Alcohol, cannabis and other drugs and subsequent suicide ideation and attempt among young Mexicans
Introduction
According to a recent WHO report, in Mexico the number of suicides between the years 2000 and 2012 increased by 10.6% and the suicide death rate increased by 17.1%, while at the international level the suicide death rate decreased by 26% (World Health Organization, 2014a). Evidence-based actions need to be implemented to stop the increasing trend of suicides in Mexico. However, because suicide is a rare outcome, few analytical studies on death by suicide exist in Mexico to provide the empirical evidence needed (Chávez-Hernández and Macías-García, 2016). Nevertheless, a key risk factor for death by suicide is suicidal ideation and attempts (World Health Organization, 2014a, Nock et al., 2008), also a matter of great psychological distress by themselves and more readily available for study (Borges et al., 2009).
Mental disorders, including alcohol use disorders (World Health Organization, 2014b) and drug use disorders (Borges et al., 2000) are one of the main risk factors for death by suicide and suicide attempts. Alcohol dependence was responsible for the second largest proportion (13.25%) of the suicide disability-adjusted life years (DALY) that were attributable to mental and substance use disorders in 2010, only behind major depressive disorder (Ferrari et al., 2014). The attributable fraction of alcohol on suicide in 2012 was estimated to be 20% of all DALYS ((World Health Organization, 2014a), Fig. 14). These same sources also point to the impact of other substances on suicide, especially opioid, amphetamine and cocaine dependence (Ferrari et al., 2014). New evidence is also emerging on the possible role of cannabis use on suicidal behavior (Agrawal and Lynskey, 2014, Borges et al., 2016, Shalit et al., 2016), a matter of great relevance because of the large prevalence of cannabis use in several countries, including Mexico (United Nations Office on Drugs and Crime, 2015).
There is variation in the magnitude and consistency of the association between alcohol and drug use with suicide, suicide ideation and suicide attempts (suicidal behavior). Research is more abundant and consistent for the use of alcohol, as reviewed others (Berglund and Ojehagen, 1998, Conner et al., 2008, Norström and Rossow, 2016). Recent meta-analyses have showed elevated risk for these outcomes attributed to alcohol use disorders (Darvishi et al., 2015, Roerecke and Rehm, 2014). On the other hand, there is an emerging consensus that the use of drugs (illicit drugs, specifically cocaine, amphetamines and opioids), increases the risk of suicidal behavior (Schneider, 2009). The evidence for the relation between illicit drug use and suicidal behavior is nevertheless limited in that most of the studies are cross-sectional (Borges et al., 2000, Miller et al., 2011, Wong et al., 2013), with few case-control (Petronis et al., 1990) or follow-up studies (Westman et al., 2015, Hjorthøj et al., 2015). Longitudinal research on the topic is even more limited among adolescents and young adults, two groups especially at risk for both substance use and suicidal behavior (World Health Organization, 2014a, Nock et al., 2008, World Health Organization, 2014b). Results among adolescents are inconsistent, with some positive findings (Wilcox and Anthony, 2004, Andrews and Lewinsohn, 1992, Fergusson and Lynskey, 1995, Newcomb et al., 1993, Reinherz et al., 1995, Seo and Lee, 2013, Rossow and Norström, 2014) but also some reports of no-association for both alcohol and drug use and onset of suicide ideation and attempts (Wilcox and Anthony, 2004, Strandheim et al., 2014, Cluver et al., 2015, Thompson et al., 2007, Thompson and Light, 2011, Werbeloff et al., 2016). When available, most of the evidence on substance use are of “any use” and often does not differentiate early users and heavy users, or users of alcohol and specific illicit drugs. Among the latter, cannabis use is of particular relevance because it is the drug of preference in most countries (including Mexico), changes in legislation for cannabis use are seen everywhere and its association with suicidal behavior has been a matter of considerable debate. Also, most research on the topic is from high income countries, but low and middle income countries also share a heavy burden of substance use and suicide, and the importance of particular substances varies across countries, with alcohol use usually showing a larger burden in low and middle income countries.
Because of the lack of longitudinal data for suicide ideation and attempt in Mexico, we investigated the role of alcohol, cannabis and other drug use as potential risk factors for the incidence of suicide ideation and attempt among a group of respondents living in the Mexico City Metropolitan Area, aged 12–17 when first assessed in 2005 and 19–26 years of age when assessed at follow-up (Benjet et al., 2016). In our study, by focusing on substance use and substance use disorders, we aim to narrow the impact of other variables that may play a role when studying the incidence of suicidal ideation and attempt.
Section snippets
Dataset
This is a prospective cohort study that uses data from a recent follow-up conducted in 2013 (Benjet et al., 2016) of the original Mexican Adolescent Mental Health Survey conducted in 2005 (Benjet et al., 2009). The Mexican Adolescent Mental Health Survey was a stratified multistage area probability survey, designed to be representative of the 1,834,661 adolescents aged 12 to 17 who were permanent residents of the Mexico City Metropolitan Area at the time of the survey and who were not
Results
Table 1 shows the distribution of respondents free of suicide ideation at wave I (2005) (n = 960) and those free of suicide attempt in 2005 (n = 1041) by basic sociodemographic characteristics at wave II (2013). The distributions are similar for both outcomes. Gender and age distribution was very even, in part due to the generation of weights. One third of the sample was still attending school, and most had attained a high-school level education. Almost half of sample was still living with
Discussion
In this prospective eight-year follow-up study of 1071 adolescents as they became young adults living in the Mexico City metropolitan area, we found that cannabis use and disorders before age 15 and high frequency of use and recent cannabis use disorders increased the RR of both suicide ideation and attempt. Those who used other drugs more frequently had an increased RR of suicide attempt. The relation of alcohol with suicide ideation and attempt was more limited, with only those who used
Role of the funding source
The Mexican Adolescent Mental Health Survey was supported by the National Council on Science and Technology and Ministry of Education (grant CONACYT-SEP-SSEDF-2003-CO1-22). The Mexican Adolescent Mental Health Follow-up Survey was supported by the National Council on Science and Technology (grant CB-2010-01-155221) with supplementary support from Fundación Azteca. These two surveys were carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative. We
Contributors
Authors Borges and Benjet and Medina-Mora designed and wrote the protocol, collected data and obtained funds (Benjet, PI). Authors Borges and Benjet discussed the report plan, managed the literature searches and analyses. Authors Menendez and Orozco performed coding and data analyses, review and summarized the literature. Author Borges wrote the first draft of the manuscript and subsequent versions with inputs from authors Benjet, Medina-Mora and all others. All authors contributed to and have
Conflict of interest
No authors reported any conflict of interest.
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