 414 males and 101females.Main results-Information on blood

alcohol levels at time of death, presence ofother drugs at time of death, drug andalcohol abuse history, psychiatric history,life events prior to death and method ofsuicide were collected. It was found that35 8% of cases had a positive blood alcoholreading. Those who had been drinkingalcohol prior to suicide were younger, morelikely to be male, more likely to have chosencarbon monoxide as the method of suicide,more likely to have experienced a break upof a relationship and less likely to havesought professional help than those who hadnot been drinking.Conclusions-Data from the present

study do not provide evidence for a causalrelationship between alcohol consumptionand suicide. Differences between those whohad consumed alcohol and those who hadnot are suggestive of a contributory role ofalcohol to a decision to commit suicide in asubset of suicide cases.

In the last two decades only a few studies havereported on the presence of alcohol and otherdrugs in the suicide victim's body. Estimates ofthe numbers of suicide cases affected by alcoholvary from approximately 20% to 50o/, dependingon the definition of "alcohol affected". The rolethat alcohol plays in suicide is not clear: it could beirrelevant; be used after the decision to take one'slife has been made; or its use could be part of theset of conditions that lead to the decision tocommit suicide.The first part of this paper reviews the available

data on alcohol use and suicide. It also presentsdata from a study conducted in Western Australialooking at the relationship between alcohol con-sumption prior to suicide and other possiblyrelevant variables, for instance, method of suicideused and help seeking behaviour.

THE PROPORTION OF SUICIDES WITH POSITIVE BLOODALCOHOL LEVELSFew studies have documented blood alcohollevels in suicide victims. A study of suicides inWestern Australia in the years 1961 to 1982collected data on postmortem blood and urinealcohol levels.' While a total of 293 people com-mitted suicide in those years, blood alcohol levelswere available for only 107 cases and urine alcohollevels for only 76 cases.Of the 107 suicides 40 had blood alcohol of

0 05% or more, with 47 80% of the males and18-4% of the females in that range. Of the totalsuccessful suicides, 888% had received psychiatrictreatment for alcoholism and a further 8 30 hadhistories of being alcoholics or heavy drinkers(determined from police, family or friends).Within the 76 subjects where both blood andurine samples were screened for alcohol, 47% hadlevels of 0-2% or less. The relationship betweenthe blood and urine alcohol content in theremainder (29) showed that (with four exceptions)blood alcohol was lower than urine alcoholcontent.The relationship between urine and blood

alcohol content was approximately 1 -3:1, suggest-ing "that in the great majority of cases alcohol hadbeen consumed some hours before, and that inonly four instances was the alcohol most likely tohave been taken just prior to death. In most casesof suicide associated with high blood alcohollevels the records indicated that the act had beencommitted either during, or in the early hours ofthe morning following a period of alcohol con-sumtion". 1

James' proposed that his evidence suggestedthat mental changes associated with or followingalcohol intoxication may lead to impulsive suicidein individuals who are predisposed to do so, andthat it happens more frequently in men between30 and 60 years of age than in women. Among thedata collected by James was information onwhether a person had sought psychiatric treat-ment prior to the suicide. He found that 3700 ofthe cases had at some time in the past receivedsuch treatment, and 15% were under medical carejust prior to the suicide. However, these con-clusions must be regarded as tentative because ofthe incomplete ascertainment of blood alcohollevels in this study.

Studies in theUSA and Canada have also foundrelatively high proportions of suicide cases posi-tive for blood alcohol. Kraft and Babigian2 foundthat 26% of their New York sample of 179suicides had blood alcohol of 0 05% or greater.Their sample was divided into those with adefinite psychiatric history versus those without;those with a psychiatric history were more likely

Health Department ofWestern Australia,PO Box 8172, StirlingStreet, Perth, WesternAustralia 6000:Epidemiology BranchL HaywardNeurosciences UnitS R ZubrickSelby Child andAdolescence ClinicS Silburn

Correspondence to:Dr Hayward, at Neuro-sciences Unit, Selby Centre,2 Selby St, Shenton Park6008, Western Australia

Accepted for publicationJune 1991

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to have blood alcohol of 0.05% or more (32%)than those without (19%). Furthermore, maleswere approximately twice as likely to have a bloodalcohol level over 0.05% than females. Varadarajand Mendonca,3 in a study of 58 cases ofoverdoseadmitted to accident and emergency departmentsin Ontario, found that 410% had consumed alcoholand 29% had a blood alcohol greater than 0-08%.The alcohol impaired patients, both males andfemales, were older than the non-impairedpatients. Furthermore there was a significantpositive correlation between age and bloodalcohol level.

ALCOHOL CONSUMPTION AND YOUTH SUICIDESome studies have focused on the relationshipbetween alcohol consumption and youth suicide.Friedman4 studied the relationship betweenalcohol consumption and 57 sudden deaths in SanFrancisco youths aged 12 to 24 years. Of thesuicide victims in their sample, 25% had beendrinking prior to the event. Fifty percent ofaccident victims and 21 4% of homicide victimswere intoxicated at time of death. Misuse of otherdrugs played a role in 10 5% of the 57 deaths.Brent et al,5 in a study of youth suicide in the

USA, found increases in the suicide rates forwhite youths (15 to 19 years old) from 6-47 per100 000 in 1960 to 14 37 per 100 000 in 1983. Thisincrease was paralleled by an increase in thenumber of positive blood alcohol readings from12-9% in 1968 to 46% in 1983. They also found anassociation between blood alcohol and use offirearms to commit suicide. Those positive forblood alcohol were 4-9 times more likely to usefirearms than those with no alcohol in their blood.Those under the influence of other drugs wereless likely to use firearms; 67% ofthem overdosedinstead.

DOES EXCESS ALCOHOL CONSUMPTION HAVE ACAUSAL ROLE TO PLAY IN SUICIDE?It is not at all clear what role alcohol plays insuicides. It is possible that alcohol consumptionprior to suicide occurs after the decision hasalready been made to take one's life, a form of"Dutch courage". Alternatively, alcohol may bemore directly related to the suicide by itsdepressant and disinhibiting effects combiningwith an already depressed state in the person andleading to an impulsive decision to commit suicide.The work ofJames' has already been discussed; hisfindings that urine alcohol concentrations werehigher than blood alcohol concentrations and thatsuicide occurred hours after alcohol consumptionseem more supportive of the latter view, which ishow James himself construed his findings.

Clifford6 looked at the relationship betweenalcohol consumption rate, suicides, and roaddeaths in Australian states and territories andcame to the conclusion that alcohol was probablydirectly related to suicide in some cases. Hereported that the annual average road death forWestern Australia (30 7 per 100 000) was thesecond highest of all states during 1968 to 1977and the average suicide rate for Western Australiawas 11 5 per 100 000, the third highest rate of thestates. The average ratio ofroad deaths to suicidesin Western Australia for the period 1963 to 1977was 2-5:1. Clifford noted that the results were

suggestive of a relationship between alcohol andsuicide: ". . . in comparison to other states, thelimited data available shows Western Australia tohave the second highest road death rate, thesecond highest alcohol consumption andexpenditure rates-and the third highest suiciderate. This could be more coincidental, therelationship between drunken driving and deathson the road being well established."The present study was designed to collect data

on three years of consecutive suicides in WesternAustralia in order to investigate the relationshipbetween alcohol use prior to the suicide, and theact of suicide. A major question of interest waswhether those people who consumed alcohol priorto the suicide differed from other suicide cases,and whether any resultant pattern of differencessuggested an explanation for the role of alcohol insuicide.

MethodsSUBJECTSFive hundred and fifteen consecutive suicides inWestern Australia between 1 January 1986 and31 December 1988 were studied. The PerthMetropolitan Coroner's Court dealt with 421 ofthese cases, the remaining 94 were dealt with incountry districts of Western Australia. The ratioof males to females was 4 5:1, with 414 malesuicides and 101 female suicides being studied.The average age ofthe suicide cases was 41 3 years(SD = 17 5), with no significant difference in agebetween males (412 years) and females (417years). Two hundred and ten subjects weremarried or living in defacto relationships, 181were single, and the remaining 124 were divorced,separated, or widowed. Of the sample, 6910owere Australian born (with 2 1% of the samplebeing aboriginal), 15 1% were born in England,Scotland, Wales, and Ireland, and the remaining1588% came from a number of other countries. Itwould appear that the suicide sample is similar tothe Western Australian population in terms ofcountry of birth. The 1986 Australian censusshowed that 7255% of Western Australians wereborn in Australia (2 7% of the population beingaboriginal), and that the remaining 27 5%, wereborn overseas (including the United Kingdom).Apart from those born in England, Scotland,Wales, and Ireland (who comprise 13 5% of theWestern Australian population) the numbersfrom other countries are too small to compare.

PROCEDUREAll files on sudden death in this state are held inthe Perth Coroner's Office. Cases were examinedwhere the Coroner's ruling had been deathby suicide. Coronial files contain detaileddocumentation, including: forensic pathologyreports, police records of interviews with familyand friends, documentation from the person'smedical practitioner and/or psychiatrist andhospitals (where relevant), details of thecircumstances of death, and the suicide note, ifany. The following data were extracted from thefiles: demographic details; cause of death;presence of drugs in the body at time of death(including alcohol); the relationship between thepresence of the drug and cause of death; history of

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drug misuse and type ofdrug misused; psychiatrichistory and type of psychiatric illness; number ofadmissions to psychiatric hospitals; whether theperson was currently being treated for apsychiatric problem and type of treatmentreceived; whether the person had approached anyprofessional for help prior to the suicide and typeof help received; whether friends or relativesthought the person was depressed and the reasonsthey gave for it; and whether the person left asuicide note and the reasons in it for the suicide.This paper is concerned primarily with the

relationship between alcohol, drugs, and suicide.Details regarding the person's history of drugmisuse and type of drug were recorded from avariety of sources and vary in terms of reliability.In some cases the police would note the person as aknown drug offender, in others the person'sphysician would provide the detail, and in othersthe information would be obtained frominterviews by police with family and friends. It isin the latter category that judgments about drugabuse may be inaccurate, although the most likelysource of error would probably be that ofunderreporting rather than overreporting. Detailsregarding drugs present in the body at time ofdeath and relationship between the drug andcause of death are likely to be reasonably accuratesince this information was obtained from forensicpathology reports. The largest source of error inthe latter data is the variations between cases inthe time elapsing between collection of specimensand time of death.

ResultsBLOOD ALCOHOL LEVELS AT TIME OF DEATH

Blood alcohol levels at time of death were taken inall but six cases, where the condition of the bodydid not enable a measurement to be taken. At thetime of death 327 cases had no alcohol in theirblood, in 56 cases the blood alcohol was between0 001 and 0 049%, in 23 between 0 05 and0.079% (moderate impairment), and in 103 it was0 08% or greater (significant impairment). Inother words, 3588% of all suicides had somealcohol in their blood, and 24.5% weremoderately to significantly impaired by alcohol atthe time of death. Males were more likely to haveconsumed any alcohol than females (39 7% versus19.8%). Overall, there was a small but significantnegative correlation between blood alcohol andage for the entire group (r= - 0 14, p < 0 001) andfor males (r= -0 16, p<0 001); females,however, had no correlation between alcoholconsumption and age (r = 0 00).

Table I Blood alcohol levels (BAL) by method of suicide, 1986-1988

Blood alcohol levels (%) % BALType of suicide 0 0 0-001-0049 0 05-0079 0-08+ positive*

Carbon monoxide poisoning 92 31 11 47 49 2Firearms 53 7 1 25 38 4Drug overdose 49 8 2 8 26-9Hanging 74 3 5 16 24-5Jumping 11 0 0 1 8 3Other poison 5 2 0 1 37-5Moving object 5 1 0 0 16-7Drowning 9 1 2 1 30 8Stabbing/cutting 4 1 0 1 33 3Other 25 2 2 3 21-9

Totals 327 56 23 103

*BALs not available for six cases

When cases with positive blood alcohol testswere broken down into age groups, a highpercentage of 15 to 19 year olds (4488%) wererepresented. The 20 to 24 year age group had asmaller proportion of cases with positive bloodalcohol tests (35 1%), the 25 to 44 year olds hadthe lowest proportion with positive blood alcoholtests in 25 9%.

BLOOD ALCOHOL LEVELS AND METHOD OF SUICIDE

The most common methods of suicide werecarbon monoxide poisoning (n = 181), hanging(n = 98), firearms (n = 86), and drug overdose(n = 67). Details of method of suicide and bloodalcohol levels are given in table I. More casespositive for blood alcohol were found in suicidedue to carbon monoxide poisoning (4922%) thanto any other method.Of the other more common methods of suicide,

38-4% of cases of suicide by firearms werepositive for alcohol, 2699% of drug overdose, and245% of hangings. Ofthe less common methods,people who jumped off buildings or otherstructures or who placed themselves in front ofmoving objects were less likely than people whoused other methods to have consumed alcoholprior to the suicide.

BLOOD ALCOHOL LEVELS AND URINE ALCOHOLLEVELSUrine and blood alcohol levels were available for458 of the 515 subjects. Urine alcohol levels werehigher (0-045%) than blood alcohol levels(0.040%) for the entire sample (t= -324,df=457, p<0 001). Males had higher urinealcohol (0-053%) and blood alcohol (0-046%)than females (0 16o% and 0 16% respectively) onaverage (t=3 25, df=298, p<0Q001 for urinealcohol, and t = 2 85, df= 336, p < 0-005 for bloodalcohol).

Overall, 49 subjects had higher blood alcoholthan urine alcohol, that is, they had been drinkingover a relatively short period of time, and 101 hadhigher urine alcohol than blood alcohol,indicating drinking over a longer period of time.The pattern of males having higher blood

alcohol than females in the whole sampleremained the same when mean blood and urinealcohol values were calculated for only thosepeople who had consumed any alcohol. Maleswho had consumed alcohol had an average bloodalcohol of 0 12% and a urine alcohol of 0 13%; infemales the average blood and urine alcohol valueswere 0 08% and 0 07% respectively.

BLOOD ALCOHOL LEVELS AND DRUG MISUSE HISTORY

Of all suicide cases 26-2% (135) had a history ofdrug or alcohol misuse, with alcohol beingidentified as a drug of misuse in 108 cases.On average, those with a history of drug or

alcohol misuse had a higher blood alcohol(0-062%) than those without (0 032%) at the timeof suicide (t = 4 10, p < 0 001). Of those cases witha history of abuse, 4444% were positive for bloodalcohol versus 32-7% of those with no suchhistory. The differences were at the extremes ofalcohol consumption; those people with noalcohol in their blood were less likely to have analcohol or drug misuse history (67-300) than thosewith such a history (55 6%). People with a drug

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misuse history were more likely to have a bloodalcohol level of0 08% or more (31 1 %) than thosewithout (16 40%). However, there were nodifferences between those with or without a drugmisuse history for blood alcohol levels between0 01% and 0 79% (13 3°/o and 16 3°/respectively).

RELATIONSHIP BETWEEN ALCOHOL CONSUMPTIONPRIOR TO SUICIDE AND PSYCHIATRIC HISTORY ANDPSYCHOLOGICAL STATEEight percent of people with a previous historyof psychiatric illness (ie, prior to the episodeimmediately preceding the suicide) had no alcoholin their blood, compared to 5970o of those withno psychiatric history.

People negative for blood alcohol were morelikely to have sought help from a professional(50O0%) than those positive for alcohol (33 3%h)(X2 = 12 4, p<0001). Those members of thealcohol negative group who sought help weremore likely to have gone to a psychiatrist (70 40/%)than a general practitioner (27-7%), whereasalcohol positive people were equally likely to havegone to a psychiatrist (55-7%O) or a generalpractitioner (410%) if they sought help.As might be expected, help seeking and

treatment were related, so that people who werenegative for blood alcohol were also more likely tobe receiving treatment (45 30,h) than those whowere positive for alcohol (27OoO) (X215-5,p < 00001).

Regardless of a person's alcohol consumptionprior to suicide, friends and relatives were equallylikely to describe them as depressed immediatelyprior to the suicide (7344% and 69 1% of thosenegative and positive for alcohol respectively).

In the majority of suicide cases (509) an eventoccurring prior to the suicide was nominated as acontributing factor to the suicide by friends orrelatives. The frequency ofnomination of such anevent did not differ between the negative (878 oI)and positive (89 0%) alcohol groups. Thefollowing types ofevents were identified: financialproblems, break up of a significant relationship,death of a close friend or family member, familyproblems, trouble with the law, physical illness,old age, loss of job, loneliness, or psychiatricillness (see table II). The alcohol positive groupwas significantly more likely than the alcoholnegative group to have experienced break up of arelationship (59 3 versus 37A4%), or loss of job(17-0 versus 58%/O). The only event that wasmentioned more often for the alcohol negativegroup was psychiatric illness (20 9 versus 6 0%/).The two groups did not differ on either

threatening to commit suicide (391-I% and 35-4Oe,

Blood alcoholEvent Negative PositiveFinancial problems 12 9 19-2*Relationship break up 37-4 59-3tDeath of spouse/friend 12-0 9-3Family problems 6-7 6-0Problems with law 9-2 8-8Illness 23-9 15-9Old age 2-8 1-6Job loss 5-8 17-0tLoneliness 4-0 1-6Psychiatric illness 20-9 6-0tOther 3-1 2-2

alcohol negative and positive groups respectively)or having made previous attempts (32O0o versus28 00 ).

ALCOHOL IMPAIRMENTPeople who were alcohol impaired (a blood alcoholof 0.0500 or more) at time of death were comparedto the rest of the suicide cases. Alcohol impairedcases were younger (mean age 37 0 years) thanthose who were not (mean age 42 8 years, t= 3 28,p<0 001). Proportionally more males (27 9",,)than females (11 9-o) were impaired by alcohol. Ofthose in the alcohol impaired group, 46 000 usedcarbon monoxide, 20 600 used firearms, and16 7%/ hanged themselves.There were no differences between the two

groups in threatening (37 50,, and 38 40o) orattempting (3120° and 28 6"0) to commitsuicide. The alcohol impaired group, however,were more likely to have experienced a break up ofa relationship (61 90`0) than the rest of the sample(39 80o), more likely to have lost their job (20-6U)versus 6 30o), and less likely to have a physicalillness (12 70, versus 23 800).

DiscussionGenerally, results from this study have producedsimilar findings to those from earlier studies. Thenumber of people with a history of alcohol abusein this study (26 6o0) is similar to the findings ofstudies from overseas7 and Australia.8A substantial number of suicides had positive

blood alcohol at time of death (35 80o), with24800o of all suicides being moderately orsignificantly impaired by alcohol (ie, an alcohollevel of 0050o or more) at the time of the suicide,results strikingly similar to those reported byKraft and Babigian.2 Males were more likely tohave consumed any alcohol (39.70o) than females(19.80 ), a finding similar to that ofVaradaraj andMendonca.3 Overall, there was a small negativecorrelation between blood alcohol and age, with44-80o of teenagers, and 35- 100 of 20-24 year oldsbeing positive for blood alcohol; positive bloodalcohols were found less frequently in people over45 years of age (25 90 ). This trend for those whohave been drinking to be younger is opposite tothat reported by Varadaraj and Mendonca.3 Brentet al,5 however, also found that 46°o0 of youthsuicides were positive for blood alcohol andrelated their findings to increases in alcoholconsumption among young people.Urine alcohol levels were higher on average

than blood alcohol levels. The finding of morecases with higher urine than blood alcoholreplicates those of James' and suggests that manysuicide cases had been drinking for some timeprior to their death. The present study, however,does seem to contain more subjects who had beendrinking over a shorter period of time, although itshould be noted that the data for blood and urinealcohol levels in this study were far more completethan in the earlier one.1The most common method of suicide in the

present study was carbon monoxide poisoning,followed by hanging, firearms, and drugoverdose. More positive blood alcohol valueswere found in suicides by carbon monoxidepoisoning than by any other method.

Table II Type of eventdescribed as precipitatingsuicide in blood alcoholpositive and negative cases

Note: More than one event per person could be nominated*p < 0-05; tp < 0-001 v negative group

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Cases positive or negative for blood alcoholwere compared for a number of psychologicalvariables and psychiatric history. People whowere alcohol positive were less likely to havesought help from a professional than those whowere alcohol negative. Where professional helphad been sought, alcohol negative people weremore likely to have gone to a psychiatrist than to ageneral practitioner, whereas alcohol positivepeople were equally likely to have gone to either.

Alcohol negative people were also more likely tohave a history of psychiatric illness than thealcohol positive group. Both groups, however,were equally likely to have been described byfamily or friends as being depressed immediatelyprior to the suicide; furthermore there was nodifference in the identification rate of a possibleprecipitating event prior to the suicide. Thenegative and positive alcohol groups did differ,however, in the type of precipitating eventidentified. Those positive for alcohol were morelikely to have experienced the break up of arelationship and loss of job. The only event thatwas mentioned more for the alcohol negativegroup was previous psychiatric illness.Interestingly, there were no differences in thenumber of people who threatened and hadpreviously attempted suicide, with approximately37% of the suicide cases having threatenedsuicide, and approximately 30% having made aprevious attempt.When those cases with blood alcohol levels

greater than 0 05% (alcohol impaired) werecompared to the other suicide cases, the alcoholimpaired group were younger, and more likely tobe male and to have used carbon monoxide,firearms, and hanging as methods of suicide.Alcohol impaired suicides were also more likely tohave experienced a relationship break up or loss ofjob and less likely to have a physical illness thanother suicide cases.Many of these people had been drinking for

some time prior to their death, and it is possiblethat in such cases the depressant and disinhibitingeffects of alcohol, combined with depressionarising from a recent loss of a relationship and lackof attempt to seek professional help, created anemotional state where they sought to take theirlives.

It has been suggested that impulsive suicides,which, it could be argued, are likely to includethose committed under the influence of alcohol,are most likely to use easily accessible or

convenient methods.9 The choice of carbonmonoxide poisoning from a motor vehicle couldfall into this category as it is a method which is

convenient and accessible (most people inWestern Australia have access to motor cars). Inthe present study it was also the method mostcommonly used by those who were positive foralcohol. In the USA, studies have linked suicideusing firearms to increases in alcoholconsumption.9 Firearms are more widelyavailable in the USA than in Australia, and it ispossible that a similar effect due to availability isbeing seen in Western Australia, with the use ofcarbon monoxide as a method of suicide.

It is of interest that 30% of alcohol positivesuicides were receiving treatment from aprofessional prior to their suicide. Perhaps someimpact could be made on suicide rates ifprofessionals were alerted to the danger of alcoholconsumption during depression, and stressed totheir patients the need to avoid consuming alcoholduring such times.The data from the present study do not provide

evidence for a direct causal realtionship betweenexcess alcohol consumption and suicide. On theother hand, the data we present here suggest thatalcohol consumption may function as animportant effect modifier to the act of suicide.The differences betwen alcohol impaired casesand the other cases of suicide in age, lack ofprevious psychiatric history, differences in priorpsychological stressors, and in particular the highrate of relationship break up and lack of helpseeking behaviour, suggest that alcohol may be animportant factor in the final act of suicide. Assuch, alcohol consumption is best understood asin the first place a response to (or symptom of)mental health and psychosocial morbidity, andthen, for some, as a potential modifier in the chainof decisions leading to the act of suicide.

We would like to thank Doreen Hayward and ColleenLang for coding and entering the suicide data and MariaKent and Shelley Frowen for typing the manuscript.

1 James P. Blood alcohol levels following successful suicide. QJStud Alcohol 1966; 27: 23-9.

2 Kraft DP, Babigian HM. Suicide by persons with and withoutpsychiatric contacts. Arch Gen Psychiatry 1976; 33: 209-15.

3 Varadaraj R, Mendonca J. A survey of blood alcohol levels inself-poisoning cases. Adv Alcohol Subst Abuse 1987; 7:63-9.

4 Friedman IM. Alcohol and unnatural deaths in San Franciscoyouths. Pediatrics 1985; 76: 191-3.

5 Brent DA, Perper JA, Allman CJ. Alcohol, firearms, andsuicide among young. JAMA 1987; 257: 3369-72.

6 Clifford W. Suicide in Western Australia. Canberra:Australian Institute of Criminology, 1979.

7 Berglund M. Suicide in alcoholism: a prospective study of 88suicides: 1. The multidimensional diagnosis at firstadmission. Arch Gen Psychiatry 1984; 41: 888-91.

8 Chynoweth R, Tonge JI, Armstrong J. Suicide in Brisbane: aretrospective psychosocial study. Aust NZ J Psychiatry1980; 14: 37-45.

9 Farmer RDT. Assessing the epidemiology of suicide andparasuicide. Br J Psychiatry 1988; 153: 16-20.

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