Prof Ella Arensman's presentation about the impact of alcohol on self-harm and suicide in Ireland, providing new insights from recently collected data. Prof Arensman is Director of Research with the National Suicide Research Foundation and Adjunct Professor with the Department of Epidemiology and Public Health, University College Cork. This presentation was given at Alcohol Action Ireland's conference, Facing 'The Fear': Alcohol and Mental Health in Ireland, on November 20, 2013.

1. The Impact of Alcohol on Self-harm and Suicide
In Ireland - New Insights
Prof Ella Arensman
National Suicide Research Foundation &
Department of Epidemiology and Public Health,
University College Cork, Ireland
“Facing the Fear”: Alcohol and Mental Health in Ireland
Dublin, 20th November 2013

2. Overview





The association between alcohol and self-harm
The impact of alcohol on seasonal patterns of self-harm
among men and women
The impact of alcohol on self-harm among adolescents
Alcohol, associated mental health problems and suicide
risk
Evidence based actions

3. Irish National Registry of Deliberate Self-Harm
(NRDSH)
•
Objectives
To establish the incidence of
hospital treated deliberate selfharm
•
To describe the pattern of
presentations and the nature of the
self-harm behaviour involved
•
To monitor trends over time and by
area
•
To estimate the risk of repeated
self-harm presenting to hospital
In 2012, there were 12,010 presentations made by 9,483 individuals

4. Trends in rates of self-harm, 2002-2012 NRDSH
250
+6%
Age-standardised rate per 100,000
225
200
+20%
175
150
125
100
75
50
25
Women
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Men

5. Incidence of self-harm by age and gender
(NRDSH, 2012)
700
600
Rate per 100,000
500
400
300
200
100
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0
Age group
Men
Alcohol was involved in 38% of all cases (42% in men, 36% in women)
Women

6. Alcohol involvement in self-harm by age and gender
(NRDSH, 2012)
60%
% of cases involving alcohol
50%
40%
30%
Male
Female
20%
10%
0%

7. 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 and 18th
- June 5th

8. 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
Rossow et al, 2007; Madge et al, 2008;
McMahon et al, 2010;Khalily & Hallahan, 2012

11. Main outcomes
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.
This peak would not exist if alcohol would not be involved.

12. Proportion of ED presentations involving alcohol
by weekday
Percentgae of presentations involving alcohol
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Monday
Tuesday
Wednesday
Male
Thursday
Female
Friday
Saturday
Sunday

13. Alcohol involvement by hour of presentation to
hospital due to self-harm
No alcohol involved
Alcohol involved
3500
Number of presentations
3000
2500
2000
1500
1000
500
0
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0
Hour of presentation
1
2
3
4
5
6
7

14. 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
300
Number of presentations
250
200
150
Alcohol
involved
100
No alcohol
involved
50
0
Mon
Tue
Wed
Thu
Fri
Day of the week
Sat
Sun

15. Western Area of Northern Ireland: Frequency of selfharm presentations to hospital by day of the week with
and without the involvement of alcohol
Women
350
Number of presentations
300
250
Alcohol involved
200
150
100
No alcohol
involved
50
0
Mon
Tue
Wed
Thu
Fri
Day of the week
Sat
Sun

16. Trends in highly lethal methods of self-harm and alcohol
involvement (2004-2012)
250
Number of presentations
200
Males with alcohol
150
100
50
Females with alcohol
0
2004
2005
2006
2007
2008
2009
2010
2011
2012

17. Main outcomes



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

18. International comparative study on
self-harm and associated factors
Child and Adolescent Self Harm in Europe (CASE)
The CASE study is a multi-centre study in 6 countries across Europe
and 1 non-European centre (Australia).
Objectives:
 The prevalence of self harm-among 15-17 year olds
and the relationship with risk factors (e.g. depression, anxiety,
alcohol, drug use/misuse etc.) and protective factors (e.g.
coping, help seeking) across different countries
 Young people’s opinions on the prevention of mental health
difficulties

19. Prevalence of self-harm in adolescents across
different countries
Females
Males
25
%
20
15
10
5
0
Australia
England
Madge et al, 2008
Norway
Belgium
Ireland
Hungary
Netherlands

20. Proportion of adolescent self-harm
due to heavy drinking
Norway
Hungary
England
Netherlands
Australia
Belgium
Ireland
0
10
20
30
Percentage
Other factors considered: age, gender, depression,
impulsivity and negative life events
40
50
Rossow et al, 2007
60

21. Main outcomes
Heavy alcohol consumption increases risk of selfharm 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%)
GP/Psychiatrist/
Psychologist
(Response Rate:
77.1%)
Close family
members/
friends
(Response Rate:
66.0%)
• 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. Second SSIS Report: Key findings from a study
looking at 307 suicide deaths in Cork
•
•
•
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

24. Characteristics of the suicide act



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
History of alcohol only abuse
Method of suicide: Hanging
Marital status: Single
Method of suicide: Hanging
Opiates in toxicology
Living alone
Benzodiazepines in toxicology
Drugs in toxicology
Alcohol in toxicology
Marital status: Married/Co-habiting
History of alcohol and drug abuse
Antidepressants in toxicology
Unemployed
In paid employment
Living with family of origin
Diagnosed with a physical illness
History of self-harm
Diagnosed with depression
Family or close friend died by suicide
Agricultural occupation
Diagnosed with depression
Day of the week died: Saturday
Day of the week died: Monday
History of self-harm
Full-time student
Family or close friend died by suicide
0
10 20 30 40 50 60 70 80
Men aged < 40 Years
0
10
20
30
40
50
Men aged ≥ 40 Years
60
70
80

26. Demographic, psychosocial and psychiatric factors associated with
suicide in those with and without a history of self-harm
Had history of self-harm
No history of self-harm
Cause of death: Hanging
Cause of death: Hanging
Drugs in toxicology
Psychiatric diagnosis
In paid employment
History of alcohol and/or drug abuse
Married/Co/habiting
Unemployed
Treated as psychiatric out-patient
Construction/production sector
Family or close friend died by
suicide
Diagnosed with depression
History of alcohol and/or drug abuse
Treated as psychiatric in-patient
Living with family of origin
Left suicide note/message
Living alone
Day of the week died: Saturday
Divorced/Seperated
Agricultural sector
Day of the week died: Thursday
0
10 20 30 40 50 60 70 80
Percentage
0
10 20 30 40 50 60 70 80
Percentage

27. 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 preadolescent 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
and alcohol/drug abuse).

28. Evidence based actions
Health care professionals working with people who engage in selfharm 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.

29. 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

30. Thank you!
Prof Ella Arensman
National Suicide Research Foundation &
Department of Epidemiology and Public Health
University College Cork
Western gateway Building
Western Road
Cork
T: 021 4205551
E-mail: earensman@ucc.ie
The National Suicide Research Foundation is in receipt of funding from the
National Office for Suicide Prevention