The Impact of Alcohol on Self Harm & Suicide in Ireland (NSRF)

1. 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-Lehnen
RGN, 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

2. Trends in Rates of Self-Harm, 2002-2012 - NRDSH
0
25
50
75
100
125
150
175
200
225
250
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Age-standardisedrateper100,000
Women Men
+20%
+6%

3. Incidence of Self-Harm by Age and Gender
(NRDSH, 2012)
0
100
200
300
400
500
600
700
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+
Rateper100,000
Age group
Men Women
Alcohol was involved in 38% of all cases (42% in men, 36% in women)

4. Alcohol Involvement in Self-Harm by Age and
Gender (NRDSH, 2012)
0%
10%
20%
30%
40%
50%
60%
%ofcasesinvolvingalcohol
Male
Female

5. National Registry of Deliberate
Self-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

6. 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

7. Rates of Self-Harm per 100,000 by Age and
Gender
0
100
200
300
400
500
600
700
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+
Rateper100,000
Age group
Men Women

8. Methods of Self-Harm by Gender
Alcohol was involved in 38% of all cases
(42% in men, 36% in women)
54%
19%
5%
7%
3% 12%
Drug overdose only
Self-cutting only
Overdose & self-
cutting
Attempted hanging
only
Attempted drowning
only
Other
69%
16%
4%
2% 2%
7%
Men Women

9. 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

10. Repetition of Self-Harm
by Gender
Repetition of Self-
Harm by Method

11. Repetition of Self-Harm
by Recommended Next
Care
Repetition by Number of
Self-Harm Presentations

12. 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%

13. 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

14. A&E Presentations Involving Alcohol
By Weekday
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Percentgaeofpresentationsinvolvingalcohol
Male Female

15. Alcohol Involvement by Hour of Presentation to
Hospital due to Self-Harm
0
500
1000
1500
2000
2500
3000
3500
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5 6 7
Numberofpresentations
Hour of presentation
No alcohol involved Alcohol involved

16. Western Area of Northern Ireland:
Frequency of Self-Harm Presentations to Hospital by Day of the Week
With and Without the Involvement of Alcohol
Men
0
50
100
150
200
250
300
Mon Tue Wed Thu Fri Sat Sun
Numberofpresentations
Day of the week
Alcohol involved
No alcohol
involved

17. Western Area of Northern Ireland: Frequency of Self-Harm
Presentations to Hospital by Day of the Week With and
Without the Involvement of Alcohol
Women
0
50
100
150
200
250
300
350
Mon Tue Wed Thu Fri Sat Sun
Numberofpresentations
Day of the week
Alcohol involved
No alcohol
involved

18. Trends in Highly Lethal Methods of Self-Harm and Alcohol
Involvement (2004-2012)
0
50
100
150
200
250
2004 2005 2006 2007 2008 2009 2010 2011 2012
Numberofpresentations
Males with alcohol
Females with alcohol

19. 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

20. 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

21. 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%)

22. Suicide Support and Information System (SSIS):
Obtaining a Complete Picture of Suicide Cases and Open
Verdicts by accessing Multiple Sources
Coroners' verdict records
& Post mortem reports
(Response Rate: 100%)
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

23. • 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

24. 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)

25. Demographic, Psychosocial and Psychiatric Factors Associated with
Suicide in Men aged <40 years Versus Men aged > 40 years
0 10 20 30 40 50 60 70 80
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
Men aged ≥ 40 Years
0 10 20 30 40 50 60 70 80
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
Men aged < 40 Years

26. 0 10 20 30 40 50 60 70 80
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
Percentage
0 10 20 30 40 50 60 70 80
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
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

27. 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

28. 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).

29. 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.

30. 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

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

32. 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
•