Depressive symptoms and factors associated with depression and suicidal behavior in substances user in treatment: Focus on suicidal behavior and psychological problems
Introduction
Depression and drug use are considered important public health problems. There is evidence to suggest that youths, adolescents and adults in treatment for substance-related disorders are vulnerable to depressive symptoms and psychological problems (Snyder & Platt, 2013; Zimerman et al., 2018). Additionally, the findings of various studies (Silva, Sousa, Ferreira, & Peixoto, 2012; Brazilian National for Alcohol and Other Drugs Survey, [BNADS], 2012) have shown that depression is a strong risk factor for other health problems, such as alcohol and other substance use.
An important aspect of this problem is that the comorbidity of depression with drug use may increase the risk for suicide (Fontanella et al., 2017); this constitutes a global public health concern. On a global scale, 804,000 suicide deaths per year have recently been recorded (World Health Organization [WHO], 2014). The annual incidence of suicide, based on data from 2012, was 11.4 per 100,000 inhabitants, thus representing the 15th general cause of death worldwide. Among people aged between 15 and 29 years, suicide represents 8.5% of deaths, being the second leading cause of death in this age group (WHO, 2014). A Mexican study, investigating the factors associated with depression and suicide attempts in patients receiving treatment for drug use, identified factors that are associated with suicide attempts and these include the diagnosis of depression and previous suicide attempts in the drug users (Ortíz-Gómez, López-Canul, & Arankowsky-Sandoval, 2014).
In relation to associations between suicide and alcohol and/or drug use, many risk factors have already been identified (Borges et al., 2017; Poorolajal, Haghtalab, Farhadi, & Darvishi, 2016). The phenomenon of drug use in the world is dynamic. With the frequent emergence of new synthetic drugs and patterns of consumption, these can have an impact on suicidal behaviours. Alcohol is the psychoactive substance with the most well-established positive associations with suicidal behaviours (WHO, 2014). This relationship must be understood in terms of two separate constructs: acute alcohol use and more chronic alcohol dependence (Conner, Bagge, Goldston, & Ilgen, 2014). A meta-analysis study (Borges, Bagge, & Orozco, 2016) highlighted that acute alcohol use, in any amount, was associated with increased risk for suicide attempts: relative risk 6.97 (95% CI 4.77–10.17). When considering ‘large amounts’ of the substance, this risk increased significantly to 37.18 (95% CI 17.38–79.53), highlighting an important dose-related relationship. The estimated risk for acute alcohol use was greater than the effect of chronic use, underscoring that there are specific mechanisms by which alcohol sharply enhances the risk of suicide attempts. Most likely, these findings are related to the effects of alcohol on the central nervous system (CNS), in that it increases potential aggression and impulsivity (Caswell, Morgan, & Duka, 2013; Dougherty, Marsh-Richard, Hatzis, Nouvion, & Mathias, 2008), amplifies feelings of sadness and loss of good humour (Heinz, Mann, Weinberger, & Goldman, 2001) and compromises cognitive functions (Popke, Allen, & Paule, 2000). Park et al. (2017) noted that acute alcohol use was related to a greater use of so-called high-lethality suicide methods, such as the use of firearms or jumping from high places.
In Brazil, studies corroborate the international findings. A study by Diehl and colleagues was conducted with 80 patients admitted for suicide attempts in São Paulo state city, Brazil. Of these patients, 21.2% confirmed having consumed alcoholic beverages 6 h before the suicide attempt, 7.5% reported using illicit drugs and 10% met criteria for substance dependence (Diehl & Laranjeira, 2009). Another study conducted among suicide victims necropsied in the medicolegal service of the city of São Paulo in 2005 showed positive blood alcohol concentration (BAC) in 33.1% of cases (Ponce, Andreuccetti, Jesus, Leyton, & Muñoz, 2008).
Currently, there is strong evidence that alcohol dependence is a potential risk factor for suicidal behaviours. Studies examining alcohol and drug use in suicidal behaviours (e.g. Borges & Loera, 2010) have showed that people with alcohol dependence are between 2.6 and 3.7 times more likely to attempt suicide than non-alcohol users. A study conducted in Israel (Shoval et al., 2014), with 1237 adults with a positive history for the use of least some amount of alcohol in the last 12 months, showed that among those who meet the criteria for dependence, the risk of suicidal ideation and suicide-related behaviours was 2.18 times greater (9.0% versus 4.1%). The mechanisms by which chronic use of alcohol are associated with suicidal behaviours have also been discussed in the literature. Borges and Loera (2010) divided chronic alcohol users into two distinct classes: (1) predisposing factors such as impulsiveness, negativity, and hopelessness and (2) precipitating factors including interpersonal breaks caused by substance use and comorbidities such as major depression.
There is a relationship between the use of psychoactive substances including marijuana, cocaine, crack, heroin, methamphetamine and the potential risk of suicide and suicidal attempts. Data from the Institute for Health Metrics and Evaluation (IHME), Global Burden of Disease (GBD, 2010), as described by Ferrari et al. (2014),showed that after alcohol (13.25%), amphetamine users presented the highest rates of suicide, with 2.4% of Disability-Adjusted Life Year (DALYS), followed by use of opiates (1.9%) and cocaine (0.9%).
According to the National Institute of Drug Abuse (NIDA), there are three important facts that clarify the high rates of opioid use disorders and suicide in the United States (US): (1) the diagnosis of opioid use disorder leading to an increased risk of suicide for both men and women; (2) researchers have calculated that the suicide rate among opioid users is 86.9/100,000, compared with the alarming rate of 14/100,000 in the general US population; and (3) the risk of death from suicide was twice as high among male opioid users and eight times higher for female opioid users. These numbers are impressive enough and should be a strong stimulus for urgent action (NIDA, 2017).
A meta-analysis (Poorolajal et al., 2016) classified 43 studies as low and high quality, in accordance with The Newcastle-Ottawa Scale (NOS). Considering only the high-quality studies, substance-related disorders showed a relative risk for suicidal ideation, suicidal attempt and death by suicide, respectively 1.37, 1.80 and 1.44. Among drug abusers there was a higher association with opiates, but all illicit drugs had a relatively similar rate. Previous reviews have found that multiple drug users have a negative impact on outcomes of suicide (Wilcox, Conner, & Caine, 2004), and that the greater the number of drugs used, the higher the prediction (Substance Abuse and Mental Health Services Administration [SAMHSA, 2008]). Although cannabis dependence was not included in the list of risk factors related to suicide in the report of the Global Burden of Disease (GBD), in the meta-analysis of Borges et al. (2016), the current evidence tends to support that the chronic consumption of cannabis can predict suicidal behaviour.
In Brazil, studies tend to confirm the important association between drugs and suicidal behaviours (Diehl & Laranjeira, 2009; Werneck, Hasselmann, Phebo, Vieira, & Gomes, 2006). Data from 160 suicide attempts recorded in a general hospital in Rio de Janeiro showed that 15% had a history of alcohol use, illicit drug use (11%), and/or use of psychotropic drugs (27%). The findings of this study showed that the participants who were crack cocaine users also presented a high risk for suicide (odds ratio 4.43 CI 95% 2.20–9.32; p < 0.001), remaining with statistically significant values even when controlled by gender, socioeconomic status and cocaine use (Werneck et al., 2006).
The scenario described reveals that comorbidity between depression and substance use is a reality that can contribute to unfavourable outcomes regarding the consumption of substances, suicidal behaviours and psychological problems. It is believed that knowledge of the relationship between such variables can support the planning and monitoring of interventions focused on early recognition and treatment of disorders related to the use of alcohol and other drugs, thereby minimising suicide rates and psychological problems, especially in patients with depressive symptoms (Botega et al., 2009; Botega, Cais, & Rapeli, 2012).
Therefore, this study aims to investigate the prevalence of depressive symptoms and the associations between these symptoms with substance use, psychological problems and suicidal behaviours in a sample of alcohol and drug users in treatment.
Section snippets
Methods
A cross-sectional study was undertaken at an out-patient care centre for substance treatment in southern Brazil, in the period from July 2013 to July 2014. The eligibility criteria were those aged 18 years or older, of both genders, and users of psychoactive substances. Exclusion criteria included those with serious psychiatric symptoms, as determined by the Brief Psychiatric Rating Scale (BPRS). This scale has 18 items that evaluate the intensity of the presence of psychiatric behaviours
Socio-demographic data
The sample was composed predominantly of adults who were male, black and single. More than half had a low level of education (<8 years), were unemployed and of the Catholic religion. Regarding the presence of depressive symptoms (past 30 days), 70.0% responded affirmatively; only 8.1% reported experiencing such symptoms only under the influence of drugs or in withdrawal (Table 1).
Most participants identified cocaine as their drug of choice (DOC), most were using multiple drugs and drinking
Discussion
Participants with depressive symptoms had potential chance of having symptoms of anxiety, nervousness or concern among those presenting to be under the influence of drugs or in withdrawal, and four times greater chance of having these suicidal thoughts. The association between depressive and anxiety symptoms is well established in the literature (Casey, Perera, & Clarke, 2013). Our findings confirm the relationship between depressive and anxiety symptoms and suicidal risks for those substance
Financial support
This work was supported by National Council for Scientific and Technological Development (CNPq) [Universal 14/2011 – Process 482442/2011-5], and the São Paulo Research Foundation (FAPESP) [Process 2009/14861-2].
Conflict of interest
The authors declared any potential conflict of interest.
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