The Impact of Alcohol on Self-Harm and Suicide in Ireland

Prof. Ella Arensman

National Suicide Research Foundation

Department of Epidemiology and Public Health, UCC

Research Reproduced by

Theresa Lowry-LehnenRGN, BSc (Hon’s) Nursing Science, PGCC, Dip Counselling, Dip Psychotherapy,

BSc (Hon’s) Clinical Science, PGCE (QTS), H. Dip. Ed, MEd,PhD Student Health Psychology

Trends in Rates of Self-Harm, 2002-2012 - NRDSH

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

25

50

75

100

125

150

175

200

225

250

Women Men

Ag

e-s

tan

da

rdis

ed

ra

te p

er

10

0,0

00

+20%

+6%

Incidence of Self-Harm by Age and Gender (NRDSH, 2012)

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

+0

100

200

300

400

500

600

700

Men WomenAge group

Ra

te p

er

10

0,0

00

Alcohol was involved in 38% of all cases (42% in men, 36% in women)

Alcohol Involvement in Self-Harm by Age and Gender (NRDSH, 2012)

5-9 10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+0%

10%

20%

30%

40%

50%

60%

MaleFemale

% o

f cas

es in

volv

ing

alco

hol

National Registry of DeliberateSelf-Harm

In 2012, there were 12,010 presentations made by 9,483 individuals: Since 2003 there have been 111,682 presentations

of self-harm recorded by the Registry

A Northern Ireland registry operates

across the 5 trusts in NI, with full coverage obtained as of 2012

Suicide

Approx.550 p.a.

Medically treated DSH

Approx. 12,000 p.a

“Hidden” cases of self-harm Approx. 60,000 p.a.

Suicide and Medically Treated Deliberate Self Harm in Ireland: The Tip of the Iceberg

Rates of Self-Harm per 100,000 by Age and Gender

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85+0

100

200

300

400

500

600

700

Men Women

Age group

Rate

per

100

,000

Methods of Self-Harm by Gender

Alcohol was involved in 38% of all cases (42% in men, 36% in women)

54%

19%

5%

8%

3% 12%

Drug overdose only

Self-cutting only

Overdose & self-cut-ting

Attempted hanging only

Attempted drowning only

Other

69%

16%

4%

2%

2%

7%

Men Women

Association Between Peaks of Self-Harm and Public Holidays

Average number of self-harm presentation to hospital per day: n=33

Six dates in the year on which 50 or more self-harm presentations were made, 5 of which were public holidays or the day after:

- January 1st

- October 1st

- March 17th

- March 18th

- June 5th

Repetition of Self-Harm

by Gender

Repetition of Self-Harm by Method

Repetition of Self-Harm by

Recommended Next Care

Repetition by Number of

Self-Harm Presentations

The Extent of Repeated Self-Harm Presentations

Number of DSH acts in 2003-2011

Persons Presentations

Number (%) Number (%)

One 48,066 77.1% 48,066 48.2%

Two 7,899 12.7% 1,5798 15.8%

Three 2,709 4.3% 8,127 8.2%

Four 1,297 2.1% 5,188 5.2%

Five - Nine 1,713 2.8% 11,010 11%

10 or more 635 1.0% 11,483 11.5%

The Impact of Alcohol

Alcohol abuse is one of the factors contributing to the high rates of self-harm among young people and adults in Ireland

Direct effects: Impairs problem-solving ability Increases impulsivity and lack of control Increases feelings of depression, stress,

anger or anxiety

Long term and indirect effects: Isolation (loss of work, relationships,

etc.) Neurobiological deficits

Alcohol contributes to increasing rates of self-harm and it causes increases of self-harm at specific times in the year, such as a peak of self-harm in July and August.

Alcohol is associated with increasing self-harm among both men and women

Alcohol contributes to increases of self-harm at specific times in the year and week

Alcohol is associated with increasing trends in highly lethal methods of self-harm, in particular among men

Rossow et al, 2007; Madge et al, 2008; McMahon et al, 2010;Khalily & Hallahan, 2012

A&E Presentations Involving Alcohol By Weekday

Monday Tuesday Wednesday Thursday Friday Saturday Sunday0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Male Female

Perc

entg

ae o

f pre

sent

ation

s in

volv

ing

alco

hol

Alcohol Involvement by Hour of Presentation to Hospital due to Self-Harm

8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5 6 70

500

1000

1500

2000

2500

3000

3500

No alcohol involved Alcohol involved

Hour of presentation

Num

ber o

f pre

sent

ation

s

Western Area of Northern Ireland: Frequency of Self-Harm Presentations to Hospital by Day of the Week With and Without the

Involvement of AlcoholMen

Mon Tue Wed Thu Fri Sat Sun0

50

100

150

200

250

300

Alcohol involved

No alcohol involved

Day of the week

Num

ber o

f pre

sent

ation

s

Western Area of Northern Ireland: Frequency of Self-Harm Presentations to Hospital by Day of the Week With and Without the

Involvement of AlcoholWomen

Mon Tue Wed Thu Fri Sat Sun0

50

100

150

200

250

300

350

Alcohol involved

No alcohol involved

Day of the week

Num

ber o

f pre

sent

ation

s

Trends in Highly Lethal Methods of Self-Harm and Alcohol Involvement (2004-2012)

2004 2005 2006 2007 2008 2009 2010 2011 20120

50

100

150

200

250

Num

ber o

f pre

sent

ation

s

Males with alcohol

Females with alcohol

Prevalence of Self-Harm in Adolescents across Different Countries

0

5

10

15

20

25

Australia England Norway Belgium Ireland Hungary Netherlands

Females Males

%

Madge et al, 2008

Proportion of Adolescent Self-Harm due to Heavy Drinking

0 10 20 30 40 50 60

Ireland

Belgium

Australia

Netherlands

England

Hungary

Norway

Percentage

Other factors considered: age, gender, depression, impulsivity and negative life events . Rossow et al, 2007

Main Outcomes

Heavy alcohol consumption increases risk of self- harm independent of other factors

Less so in Ireland than in other countries

Reducing Irish adolescents’ heavy drinking should reduce their rate of deliberate self harm (<17%)

Suicide Support and Information System (SSIS): Obtaining a Complete Picture of Suicide Cases and Open

Verdicts by accessing Multiple Sources

Close family members/ friends

(Response Rate: 66.0%)

GP/Psychiatrist/Psychologist

(Response Rate: 77.1%)

• Period and area covered:

Sept. 2008-June 2012, City and County Cork

• Number of consecutive cases: 275 suicide cases + 32 open verdicts meeting screening criteria; Total N=307

• Overrepresentation of men (80.1%); Men significantly younger than women

• Nearly two thirds had a history of self-harm (65.2%); 69.1% were diagnosed with depression, and alcohol/and or drug abuse was present among 60.7%

• Among those with alcohol and/or drug abuse,

48.6% had abused alcohol, 27.6% had abused

both alcohol and drugs, and 21% had abused

drugs

Among 20.8% an increase in alcohol and/or drug

abuse was observed in the year prior to death

Second SSIS Report: Key Findings from a Study of 307 Suicide Deaths in

Cork

Characteristics of the Suicide Deaths Study

Method of suicide: hanging (63.8%), drowning (12.4%), intentional overdose of medication/drugs (9.8%), other methods (14%)

At the time of death, the majority (79%) had alcohol and/or drugs in their toxicology. 24.4% had alcohol + drugs, 34.6% had drugs only, and 20% had alcohol only

Use of alcohol and/or drugs increases the risk of a fatal outcome (Kaplan et al, 2013)

Demographic, Psychosocial and Psychiatric Factors Associated with Suicide in Men aged <40 years Versus Men aged > 40 years

Family or close friend died by suicide

History of self-harm

Day of the week died: Saturday

Agricultural occupation

Diagnosed with depression

Diagnosed with a physical illness

In paid employment

Antidepressants in toxicology

Marital status: Married/Co-habiting

Drugs in toxicology

Living alone

Method of suicide: Hanging

History of alcohol only abuse

0 10 20 30 40 50 60 70 80

Men aged ≥ 40 Years

Full-time student

Day of the week died: Monday

Diagnosed with depression

Family or close friend died by suicide

History of self-harm

Living with family of origin

Unemployed

History of alcohol and drug abuse

Alcohol in toxicology

Benzodiazepines in toxicology

Opiates in toxicology

Marital status: Single

Method of suicide: Hanging

0 10 20 30 40 50 60 70 80

Men aged < 40 Years

Day of the week died: Thursday

Divorced/Seperated

Living alone

Left suicide note/message

Treated as psychiatric in-patient

Diagnosed with depression

Construction/production sector

Treated as psychiatric out-patient

Unemployed

History of alcohol and/or drug abuse

Psychiatric diagnosis

Drugs in toxicology

Cause of death: Hanging

0 10 20 30 40 50 60 70 80

Percentage

Agricultural sector

Day of the week died: Saturday

Living with family of origin

History of alcohol and/or drug abuse

Family or close friend died by suicide

Married/Co/habiting

In paid employment

Cause of death: Hanging

0 10 20 30 40 50 60 70 80

Percentage

Had History of Self-Harm No History of Self-Harm

Demographic, Psychosocial and Psychiatric Factors Associated with Suicide in those With and Without a History of Self-Harm

National Clinical Programme for Mental Health

A programme for the management of self-harm among people presenting to hospital emergency departments

Key objectives: Enhance assessment and management of self-harm for

people presenting to EDs at national level and ensure continuity of care, e.g. referral to indicated treatment, and follow-up

Standardisation of evidence based treatment options nationally for people who have engaged in self-harm based on best available evidence

Evidence Based Actions National strategies to reduce access

to alcohol should be intensified.

National strategies to increase awareness of the risks involved in the use and misuse of alcohol should be intensified, starting at pre-adolescent age.

Active consultation and collaboration between the mental health- and addiction services needs to be arranged for patients who present with dual diagnosis (psychiatric disorder and alcohol/drug abuse).

Evidence Based Actions Health care professionals working

with people who engage in self-harm should receive training in the assessment and management of self-harm and co-morbid alcohol and drug misuse/abuse.

Health care professionals prescribing medication to people at risk of self-harm or suicide should carefully monitor compliance with appropriate use of medication.

Evidence Based Actions

Breaking the commercially reinforced links between alcohol and sport.

Recruit the major national sporting organisations as partners in the development of a national positive mental health promotion campaign.

Irish Examiner March 28th 2013

Reference

Prof. Ella Arensman

National Suicide Research Foundation

Department of Epidemiology and Public Health, UCC

Acknowledgements

•Data Registration Officers: Liisa Aula, Agnieszka Biedrycka, Grace Boon, Kate Brennan, James Buckley, Ursula Burke, Lisa Byrne, Laura Cosgrove, Rita Cullivan, Breda Heavey, Ailish Melia, Catherine Murphy, Mary Nix, Diarmuid O’Connor, Kathleen O’Donnell, Eileen Quinn, Karen Twomey, Una Walsh

•Department of Health

•Health Service Executive – South: Daniel Flynn, Mary Kells, Mary Joyce, Catalina Suares, Louise Dunne

• Health Service Executive: National Office for Suicide Prevention, Suicide Prevention Resource Officers, Hospital staff, HSE departments/units

•NSRF: Ivan Perry, Margaret Kelleher, Eileen Williamson, Paul Corcoran, Eve Griffin, Amanda Wall, Helen Keeley, Caroline Daly, Celine Larkin. The late Dr Michael Kelleher, founder of the NSRF

•Prof. Ella Arensman. National Suicide Research Foundation. Department of Epidemiology and Public Health, UCC

•