Objective
The present study examined the association between lifetime violent behavior and suicidal thoughts and attempts in a national sample of patients seeking substance use disorder (SUD) treatment.
Method
A large national sample of adults entering substance use disorder treatment (N = 6,233) was examined. After describing the correlates of prior suicidal thoughts and attempt(s) in this sample, we examined the association between self-report of lifetime violence and suicidal ideation, a single prior attempt and multiple prior attempts in patients seeking SUD treatment.
Results
In bivariate analyses, individuals with prior violence were more likely to report suicidal ideation, single and multiple suicide attempts than those without prior violence. These associations remained significant after controlling for demographic factors, symptoms of depression, and childhood victimization. In examinations of specific types of violence, more extreme forms of violence (i.e., murder, rape) were most strongly associated with risk of multiple suicide attempts.
Conclusions
Prior violence is consistently associated with greater risk for suicidal thoughts and behaviors in patients seeking SUD treatment. Treatment providers should be aware that those patients with some of the greatest violence in their past are also those at elevated risk for harm to themselves.
Prior suicidal thoughts and behaviors are common in patients treated for Substance Use Disorders (SUDs; Darke et al., 2004, Roy, 2002, Roy et al., 1990 and Tiet et al., 2006). For example, rates of lifetime suicide attempts among SUD patients are as high as 45% (Johnsson & Fridell, 1997) and a recent study found that approximately a third of patients reported suicidal ideation within the two weeks prior to seeking SUD treatment (Ilgen et al., 2009). Additionally, although SUD treatment engagement is positively associated with reductions in suicide attempts, patients with SUDs remain at high risk for suicidal behaviors following SUDs treatment (Darke et al., 2007 and Ilgen et al., 2007). Further work is needed to better elucidate the risk factors for suicidal thoughts and behaviors in SUD patients.
The examination of factors associated with a suicide attempt prior to SUD treatment entry has identified several pre-treatment factors, including previous suicide attempts, suicidal ideation, depression, psychotic symptoms, past physical and/or sexual abuse, and more severe pre-treatment alcohol or other substance use (Darke et al., 2004, Ilgen et al., 2004, Roy, 2002 and Roy et al., 1990). Additionally, Tiet et al. (2006) found that patients in SUD treatment with a recent suicide attempt were more likely to report difficulty controlling violent behavior than those without a recent attempt. Conner & Duberstein (2004) proposed that prior aggression and/or violence was an important risk factor for suicidal thoughts and behaviors in those with alcohol use disorder. However, the link between violence and suicidal behaviors is still preliminary and requires more research.
Prior violent behavior is common in individuals entering SUD treatment with up to 70% of some treatment seeking samples reporting prior violent behaviors (Burnette et al., 2008, Chermack and Blow, 2002 and Chermack et al., 2000). Patients with prior violence generally report greater severity of psychopathology, pre-treatment substance use and psychosocial problems than those without violence (Burnette et al., 2008 and Chermack et al., 2000). Additionally, research on alcohol dependent samples indicates that lifetime suicide attempts are more common in those who report higher rates of lifetime aggression and aggressive behavior during periods of alcohol use (Koller et al., 2002 and Preuss et al., 2002). Finally, psychological autopsy studies comparing those who died by suicide to matched controls indicates that suicide is more common in those with a history of domestic violence (Conner et al., 2001) and verbal and non-verbal aggression towards others (Conner et al., 2004, Conner et al., 2000 and Dumais et al., 2005). More broadly, psychological autopsies are based largely on interviews with persons who knew the deceased individual (e.g., family members). This design makes it harder to assess the nature of prior lifetime violence and to control for other potential confounds such as prior childhood sexual or physical abuse. However, this research has not directly examined the association between lifetime violence and suicidal thoughts and behaviors in more representative samples of patients seeking SUD treatment.
A recent study examined the association between self-reports of prior aggression and suicidal ideation in a sample of 488 patients seeking SUD treatment (Ilgen et al., 2009). The results of this study indicate that aggression towards a partner is more strongly associated with risk of suicidal ideation than aggression towards a non-partner. Additionally, in multivariate models that controlled for severity of baseline substance use and childhood physical and sexual abuse, aggression towards a partner was still significantly associated with a greater likelihood of suicidal ideation. However, the risk factors for suicidal thoughts and attempts usually differ (Kessler, Borges, & Walters, 1999) and it is not known whether prior violence is associated with suicide attempts in those seeking SUD treatment. Additionally, patients seeking SUD treatment report a wide array of violent behaviors, from physical assault to mugging or attacking with a weapon (Burnette et al., 2008) and the link between different forms of violence and the risk of suicidal thoughts and behaviors has not been established.
The present study utilized data from 6,228 patients from a national sample of drug and alcohol treatment programs. After describing the correlates of prior violence in this sample, this study examined the association between self-report of lifetime violence and suicidal ideation, a single prior suicide attempt, and multiple attempts in patients seeking SUD treatment. The final set of analyses focused on the specific association between different types of violence and suicidal thoughts and behaviors.
