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1.  Early Initiation of Alcohol Drinking, Cigarette Smoking, and Sexual Intercourse Linked to Suicidal Ideation and Attempts: Findings from the 2006 Korean Youth Risk Behavior Survey 
Yonsei Medical Journal  2009;51(1):18-26.
Purpose
This study examined the association between early initiation of problem behaviors (alcohol drinking, cigarette smoking, and sexual intercourse) and suicidal behaviors (suicidal ideation and suicide attempts), and explored the effect of concurrent participation in these problem behaviors on suicidal behaviors among Korean adolescent males and females.
Materials and Methods
Data were obtained from the 2006 Korean Youth Risk Behavior Survey, a nationally representative sample of middle and high school students (32,417 males and 31,467 females) in grades seven through twelve. Bivariate and multivariate logistic analyses were conducted. Several important covariates, such as age, family living structure, household economic status, academic performance, current alcohol drinking, current cigarette smoking, current butane gas or glue sniffing, perceived body weight, unhealthy weight control behaviors, subjective sleep evaluation, and depressed mood were included in the analyses.
Results
Both male and female preteen initiators of each problem behavior were at greater risk for suicidal behaviors than non-initiators, even after controlling for covariates. More numerous concurrent problematic behaviors were correlated with greater likelihood of seriously considering or attempting suicide among both males and females. This pattern was more clearly observed in preteen than in teen initiators although the former and latter were engaged in the same frequency of problem behavior.
Conclusion
Early initiation of alcohol drinking, cigarette smoking, and sexual intercourse, particularly among preteens, represented an important predictor of later suicidal ideation and suicide attempts in both genders. Thus, early preventive intervention programs should be developed and may reduce the potential risks for subsequent suicidal behaviors.
doi:10.3349/ymj.2010.51.1.18
PMCID: PMC2799971  PMID: 20046509
Alcohol drinking; cigarette smoking; sexual intercourse; suicidal ideation; attempted suicide; life experience
2.  A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP) 
PLoS Medicine  2016;13(3):e1001968.
Background
Attempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance.
Methods and Findings
Patients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period.
The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated.
During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ21 = 13.1, 95% CI 12.4–13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts.
Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment.
Conclusions
ASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings.
Trial registration
ClinicalTrials.gov NCT02505373
In a randomized controlled trial, Konrad Michel and colleagues test the efficacy of a manual-based therapy intended to prevent repeat suicide attempts.
Editors' Summary
Background
Suicide is a serious public health problem. Over 800,000 people worldwide die by suicide every year. In the US, one suicide death occurs approximately every 12 minutes. While the causes of suicide are complex, the goals of suicide prevention are simple—reduce factors that increase risk, and increase factors that promote resilience or coping. Factors that increase suicide risk include family history of suicide, family history of child abuse, previous suicide attempts, history of mental disorders (particularly depression), history of alcohol and substance abuse, and access to lethal means. Factors that are protective against suicide include effective clinical care for mental, physical, and substance abuse disorders; connectedness to family and community; and problem solving and conflict resolution skills. A previous suicide attempt is the main risk factor for repeat attempts and for completed suicide. Fifteen to 25 percent of people who attempt suicide make another attempt, and five to ten percent eventually die by suicide.
Why Was This Study Done?
A number of suicide prevention treatments have been developed. Most of them involve therapy sessions and personal follow-up. While some of them have been shown to work in clinical trials—often with participants who have made a previous suicide attempt—few interventions have proven to be effective consistently in different settings. For this study, the researchers developed a treatment called Attempted Suicide Short Intervention Program (ASSIP) composed of three therapy sessions shortly after the suicide attempt and follow-up over two years with personalized mailed letters. They wanted the therapy part to be short, in order to provide a treatment that would allow a psychiatric service to cope with the large number of patients seen in the emergency department after a suicide attempt. The therapeutic elements of the treatment emphasized building an early therapeutic alliance, which would then serve as a basis (“anchoring”) for long-term outreach contact through regular letters. The therapy sessions and letters follow a detailed script, which the researchers developed into a manual that includes a step-by-step description of the highly structured treatment, checklists, handouts, and standardized letters for use by health professionals in various clinical settings. This study was done to test whether ASSIP can reduce suicidal behavior in addition to routine treatment.
What Did the Researchers Do and Find?
The researchers carried out a randomized clinical trial testing ASSIP in people who had attempted suicide (the majority by intentional overdosing) and been admitted to the emergency department of the Bern University General Hospital in Switzerland. Participants were randomly assigned to two groups. The treatment group received ASSIP in addition to treatment as usual (inpatient, day patient, and outpatient care as deemed appropriate by the hospital clinicians); the control group received a single structured assessment interview plus treatment as usual. The study objective was to evaluate—with follow-up questionnaires and health-care data—whether ASSIP can reduce the rate of repeated suicide attempt in the 24 months after a suicide attempt. The researchers also compared suicidal ideation (i.e., whether and how often participants had suicidal thoughts), levels of depression, and how often people were hospitalized between the two groups.
A total of 120 patients who had recently attempted suicide were randomly allocated to treatment as usual or treatment as usual plus ASSIP. The 60 ASSIP participants received three therapy sessions followed by regular contact over 24 months. During the first therapy session, the patient was prompted to tell the story of how he or she had reached the point of attempting suicide. Narrative interviewing is a key element of ASSIP’s patient-centered collaborative approach. The first session was videotaped, and parts were watched and discussed by patient and therapist during the second session, to recreate the experience of psychological pain and analyze how stress developed into suicidal action. During the final session, therapist and patient developed a list of long-term goals, warning signs, and safety strategies. These were printed and given to the patient in a credit-card-sized folded leaflet along with a list of telephone help numbers. Patients were told to carry both items at all times and to use them in the event of an emotional crisis. Over the subsequent two years, patients received six letters from their therapist reminding them of the risk of future suicidal crises and the importance of the collaboratively developed safety strategies.
During the 24 months of follow-up, one death by suicide occurred in each group, five repeat suicide attempts were recorded in the ASSIP group, and 41 repeat suicide attempts were recorded in the control group. ASSIP was associated with an approximately 80% reduced risk of repeat suicide attempt. In addition, ASSIP participants spent 72% fewer days in the hospital during follow-up. There was no difference in patient-reported suicidal ideation or in levels of depression.
What Do these Findings Mean?
The results show that ASSIP, administered in addition to the usual clinical treatment, was able to reduce suicidal behavior over 24 months in patients who had recently attempted suicide. The addition of ASSIP to usual treatment directly or its effect on repeat attempts might also reduce health care costs. The absence of effects on suicidal thoughts and depression is consistent with ASSIP’s objective to help people cope with crises as opposed to eliminating them. The study’s findings in a real-world clinical setting (a university hospital in the Swiss capital) are promising. They justify further testing in large clinical trials and diverse settings to answer conclusively whether and where ASSIP can reduce repeat suicide attempts, prevent deaths from suicide, and reduce health-care costs.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001968.
National Action Alliance for Suicide Prevention has information on research prioritization for suicide prevention
There is also a supplemental issue of the American Journal of Preventive Medicine focused on research about suicide prevention
More information about suicide is available from ZEROSuicide http://zerosuicide.sprc.org/ and the Suicide Prevention Resource Center http://www.sprc.org/
The US Centers for Disease Control and Prevention has information on suicide
The UK Mental Health Foundation also has information on suicide
The page “About Suicide” from the American Foundation for Suicide Prevention has information on warning signs, risk factors, and statistics
The US National Suicide Prevention Lifeline offers help and information
The Bern University Hospital of Psychiatry has a page describing ASSIP for patients (in German)
The Finnish Association for Mental Health has a page describing ASSIP (in English)
doi:10.1371/journal.pmed.1001968
PMCID: PMC4773217  PMID: 26930055
3.  Current drinking and health-risk behaviors among male high school students in central Thailand 
BMC Public Health  2011;11:233.
Background
Alcohol drinking is frequently related to behavioral problems, which lead to a number of negative consequences. This study was to evaluate the characteristics of male high school students who drink, the drinking patterns among them, and the associations between current drinking and other health risk behaviors which focused on personal safety, violence-related behaviors, suicide and sexual behaviors.
Method
A cross-sectional study was conducted to explore current alcohol drinking and health-risk behaviors among male high school students in central Thailand. Five thousand one hundred and eighty four male students were classified into 2 groups according to drinking in the previous 30 days (yes = 631, no = 4,553). Data were collected by self-administered, anonymous questionnaire which consisted of 3 parts: socio-demographic factors, health-risk behaviors and alcohol drinking behavior during the past year from December 2007 to February 2008.
Results
The results showed that the percent of current drinking was 12.17. Most of them were 15-17 years (50.21%). Socio-demographic factors such as age, educational level, residence, cohabitants, grade point average (GPA), having a part time job and having family members with alcohol/drug problems were significantly associated with alcohol drinking (p < 0.05). Multiple logistic regression analysis, after adjusting for socio-demographic factors, revealed that health-risk behavioral factors were associated with current alcohol consumption: often drove after drinking alcohol (OR = 3.10, 95% CI = 1.88-5.12), often carried a weapon (OR = 3.51, 95% CI = 2.27-5.42), often got into a physical fight without injury (OR = 3.06, 95% CI = 1.99-4.70), dating violence (OR = 2.58, 95% CI = 1.79-3.71), seriously thought about suicide (OR = 2.07, 95% CI = 1.38-3.11), made a suicide plan (OR = 2.10, 95% CI = 1.43-3.08), ever had sexual intercourse (OR = 5.62, 95% CI = 4.33-7.29), alcohol or drug use before last sexual intercourse (OR = 2.55, 95% CI = 1.44-4.53), and got someone pregnant (OR = 3.99, 95% CI = 1.73-9.25).
Conclusions
An increased risk of health-risk behaviors, including driving vehicles after drinking, violence-related behaviors, sad feelings and attempted suicide, and sexual behaviors was higher among drinking students that led to significant health problems. Effective intervention strategies (such as a campaign mentioning the adverse health effects and social consequences to the risk groups, and encouraging parental and community efforts to prevent drinking) among adolescents should be implemented to prevent underage drinking and adverse consequences.
doi:10.1186/1471-2458-11-233
PMCID: PMC3090349  PMID: 21492419
4.  Children at Risk for Suicide Attempt and Attempt-related Injuries: Findings from the 2007 Youth Risk Behavior Survey 
Purpose:
The current study examines the associations between a range of risk factors and reports of suicide attempts and attempts requiring medical care in a nationally representative study of high school students. The goal is to examine sex differences in the risk factors associated with suicide attempts and attempt-related injuries requiring treatment by a health-care provider.
Methods:
We used data from the 2007 Youth Risk Behavior Survey for students in grades 9–12 to assess the prevalence and risk factors for suicidal behavior, as well as differences in these for boys and girls. Cross-sectional multivariate logistic regression analyses were computed to determine the most important risk factors for suicide attempts and for suicide attempts requiring medical care for the sample overall and also stratified for boys and for girls.
Results:
Overall, 6.9% of adolescents attempted suicide (9.3% of girls versus 4.6% of boys). Girls were more likely than boys to report a suicide attempt in the past year (Adj.OR=2.89). Among girls, sadness (Adj.OR=5.74), weapon carrying (Adj.OR=1.48), dating violence (Adj.OR=1.60), forced sex (Adj.OR=1.72), and huffing glue (Adj.OR=2.04) were significantly associated with suicide attempts. Among boys, sadness (Adj.OR=10.96), weapon carrying (Adj.OR=1.66), forced sex (Adj.OR=2.60), huffing glue (OR=1.63), hard drug use (Adj.OR=2.18), and sports involvement (Adj.OR=1.52) were significantly associated with suicide attempts.
Conclusion:
These findings demonstrate similarities and differences in the modifiable risk factors that increase risk for suicide attempts among boys and girls. In terms of the differences between boys and girls, hard drug use and sports involvement may be important factors for suicide-prevention strategies directed specifically towards boys, while dating violence victimization may be an important risk factor to address for girls. Overall, these findings can help guide prevention, clinical practice, and intervention strategies to prevent suicidal behaviors among adolescents.
PMCID: PMC2941363  PMID: 20882146
5.  Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior: Findings from the WHO World Mental Health Surveys 
PLoS Medicine  2009;6(8):e1000123.
Using data from over 100,000 individuals in 21 countries participating in the WHO World Mental Health Surveys, Matthew Nock and colleagues investigate which mental health disorders increase the odds of experiencing suicidal thoughts and actual suicide attempts, and how these relationships differ across developed and developing countries.
Background
Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts.
Methods and Findings
Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9–8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5–5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies.
Conclusions
This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.
Please see later in the article for Editors' Summary
Editors' Summary
Background
Suicide is a leading cause of death worldwide. Every 40 seconds, someone somewhere commits suicide. Over a year, this adds up to about 1 million self-inflicted deaths. In the USA, for example, where suicide is the 11th leading cause of death, more than 30,000 people commit suicide every year. The figures for nonfatal suicidal behavior (suicidal thoughts or ideation, suicide planning, and suicide attempts) are even more shocking. Globally, suicide attempts, for example, are estimated to be 20 times as frequent as completed suicides. Risk factors for nonfatal suicidal behaviors and for suicide include depression and other mental disorders, alcohol or drug abuse, stressful life events, a family history of suicide, and having a friend or relative commit suicide. Importantly, nonfatal suicidal behaviors are powerful predictors of subsequent suicide deaths so individuals who talk about killing themselves must always be taken seriously and given as much help as possible by friends, relatives, and mental-health professionals.
Why Was This Study Done?
Experts believe that it might be possible to find ways to decrease suicide rates by answering three questions. First, which individual mental disorders are predictive of nonfatal suicidal behaviors? Although previous studies have reported that virtually all mental disorders are associated with an increased risk of suicidal behaviors, people often have two or more mental disorders (“comorbidity”), so many of these associations may reflect the effects of only a few disorders. Second, do some mental disorders predict suicidal ideation whereas others predict who will act on these thoughts? Finally, are the associations between mental disorders and suicidal behavior similar in developed countries (where most studies have been done) and in developing countries? By answering these questions, it should be possible to improve the screening, clinical risk assessment, and treatment of suicide around the world. Thus, in this study, the researchers undertake a cross-national analysis of the associations among mental disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV]) and nonfatal suicidal behaviors.
What Did the Researchers Do and Find?
The researchers collected and analyzed data on the lifetime presence and age-of-onset of mental disorders and of nonfatal suicidal behaviors in structured interviews with nearly 110,000 participants from 21 countries (part of the World Health Organization's World Mental Health Survey Initiative). The lifetime presence of each of the 16 disorders considered (mood disorders such as depression; anxiety disorders such as post-traumatic stress disorder [PTSD]; impulse-control disorders such as attention deficit/hyperactivity disorder; and substance misuse) predicted first suicide attempts in both developed and developing countries. However, the increased risk of a suicide attempt associated with each disorder varied. So, for example, in developed countries, after controlling for comorbid mental disorders, major depression increased the risk of a suicide attempt 3-fold but drug abuse/dependency increased the risk only 2-fold. Similarly, although the strongest predictors of suicide attempts in developed countries were mood disorders, in developing countries the strongest predictors were impulse-control disorders, substance misuse disorders, and PTSD. Other analyses indicate that mental disorders were generally more predictive of the onset of suicidal thoughts than of suicide plans and attempts, but that anxiety and poor impulse-control disorders were the strongest predictors of suicide attempts in both developed and developing countries.
What Do These Findings Mean?
Although this study has several limitations—for example, it relies on retrospective self-reports by study participants—its findings nevertheless provide a more detailed understanding of the associations between mental disorders and subsequent suicidal behaviors than previously available. In particular, its findings reveal that a wide range of individual mental disorders increase the chances of an individual thinking about suicide in both developed and developing countries and provide new information about the mental disorders that predict which people with suicidal ideas will act on such thoughts. However, the findings also show that only half of people who have seriously considered killing themselves have a mental disorder. Thus although future suicide prevention efforts should include a focus on screening and treating mental disorders, ways must also be found to identify the many people without mental disorders who are at risk of suicidal behaviors.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000123.
The US National Institute of Mental Health provides information about suicide in the US: statistics and prevention
The UK National Health Service provides information about suicide, including statistics about suicide in the UK and links to other resources
The World Health Organization provides global statistics about suicide and information on suicide prevention
MedlinePlus provides links to further information and advice about suicide and about mental health (in English and Spanish)
Further details about the World Mental Health Survey Initiative and about DSM-IV are available
doi:10.1371/journal.pmed.1000123
PMCID: PMC2717212  PMID: 19668361
6.  Extreme Binge Drinking among 12th-Grade Students in the U.S.: Prevalence and Predictors 
JAMA pediatrics  2013;167(11):10.1001/jamapediatrics.2013.2392.
Importance
The prevalence of underage alcohol use has been studied extensively but binge drinking among youth in the U.S. is not yet well understood. In particular, adolescents may drink much larger amounts than the threshold (5 drinks) often used in definitions of binge drinking. Delineating various levels of binge drinking, including extreme levels, and understanding predictors of such extreme binge drinking among adolescents will benefit public health efforts.
Objective
To examine the prevalence and predictors of 5+ binge drinking and of 10+ and 15+ extreme binge drinking among 12th graders in the U.S.
Design
A non-clinical nationally representative sample.
Setting
High school seniors in the annual Monitoring the Future study between 2005 and 2011.
Participants
The sample included 16,332 12th graders (modal age 18) in the U.S. Response rates were 79–85%.
Main Outcome Measures
Prevalence of consuming 5+, 10+, and 15+ drinks in a row in the past two weeks.
Results
Between 2005 and 2011, 20.2% of high school seniors reported 5+ binge drinking, 10.5% reported 10+ extreme binge drinking, and 5.6% reported 15+ extreme binge drinking in the past 2 weeks. Rates of 5+ binge drinking and 10+ extreme binge drinking have declined since 2005, but rates of 15+ extreme binge drinking have not. Students with college-educated parents were more likely to consume 5+ drinks but less likely to consume 15+ drinks than students whose parents were not college educated. Students from more rural areas were more likely than students from large metropolitan areas to drink 15+ drinks. Socializing with substance-using peers, number of evenings out with friends, substance-related attitudes, and other substance use (cigarettes, marijuana) predicted all three levels of binge and extreme binge drinking.
Conclusions
Binge drinking at the traditionally defined 5+ drinking level was common among high school seniors representative of all 12th graders in the contiguous U.S. A significant segment of students also reported extreme binge drinking at levels two and three times higher. These data suggest the importance of assessing multiple levels of binge drinking behavior and their predictors among adolescents in order to target effective screening and intervention efforts.
doi:10.1001/jamapediatrics.2013.2392
PMCID: PMC3818300  PMID: 24042318
7.  Alcohol Sales and Risk of Serious Assault 
PLoS Medicine  2008;5(5):e104.
Background
Alcohol is a contributing cause of unintentional injuries, such as motor vehicle crashes. Prior research on the association between alcohol use and violent injury was limited to survey-based data, and the inclusion of cases from a single trauma centre, without adequate controls. Beyond these limitations was the inability of prior researchers to comprehensively capture most alcohol sales. In Ontario, most alcohol is sold through retail outlets run by the provincial government, and hospitals are financed under a provincial health care system. We assessed the risk of being hospitalized due to assault in association with retail alcohol sales across Ontario.
Methods and Findings
We performed a population-based case-crossover analysis of all persons aged 13 years and older hospitalized for assault in Ontario from 1 April 2002 to 1 December 2004. On the day prior to each assault case's hospitalization, the volume of alcohol sold at the store in closest proximity to the victim's home was compared to the volume of alcohol sold at the same store 7 d earlier. Conditional logistic regression analysis was used to determine the associated relative risk (RR) of assault per 1,000 l higher daily sales of alcohol. Of the 3,212 persons admitted to hospital for assault, nearly 25% were between the ages of 13 and 20 y, and 83% were male. A total of 1,150 assaults (36%) involved the use of a sharp or blunt weapon, and 1,532 (48%) arose during an unarmed brawl or fight. For every 1,000 l more of alcohol sold per store per day, the relative risk of being hospitalized for assault was 1.13 (95% confidence interval [CI] 1.02–1.26). The risk was accentuated for males (1.18, 95% CI 1.05–1.33), youth aged 13 to 20 y (1.21, 95% CI 0.99–1.46), and those in urban areas (1.19, 95% CI 1.06–1.35).
Conclusions
The risk of being a victim of serious assault increases with alcohol sales, especially among young urban men. Akin to reducing the risk of driving while impaired, consideration should be given to novel methods of preventing alcohol-related violence.
In a population-based case-crossover analysis, Joel Ray and colleagues find that the risk of being a victim of serious assault increases with retail alcohol sales, especially among young urban men.
Editors' Summary
Background.
Alcohol has been produced and consumed around the world since prehistoric times. In the Western world it is now the most commonly consumed psychoactive drug (a substance that changes mood, behavior, and thought processes). The World Health Organization reports that there are 76.3 million persons with alcohol use disorders worldwide. Alcohol consumption is an important factor in unintentional injuries, such as motor vehicle crashes, and in violent criminal behavior. In the United Kingdom, for example, a higher proportion of heavy drinkers than light drinkers cause violent criminal offenses. Other figures suggest that people (in particular, young men) have an increased risk of committing a criminally violent offense within 24 h of drinking alcohol. There is also some evidence that suggests that the victims as well as the perpetrators of assaults have often been drinking recently, possibly because alcohol impairs the victim's ability to judge potentially explosive situations.
Why Was This Study Done?
The researchers wanted to know more about the relationship between alcohol and intentional violence. The recognition of a clear link between driving when impaired by alcohol and motor vehicle crashes has led many countries to introduce public awareness programs that stigmatize drunk driving. If a clear link between alcohol consumption by the people involved in violent crime could also be established, similar programs might reduce alcohol-related assaults. The researchers tested the hypothesis that the risk of being hospitalized due to a violent assault increases when there are increased alcohol sales in the immediate vicinity of the victim's place of residence.
What Did the Researchers Do and Find?
The researchers did their study in Ontario, Canada for three reasons. First, Ontario is Canada's largest province. Second, the province keeps detailed computerized medical records, including records of people hospitalized from being violently assaulted. Third, most alcohol is sold in government-run shops, and the district has the infrastructure to allow daily alcohol sales to be tracked. The researchers identified more than 3,000 people over the age of 13 y who were hospitalized in the province because of a serious assault during a 32-mo period. They compared the volume of alcohol sold at the liquor store nearest to the victim's home the day before the assault with the volume sold at the same store a week earlier (this type of study is called a “case-crossover” study). For every extra 1,000 l of alcohol sold per store per day (a doubling of alcohol sales), the overall risk of being hospitalized for assault increased by 13%. The risk was highest in three subgroups of people: men (18% increased risk), youths aged 13 to 20 y (21% increased risk), and those living in urban areas (19% increased risk). At peak times of alcohol sales, the risk of assault was 41% higher than at times when alcohol sales were lowest.
What Do These Findings Mean?
These findings indicate that the risk of being seriously assaulted increases with the amount of alcohol sold locally the day before the assault and show that the individuals most at risk are young men living in urban areas. Because the study considers only serious assaults and alcohol sold in shops (i.e., not including alcohol sold in bars), it probably underestimates the association between alcohol and assault. It also does not indicate whether the victim or perpetrator of the assault (or both) had been drinking, and its findings may not apply to countries with different drinking habits. Nevertheless, these findings support the idea that the consumption of alcohol contributes to the occurrence of medical injuries from intentional violence. Increasing the price of alcohol or making alcohol harder to obtain might help to reduce the occurrence of alcohol-related assaults. The researchers suggest that a particularly effective approach may be to stigmatize alcohol-related brawling, analogous to the way that driving under the influence of alcohol has been made socially unacceptable.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050104.
This study is further discussed in a PLoS Medicine Perspective by Bennetts and Seabrook
The US National Institute on Alcohol Abuse and Alcoholism provides information on all aspects of alcohol abuse, including an article on alcohol use and violence among young adults
Alcohol-related assault is examined in the British Crime Survey
Alcohol Concern, the UK national agency on alcohol misuse, provides fact sheets on the health impacts of alcohol, young people's drinking, and alcohol and crime
The Canadian Centre for Addiction and Mental Health in Toronto provides information about alcohol addiction (in English and French)
doi:10.1371/journal.pmed.0050104
PMCID: PMC2375945  PMID: 18479181
8.  Factors Associated with Suicidal Ideation and Suicide Attempt among School-Going Urban Adolescents in Peru 
The study examines the prevalence of suicidal ideation and suicide attempt, and associated factors among school-going urban adolescents in Peru. A cross-sectional survey was conducted in a sample of 916 secondary school adolescents in 2014. A structured questionnaire adapted from Global School-based Student Health Survey was used to obtain information. Data were analyzed using logistic regression models at 5% level of significance. Overall, 26.3% reported having suicidal ideation, and 17.5% reported having attempted suicide during the past 12 months. Multivariate logistic regression analysis showed that female sex, being in a fight, being insulted, being attacked, perceived unhappiness, smoking and sexual intercourse initiation were significantly associated with increased risk of suicidal ideation, while female sex, being in a fight, being insulted, being attacked, perceived unhappiness, alcohol and illicit drug use were related to suicide attempt. The prevalence of suicidal ideation and suicide attempts observed in the survey area is relatively high. Female adolescents are particularly vulnerable to report suicidal ideation and suicide attempt. Interventions that address the issue of violence against adolescents, fighting with peers, health risk behaviors particularly initiation of smoking, alcohol and illicit drug use and encourage supportive role of parents may reduce the risk of suicidal behaviors.
doi:10.3390/ijerph121114842
PMCID: PMC4661683  PMID: 26610536
suicidal ideation; suicide attempt; factors; adolescents; Peru
9.  Intoxication and Binge and High-Intensity Drinking Among US Young Adults in Their Mid-Twenties 
Substance abuse  2016;37(4):597-605.
Background
Alcohol use is a key risk factor for young adult mortality and disease, but limited research has focused on high-risk alcohol use among individuals moving from early young adulthood into building and maintaining an initial structure of adult life. This study estimated the prevalence of a range of alcohol use behaviors among US young adults aged 25/26, examined evidence for historical change in prevalence rates, and estimated associations between alcohol use and key demographic, substance use, and adult social role characteristics.
Methods
Data were obtained from 3,542 individuals selected for follow-up from the nationally-representative 12th grade student Monitoring the Future study. Respondents self-reported alcohol use behaviors at age 25/26 during calendar years 2005–2014.
Results
Two-fifths (39.9%) of young adults aged 25/26 reported being intoxicated at least once in the past 30 days; 25.6% reported usually experiencing a sustained high of 3 or more hours when drinking alcohol. Past two-week binge drinking (5+ drinks in a row) was reported by 36.3% of respondents. Past two-week high-intensity drinking (10+ drinks in a row) was reported by 12.4%. These age 25/26 alcohol use prevalence rates remained stable over the ten years of data examined, in contrast to significant declines over historical time in alcohol prevalence rates among these same individuals at age 18. High-risk drinking was particularly associated with being male, White, unmarried, employed, a non-parent, and an alcohol user before finishing high school.
Conclusions
Among US young adults in their mid-twenties, alcohol use was highly normative and frequently included participation in high-risk drinking behaviors. High-risk alcohol use prevention approaches developed specifically to reach young adults in their mid-twenties are needed, as well as efforts to increase proactive clinician screening to identify young adults participating in high-risk alcohol use.
doi:10.1080/08897077.2016.1178681
PMCID: PMC5308065  PMID: 27092592
Alcohol consumption; young adult; binge drinking; high-intensity drinking; alcoholic intoxication
10.  Intimate Partner Violence and Incident Depressive Symptoms and Suicide Attempts: A Systematic Review of Longitudinal Studies 
PLoS Medicine  2013;10(5):e1001439.
Karen Devries and colleagues conduct a systematic review of longitudinal studies to evaluate the direction of association between symptoms of depression and intimate partner violence.
Please see later in the article for the Editors' Summary
Background
Depression and suicide are responsible for a substantial burden of disease globally. Evidence suggests that intimate partner violence (IPV) experience is associated with increased risk of depression, but also that people with mental disorders are at increased risk of violence. We aimed to investigate the extent to which IPV experience is associated with incident depression and suicide attempts, and vice versa, in both women and men.
Methods and Findings
We conducted a systematic review and meta-analysis of longitudinal studies published before February 1, 2013. More than 22,000 records from 20 databases were searched for studies examining physical and/or sexual intimate partner or dating violence and symptoms of depression, diagnosed major depressive disorder, dysthymia, mild depression, or suicide attempts. Random effects meta-analyses were used to generate pooled odds ratios (ORs). Sixteen studies with 36,163 participants met our inclusion criteria. All studies included female participants; four studies also included male participants. Few controlled for key potential confounders other than demographics. All but one depression study measured only depressive symptoms. For women, there was clear evidence of an association between IPV and incident depressive symptoms, with 12 of 13 studies showing a positive direction of association and 11 reaching statistical significance; pooled OR from six studies = 1.97 (95% CI 1.56–2.48, I2 = 50.4%, pheterogeneity = 0.073). There was also evidence of an association in the reverse direction between depressive symptoms and incident IPV (pooled OR from four studies = 1.93, 95% CI 1.51–2.48, I2 = 0%, p = 0.481). IPV was also associated with incident suicide attempts. For men, evidence suggested that IPV was associated with incident depressive symptoms, but there was no clear evidence of an association between IPV and suicide attempts or depression and incident IPV.
Conclusions
In women, IPV was associated with incident depressive symptoms, and depressive symptoms with incident IPV. IPV was associated with incident suicide attempts. In men, few studies were conducted, but evidence suggested IPV was associated with incident depressive symptoms. There was no clear evidence of association with suicide attempts.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Depression and suicide are responsible for a substantial proportion of the global disease burden. Depression—an overwhelming feeling of sadness and hopelessness that can last for months or years—affects more than 350 million people worldwide. It is the eleventh leading cause of global disability-adjusted life-years (a measure of overall disease burden), and it affects one in six people at some time during their lives. Globally, about a million people commit suicide every year, usually because they have depression or some other mental illness. Notably, in cross-sectional studies (investigations that look at a population at a single time point), experience of intimate partner violence (IPV, also called domestic violence) is strongly and consistently associated with both depressive disorders and suicide. IPV, like depression and suicide, is extremely common—in multi-country studies, 15%–71% of women report being physically assaulted at some time during their lifetime. IPV is defined as physical, sexual, or psychological harm by a current or former partner or spouse; men as well as women can be the victims of IPV.
Why Was This Study Done?
It may seem obvious to assume that IPV is causally related to subsequent depression and suicidal behavior. However, cross-sectional studies provide no information about causality, and it is possible that depression and/or suicide attempts cause subsequent IPV or that there are common risk factors for IPV, depression, and suicide. For example, individuals with depressive symptoms may be more accepting of partners with characteristics that predispose them to use violence, or early life exposure to violence may predispose individuals to both depression and choosing violent partners. Here, as part of the Global Burden of Disease Study 2010, the researchers investigate the extent to which experience of IPV is associated with subsequent depression and suicide attempts and vice versa in both men and women by undertaking a systematic review and meta-analysis of longitudinal studies that have examined IPV, depression, and suicide attempts. A systematic review uses predefined criteria to identify all the research on a given topic, meta-analysis combines the results of several studies, and longitudinal studies track people over time to investigate associations between specific characteristics and outcomes.
What Did the Researchers Do and Find?
The researchers identified 16 longitudinal studies involving a total of 36,163 participants that met their inclusion criteria. All the studies included women, but only four also included men. All the studies were undertaken in high- and middle-income countries. For women, 11 studies showed a statistically significant association (an association unlikely to have occurred by chance) between IPV and subsequent depressive symptoms. In a meta-analysis of six studies, experience of IPV nearly doubled the risk of women subsequently reporting depressive symptoms. In addition, there was evidence of an association in the reverse direction. In a meta-analysis of four studies, depressive symptoms nearly doubled the risk of women subsequently experiencing IPV. IPV was also associated with subsequent suicide attempts among women. For men, there was some evidence from two studies that IPV was associated with depressive symptoms but no evidence for an association between IPV and subsequent suicide attempt or between depressive symptoms and subsequent IPV.
What Do These Findings Mean?
These findings suggest that women who are exposed to IPV are at increased risk of subsequent depression and that women who are depressed are more likely to be at risk of IPV. They also provide evidence of an association between IPV and subsequent suicide attempt for women. The study provides little evidence for similar relationships among men, but additional studies are needed to confirm this finding. Moreover, the accuracy of these findings is likely to be affected by several limitations of the study. For example, few of the included studies controlled for other factors that might have affected both exposure to IPV and depressive symptoms, and none of the studies considered the effect of emotional violence on depressive symptoms and suicide attempts. Nevertheless, these findings have two important implications. First, they suggest that preventing violence against women has the potential to reduce the global burden of disease related to depression and suicide. Second, they suggest that clinicians should pay attention to past experiences of violence and the risk of future violence when treating women who present with symptoms of depression.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001439.
This study is further discussed in a PLOS Medicine Perspective by Alexander Tsai
The US National Institute of Mental Health provides information on all aspects of depression and of suicide and suicide prevention (in English and Spanish)
The UK National Health Service Choices website provides detailed information about depression, including personal stories about depression, and information on suicide and its prevention; it has a webpage about domestic violence, which includes descriptions of personal experiences
The World Health Organization provides information on depression, on the global burden of suicide and on suicide prevention, and on intimate partner violence (some information in several languages)
MedlinePlus provides links to other resources about depression, suicide, and domestic violence (in English and Spanish)
The charity Healthtalkonline has personal stories about depression and about dealing with suicide
doi:10.1371/journal.pmed.1001439
PMCID: PMC3646718  PMID: 23671407
11.  The Effectiveness of Community Action in Reducing Risky Alcohol Consumption and Harm: A Cluster Randomised Controlled Trial 
PLoS Medicine  2014;11(3):e1001617.
In a cluster randomized controlled trial, Anthony Shakeshaft and colleagues measure the effectiveness of a multi-component community-based intervention for reducing alcohol-related harm.
Background
The World Health Organization, governments, and communities agree that community action is likely to reduce risky alcohol consumption and harm. Despite this agreement, there is little rigorous evidence that community action is effective: of the six randomised trials of community action published to date, all were US-based and focused on young people (rather than the whole community), and their outcomes were limited to self-report or alcohol purchase attempts. The objective of this study was to conduct the first non-US randomised controlled trial (RCT) of community action to quantify the effectiveness of this approach in reducing risky alcohol consumption and harms measured using both self-report and routinely collected data.
Methods and Findings
We conducted a cluster RCT comprising 20 communities in Australia that had populations of 5,000–20,000, were at least 100 km from an urban centre (population ≥ 100,000), and were not involved in another community alcohol project. Communities were pair-matched, and one member of each pair was randomly allocated to the experimental group. Thirteen interventions were implemented in the experimental communities from 2005 to 2009: community engagement; general practitioner training in alcohol screening and brief intervention (SBI); feedback to key stakeholders; media campaign; workplace policies/practices training; school-based intervention; general practitioner feedback on their prescribing of alcohol medications; community pharmacy-based SBI; web-based SBI; Aboriginal Community Controlled Health Services support for SBI; Good Sports program for sports clubs; identifying and targeting high-risk weekends; and hospital emergency department–based SBI. Primary outcomes based on routinely collected data were alcohol-related crime, traffic crashes, and hospital inpatient admissions. Routinely collected data for the entire study period (2001–2009) were obtained in 2010. Secondary outcomes based on pre- and post-intervention surveys (n = 2,977 and 2,255, respectively) were the following: long-term risky drinking, short-term high-risk drinking, short-term risky drinking, weekly consumption, hazardous/harmful alcohol use, and experience of alcohol harm. At the 5% level of statistical significance, there was insufficient evidence to conclude that the interventions were effective in the experimental, relative to control, communities for alcohol-related crime, traffic crashes, and hospital inpatient admissions, and for rates of risky alcohol consumption and hazardous/harmful alcohol use. Although respondents in the experimental communities reported statistically significantly lower average weekly consumption (1.90 fewer standard drinks per week, 95% CI = −3.37 to −0.43, p = 0.01) and less alcohol-related verbal abuse (odds ratio = 0.58, 95% CI = 0.35 to 0.96, p = 0.04) post-intervention, the low survey response rates (40% and 24% for the pre- and post-intervention surveys, respectively) require conservative interpretation. The main limitations of this study are as follows: (1) that the study may have been under-powered to detect differences in routinely collected data outcomes as statistically significant, and (2) the low survey response rates.
Conclusions
This RCT provides little evidence that community action significantly reduces risky alcohol consumption and alcohol-related harms, other than potential reductions in self-reported average weekly consumption and experience of alcohol-related verbal abuse. Complementary legislative action may be required to more effectively reduce alcohol harms.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12607000123448
Please see later in the article for the Editors' Summary
Editors' Summary
Background
People have consumed alcoholic beverages throughout history, but alcohol use is now an increasing global public health problem. According to the World Health Organization's 2010 Global Burden of Disease Study, alcohol use is the fifth leading risk factor (after high blood pressure and smoking) for disease and is responsible for 3.9% of the global disease burden. Alcohol use contributes to heart disease, liver disease, depression, some cancers, and many other health conditions. Alcohol also affects the well-being and health of people around those who drink, through alcohol-related crimes and road traffic crashes. The impact of alcohol use on disease and injury depends on the amount of alcohol consumed and the pattern of drinking. Most guidelines define long-term risky drinking as more than four drinks per day on average for men or more than two drinks per day for women (a “drink” is, roughly speaking, a can of beer or a small glass of wine), and short-term risky drinking (also called binge drinking) as seven or more drinks on a single occasion for men or five or more drinks on a single occasion for women. However, recent changes to the Australian guidelines acknowledge that a lower level of alcohol consumption is considered risky (with lifetime risky drinking defined as more than two drinks a day and binge drinking defined as more than four drinks on one occasion).
Why Was This Study Done?
In 2010, the World Health Assembly endorsed a global strategy to reduce the harmful use of alcohol. This strategy emphasizes the importance of community action–a process in which a community defines its own needs and determines the actions that are required to meet these needs. Although community action is highly acceptable to community members, few studies have looked at the effectiveness of community action in reducing risky alcohol consumption and alcohol-related harm. Here, the researchers undertake a cluster randomized controlled trial (the Alcohol Action in Rural Communities [AARC] project) to quantify the effectiveness of community action in reducing risky alcohol consumption and harms in rural communities in Australia. A cluster randomized trial compares outcomes in clusters of people (here, communities) who receive alternative interventions assigned through the play of chance.
What Did the Researchers Do and Find?
The researchers pair-matched 20 rural Australian communities according to the proportion of their population that was Aboriginal (rates of alcohol-related harm are disproportionately higher among Aboriginal individuals than among non-Aboriginal individuals in Australia; they are also higher among young people and males, but the proportions of these two groups across communities was comparable). They randomly assigned one member of each pair to the experimental group and implemented 13 interventions in these communities by negotiating with key individuals in each community to define and implement each intervention. Examples of interventions included general practitioner training in screening for alcohol use disorders and in implementing a brief intervention, and a school-based interactive session designed to reduce alcohol harm among young people. The researchers quantified the effectiveness of the interventions using routinely collected data on alcohol-related crime and road traffic crashes, and on hospital inpatient admissions for alcohol dependence or abuse (which were expected to increase in the experimental group if the intervention was effective because of more people seeking or being referred for treatment). They also examined drinking habits and experiences of alcohol-related harm, such as verbal abuse, among community members using pre- and post-intervention surveys. After implementation of the interventions, the rates of alcohol-related crime, road traffic crashes, and hospital admissions, and of risky and hazardous/harmful alcohol consumption (measured using a validated tool called the Alcohol Use Disorders Identification Test) were not statistically significantly different in the experimental and control communities (a difference in outcomes that is not statistically significantly different can occur by chance). However, the reported average weekly consumption of alcohol was 20% lower in the experimental communities after the intervention than in the control communities (equivalent to 1.9 fewer standard drinks per week per respondent) and there was less alcohol-related verbal abuse post-intervention in the experimental communities than in the control communities.
What Do These Findings Mean?
These findings provide little evidence that community action reduced risky alcohol consumption and alcohol-related harms in rural Australian communities. Although there was some evidence of significant reductions in self-reported weekly alcohol consumption and in experiences of alcohol-related verbal abuse, these findings must be interpreted cautiously because they are based on surveys with very low response rates. A larger or differently designed study might provide statistically significant evidence for the effectiveness of community action in reducing risky alcohol consumption. However, given their findings, the researchers suggest that legislative approaches that are beyond the control of individual communities, such as alcohol taxation and restrictions on alcohol availability, may be required to effectively reduce alcohol harms. In other words, community action alone may not be the most effective way to reduce alcohol-related harm.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001617.
The World Health Organization provides detailed information about alcohol; its fact sheet on alcohol includes information about the global strategy to reduce the harmful use of alcohol; the Global Information System on Alcohol and Health provides further information about alcohol, including information on control policies around the world
The US National Institute on Alcohol Abuse and Alcoholism has information about alcohol and its effects on health
The US Centers for Disease Control and Prevention has a website on alcohol and public health that includes information on the health risks of excessive drinking
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including information on the risks of drinking too much, tools for calculating alcohol consumption, and personal stories about alcohol use problems
MedlinePlus provides links to many other resources on alcohol
More information about the Alcohol Action in Rural Communities project is available
doi:10.1371/journal.pmed.1001617
PMCID: PMC3949675  PMID: 24618831
12.  HEAVY ALCOHOL USE AND SUICIDAL BEHAVIOR AMONG PEOPLE WHO USE ILLICIT DRUGS: A COHORT STUDY 
Drug and alcohol dependence  2015;151:272-277.
Background
People who use illicit drugs (PWUD) are known to experience high rates of suicidal behavior. While heavy alcohol use has been associated with suicide risk, its impact on the suicidal behavior of PWUD has not been well characterized. Therefore, we examined the relationship between heavy alcohol use and suicidal behavior among PWUD in Vancouver, Canada.
Methods
Data are derived from two prospective cohort studies of PWUD in Vancouver, Canada, from 2005 to 2013. Participants completed questionnaires that elicited information regarding sociodemographics, drug use patterns, and mental health problems, including suicidal behavior. We used recurrent event survival analyses to estimate the independent association between at-risk/heavy drinking (based on National Institute of Alcohol Abuse and Alcoholism [NIAAA] criteria) and risk of incident, self-reported suicide attempts.
Results
Of 1,757 participants, 162 participants (9.2%) reported 227 suicide attempts over the 8-year study period, resulting in an incidence rate of 2.5 cases per 100 person-years. After adjusting for potential confounders, including intensive illicit drug use patterns, heavy alcohol use (adjusted hazard ratio [AHR] = 1.97; 95% confidence interval [CI] = 1.39, 2.78) was positively associated with an increased risk of suicidal behavior.
Conclusions
We observed a high burden of suicidal behavior among a community-recruited sample of PWUD. Heavy alcohol use predicted a higher risk of suicide attempt, independent of other drug use patterns. These findings demonstrate the need for evidence-based interventions to address suicide risk among PWUD, particularly those who are heavy consumers of alcohol.
doi:10.1016/j.drugalcdep.2015.03.006
PMCID: PMC4447526  PMID: 25823908
alcohol; suicide; illicit drug use; survival analysis; Canada
13.  A Population-Based Study on Alcohol and High-Risk Sexual Behaviors in Botswana 
PLoS Medicine  2006;3(10):e392.
Background
In Botswana, an estimated 24% of adults ages 15–49 years are infected with HIV. While alcohol use is strongly associated with HIV infection in Africa, few population-based studies have characterized the association of alcohol use with specific high-risk sexual behaviors.
Methods and Findings
We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana using a stratified two-stage probability sample design. Multivariate logistic regression was used to assess correlates of heavy alcohol consumption (>14 drinks/week for women, and >21 drinks/week for men) as a dependent variable. We also assessed gender-specific associations between alcohol use as a primary independent variable (categorized as none, moderate, problem and heavy drinking) and several risky sex outcomes including: (a) having unprotected sex with a nonmonogamous partner; (b) having multiple sexual partners; and (c) paying for or selling sex in exchange for money or other resources. Criteria for heavy drinking were met by 31% of men and 17% of women. Adjusted correlates of heavy alcohol use included male gender, intergenerational relationships (age gap ≥10 y), higher education, and living with a sexual partner. Among men, heavy alcohol use was associated with higher odds of all risky sex outcomes examined, including unprotected sex (AOR = 3.48; 95% confidence interval [CI], 1.65 to 7.32), multiple partners (AOR = 3.08; 95% CI, 1.95 to 4.87), and paying for sex (AOR = 3.65; 95% CI, 2.58 to 12.37). Similarly, among women, heavy alcohol consumption was associated with higher odds of unprotected sex (AOR = 3.28; 95% CI, 1.71 to 6.28), multiple partners (AOR = 3.05; 95% CI, 1.83 to 5.07), and selling sex (AOR = 8.50; 95% CI, 3.41 to 21.18). A dose-response relationship was seen between alcohol use and risky sexual behaviors, with moderate drinkers at lower risk than both problem and heavy drinkers.
Conclusions
Alcohol use is associated with multiple risks for HIV transmission among both men and women. The findings of this study underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.
Alcohol use is associated with multiple risks for HIV transmission in men and women. The findings underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.
Editors' Summary
Background.
Human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS), is most commonly spread through unprotected sex with an infected partner. HIV enters the body through the lining of the sex organs, rectum, or mouth, and destroys immune system cells, leaving the infected person susceptible to other viruses and bacteria. Although HIV education and prevention campaigns emphasize the importance of safe sex in reducing HIV transmission, people continue to become infected by having unprotected sex (that is, not using a condom) with either a nonmonogamous partner or multiple sexual partners, or in situations where they are paying for or selling sex. Research in different populations suggested that heavy alcohol use is associated with risky sexual behaviors. This is because alcohol relaxes the brain and body, reduces inhibitions, and diminishes risk perception. Drinking alcohol may further increase the risk of becoming infected with HIV through its suppressive effects on the immune system.
Why Was This Study Done?
Alcohol abuse is widespread in sub-Saharan Africa where most HIV infections occur and has been associated with risky sexual behaviors. It may therefore be one of the most common, potentially modifiable HIV risk factors in this region. However, research to date has concentrated on the association between alcohol consumption and risky sex in people attending HIV-treatment clinics or recruited at beer halls, and these populations may not be representative of the general population of sub-Saharan Africa. In this study, the researchers have investigated the potential role of alcohol in perpetuating the HIV epidemic by undertaking a population-based study on alcohol use and high-risk sexual behaviors in Botswana. Nearly a quarter of adults are infected with HIV here, and alcohol abuse is also common, particularly in the townships.
What Did the Researchers Do and Find?
The researchers recruited a random cross-section of people from the five districts of Botswana with the highest number of HIV-infected individuals and interviewed all 1,268 participants using a questionnaire. This included general questions about the participants (for example, their age and marital status) and questions about alcohol use, sexual behavior, and knowledge of HIV. Overall, 31% of the men in the study and 17% of the women were heavy drinkers—more than 21 drinks/week for men, 14 for women; a drink is half a pint of beer or a glass of wine. Heavy alcohol use was associated with being male, being in an intergenerational relationship (at least 10 years age difference between partners; intergenerational sex facilitates the continued spread of HIV in sub-Saharan Africa), having had more education, and living with a sexual partner. Among men, those who drank heavily were three to four times more likely to have unprotected sex or multiple partners or to pay for sex than nondrinkers. Among women, there was a similar association between heavy drinking and having unprotected sex or multiple partners, and heavy drinkers were eight times as likely to sell sex as nondrinkers. For both men and women, the more they drank, the more likely they were to have risky sex. The study did not address behavior among same-sex partnerships.
What Do These Findings Mean?
This study indicates that heavy alcohol consumption is strongly and consistently associated with sexual risk behaviors in both men and women in Botswana. Because of the study design, it does not prove that heavy alcohol use is the cause of such behaviors but provides strong circumstantial evidence that this is the case. It is possible that these results may not apply to neighboring African countries—Botswana is unique in being relatively wealthy and in its government being strongly committed to tackling HIV. Nevertheless, taken together with the results of other studies, this research strongly argues for the need to deal with alcohol abuse within HIV prevention programs in sub-Saharan Africa. Strategies to do this could include education campaigns that target both alcohol use and HIV in schools and in social venues, including beer halls. But, stress the researchers, any strategy that is used must consider the cultural and social significance of alcohol use (in Botswana, alcohol use is a symbol of masculinity and high socioeconomic status) and must simultaneously tackle not only the overlap between alcohol use and risky sexual behavior but also the overlap between alcohol and other risk behaviors such as intergenerational sex.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030392.
US National Institute of Allergy and Infectious Diseases factsheet on HIV infection and AIDS
US Department of Health and Human Services information on AIDS
US Centers for Disease Control and Prevention information on HIV/AIDS
US National Institute on Alcohol Abuse and Alcoholism patient information on alcohol and HIV/AIDS]
Aidsmap, information on HIV and AIDS provided by the charity NAM,which includes some information on HIV infections and alcohol
AVERT information on HIV and AIDS in Botswana
doi:10.1371/journal.pmed.0030392
PMCID: PMC1592342  PMID: 17032060
14.  Factors associated with suicidal behaviors in mainland China: a meta-analysis 
BMC Public Health  2012;12:524.
Background
Suicide is a major public health issue in China. Studies of suicide risk factors have reported both inconsistent and inconclusive results. This review aimed to determine suicide risk factors in China.
Methods
Medline/PubMed, EMBASE, CNKI (China National Knowledge Infrastructure) and VIP (Chinese Journal of Science and Technology of VIP) were searched for relevant reports. Two investigators independently assessed the eligibility of identified studies and extracted data. Pooled odds ratios (and 95% confidence intervals) were calculated for each factor with Revman 5.0.
Results
Forty-four studies with 192,362 subjects were included. The pooled results indicated that mood disorders and stressful life events (physical illness, suicide of relatives) increased the risk of suicide ideation among the entire population. Socio-family environment (single or remarried parent, study pressure and academic achievement) and unhealthy behaviors (smoking, alcohol drinking, and drug use) were risk factors for suicide ideation among youth. Unhealthy behaviors (smoking and alcohol drinking), mood disorders, and stressful life events (suicide of relatives) were the main risk factors for attempted suicide. Persons living in rural areas, and those with lower education, mood disorders, and/or a history of negative life events had a higher risk of completed suicide. In China, before 2000, females had a significantly higher rate of completed suicide than males, while after 2000, no significant gender difference was found.
Conclusions
Socio-family environment, lifestyle, life events and psychiatric/psychological factors are associated with suicidal behaviors in China. Further case–control or cohort studies are needed to better understand suicide behaviors in China. Meanwhile, there is an urgent need for comprehensive studies of suicide interventions among high-risk populations.
doi:10.1186/1471-2458-12-524
PMCID: PMC3490836  PMID: 22800121
Risk factors; Suicide; China; Meta-analysis
15.  Prevalence of Health-Risk Behaviors Among Asian American and Pacific Islander High School Students in the U.S., 2001–2007 
Public Health Reports  2011;126(1):39-49.
SYNOPSIS
Objectives
We provided national prevalence estimates for selected health-risk behaviors for Asian American and Pacific Islander high school students separately, and compared those prevalence estimates with those of white, black, and Hispanic students.
Methods
We analyzed data from the Youth Risk Behavior Surveillance System. To generate a sufficient sample of Asian American and Pacific Islander students, we combined data from four nationally representative surveys of U.S. high school students conducted in 2001, 2003, 2005, and 2007 (total n=56,773).
Results
Asian American students were significantly less likely than Pacific Islander, white, black, or Hispanic students to have drunk alcohol or used marijuana. Asian American students also were the least likely to have carried a weapon, to have been in a physical fight, to have ever had sexual intercourse, or to be currently sexually active. Once sexually active, Asian American students were as likely as most other racial/ethnic groups to have used alcohol or drugs at last sexual intercourse or to have used a condom at last sexual intercourse. Pacific Islander students were significantly more likely than Asian American, white, black, or Hispanic students to have seriously considered or attempted suicide.
Conclusions
The prevalence estimates of health-risk behaviors exhibited by Asian American students and Pacific Islander students are very different and should be reported separately whenever feasible. To address the different health-risk behaviors exhibited by Asian American and Pacific Islander students, prevention programs should use culturally sensitive strategies and materials.
PMCID: PMC3001821  PMID: 21337930
16.  The consumption of alcohol mixed with energy drinks: prevalence and key correlates among Canadian high school students 
CMAJ Open  2013;1(1):E19-E26.
Background
An emerging body of research has reported high consumption of alcohol mixed with energy drinks among young adults, particularly college students. However, little is known about adolescents’ consumption of these drinks. The purpose of this study was to determine the prevalence of consumption of alcohol mixed with energy drinks and to examine its correlates among Canadian high school students.
Methods
We used a nationally representative sample of 36 155 Canadian students in grades 7 to 12 who participated in the 2010/2011 Youth Smoking Survey.
Results
About 20% of Canadian high school students reported consuming alcohol mixed with energy drinks in the last year, with considerable variation across provinces. Multivariate logistic regression analyses showed that the odds of consumption of these drinks were higher among students in lower grades (grades 7 and 8) and among students who identified their ethnicity as black or “other.” Consumption of alcohol mixed with energy drinks was positively associated with substance use (current smoking [adjusted odds ratio (OR) 1.52, 95% confidence interval (CI) 1.19–1.95], past-year heavy drinking [adjusted OR 3.41, 95% CI 2.84–4.09] and marijuana use [adjusted OR 2.29, 95% CI 1.90–2.76]), absence from school, participation in school team sports and having more weekly spending money. Students who felt more connected to school and had an academic average of 70% or higher were less likely to consume alcohol mixed with energy drinks.
Interpretation
The consumption of alcohol mixed with energy drinks is an emerging public health concern. Consumption of these drinks is substantial among Canadian high school students and can lead to many potential harms, both acute (e.g., injury) and long term (e.g., increased alcohol dependence). Our findings highlight the need for further research into the long-term effects of consumption of alcohol mixed with energy drinks among young people, as well as the development of interventions aimed at reducing consumption of these drinks.
doi:10.9778/cmajo.20120017
PMCID: PMC3985966  PMID: 25077098
17.  Alcohol Use During the Transition from Middle School to High School: National Panel Data on Prevalence and Moderators 
Developmental psychology  2013;49(11):2147-2158.
The movement from middle school to high school is a normative transition that is typically associated with increased social and academic stress. Theoretically, this transition may reflect a turning point in terms of initiating or sharply increasing heavy alcohol use, a notion that has received little attention in the empirical literature. The present study draws on a nationally representative dataset, National Longitudinal Survey of Youth-1997 (NLSY97), to examine the impact of the high-school transition on increases in alcohol use. The multi-wave multi-cohort design of NLSY97 permits coding of the high-school transition for 3,360 adolescents (48% female; 54% NonBlack/NonHispanic). Using latent transition analysis, we examined transitions among non-drinking, light drinking, and heavy drinking classes to characterize initiation of use and progression to heavier drinking. NonBlack/NonHispanic youth and those higher on delinquent behaviors were more likely to be involved in alcohol prior to the transition and more likely to rapidly escalate use with the transition. Although no sex differences were observed prior to the high-school transition, girls were more likely to transition from non-drinking to light drinking whereas boys were more likely to transition to heavy drinking. High monitoring was associated with greater progression from light drinking in middle school to heavy drinking in high school; low and moderate parental monitoring were associated with initiation of heavy drinking across the transition. The high-school transition is a time of increased risk for many young people, and greater attention to this important transition as a time that one can and should intervene is warranted.
doi:10.1037/a0031843
PMCID: PMC3933211  PMID: 23421801
alcohol; drinking; transition; middle school; high school
18.  Youth Drinking in the United States: Relationships With Alcohol Policies and Adult Drinking 
Pediatrics  2015;136(1):18-27.
BACKGROUND:
The relationship between the alcohol policy environment (ie, the combined effectiveness and implementation of multiple existing alcohol policies) and youth drinking in the United States has not been assessed. We hypothesized that stronger alcohol policy environments are inversely associated with youth drinking, and this relationship is partly explained by adult drinking.
METHODS:
Alcohol Policy Scale (APS) scores that characterized the strength of the state-level alcohol policy environments were assessed with repeated cross-sectional Youth Risk Behavior Survey data of representative samples of high school students in grades 9 to 12, from biennial years between 1999 and 2011.
RESULTS:
In fully adjusted models, a 10 percentage point increase in APS scores (representing stronger policy environments) was associated with an 8% reduction in the odds of youth drinking and a 7% reduction in the odds of youth binge drinking. After we accounted for youth-oriented alcohol policies, the subgroup of population-oriented policies was independently associated with lower odds of youth drinking (adjusted odds ratio 0.94; 95% confidence interval 0.92–0.97) and youth binge drinking (adjusted odds ratio 0.96; 95% confidence interval 0.94–0.99). State-level per capita consumption mediated the relationship between population-oriented alcohol policies and binge drinking among youth.
CONCLUSIONS:
Stronger alcohol policies, including those that do not target youth specifically, are related to a reduced likelihood of youth alcohol consumption. These findings suggest that efforts to reduce youth drinking should incorporate population-based policies to reduce excessive drinking among adults as part of a comprehensive approach to preventing alcohol-related harms. Future research should examine influence of alcohol policy subgroups and discrete policies.
doi:10.1542/peds.2015-0537
PMCID: PMC4485013  PMID: 26034246
19.  Predictive models for suicidal thoughts and behaviors among Spanish University students: rationale and methods of the UNIVERSAL (University & mental health) project 
BMC Psychiatry  2016;16:122.
Background
Suicide is a leading cause of death among young people. While suicide prevention is considered a research and intervention priority, longitudinal data is needed to identify risk and protective factors associate with suicidal thoughts and behaviors. Here we describe the UNIVERSAL (University and Mental Health) project which aims are to: (1) test prevalence and 36-month incidence of suicidal thoughts and behaviors; and (2) identify relevant risk and protective factors associated with the incidence of suicidal thoughts and behaviors among university students in Spain.
Methods
An ongoing multicenter, observational, prospective cohort study of first year university students in 5 Spanish universities. Students will be assessed annually during a 36 month follow-up. The surveys will be administered through an online, secure web-based platform. A clinical reappraisal will be completed among a subsample of respondents. Suicidal thoughts and behaviors will be assess with the Self-Injurious Thoughts and Behaviors Interview (SITBI) and the Columbia-Suicide Severity Rating Scale (C-SSRS). Risk and protective factors will include: mental disorders, measured with the Composite International Diagnostic Interview version 3.0 (CIDI 3.0) and Screening Scales (CIDI-SC), and the Epi-Q Screening Survey (EPI-Q-SS), socio-demographic variables, self-perceived health status, health behaviors, well-being, substance use disorders, service use and treatment. The UNIVERSAL project is part of the International College Surveys initiative, which is a core project within the World Mental Health consortium. Lifetime and the 12-month prevalence will be calculated for suicide ideation, plans and attempts. Cumulative incidence of suicidal thoughts and behaviors, and mental disorders will be measured using the actuarial method. Risk and protective factors of suicidal thoughts and behaviors will be analyzed by Cox proportional hazard models.
Discussion
The study will provide valid, innovative and useful data for developing prevention programs for youth suicide and for improving early identification for high-risk students. The longitudinal design of this study will improve causal interpretation of analyzed associations, needed for generating and validating predictive models. It will represent the first results about suicidal thoughts and behaviors in the Spanish university population. The World Mental Health Survey collaboration will permit accurate cross-national comparisons.
doi:10.1186/s12888-016-0820-y
PMCID: PMC4855708  PMID: 27142432
Suicide; Mental health; University students; Cohort studies; Risk factors; Protective factors; Predictive modelling
20.  Variables associated with physical fighting among US high-school students 
Background
Violence among adolescents is an important public health problem in the United States. This study was conducted to estimate the prevalence of having been engaged in physical fighting on school property and associated factors of the behavior among school-going adolescents in the United States.
Methods
This study was based on secondary analysis of the United States Youth Risk Behavior Survey (YRBS) conducted in 2005. The sampling frame included all private and public school in the country, stratified by region and urbanicity based on the US census bureau data. Frequencies and proportions were obtained for the outcome and explanatory variables. Logistic regression analysis was used to estimate the level of association between explanatory variables and the outcome (having been involved in a physical fight).
Results
Of the 13,857 respondents, 13.5% (18.2% for males and 8.8% for females) reported physical fighting onschool property in the last 12 months to the survey. Males were more likely to have been in a physical fight than females (OR = 2.23; 95% CI [1.89, 2.63]). Respondents aged 17 years or older were less likely to report physical fighting than those who were 14 years or younger. Compared to Whites, American Indians or Alaska Natives, Blacks, Native Hawaii or other Pacific Islanders, and Hispanics were more likely to report physical fighting on school property (OR = 2.11; 95% CI [1.22, 3.66], OR = 1.72; 95% CI [1.42, 2.0], OR = 2.18; 95% CI [1.01, 4.79], and OR = 1.74; 95% CI [1.41, 2.16] respectively). Physical fighting on school property was also positively associated with cigarette smoking (OR = 1.70; 95% CI [1.37, 2.10]), drinking alcohol (OR = 1.45; 95% CI [1.20, 1.76]), use of illegal drugs (OR = 1.73; 95% CI [1.42, 2.12]), having had property stolen or deliberately damaged on school property (OR = 2.06; 95% CI [1.74, 2.44]), having been threatened or injured with a weapon on school property (OR = 2.63; 95% CI [2.06, 3.34]), and playing videogame three or more hours a day (OR = 1.29; 95% CI [1.07, 1.56]).
Conclusion
These findings suggest that physical fighting among US High School students is widespread and positively associated with victimization (having been threatened or injured with a weapon on school property) and other risky behaviors such as smoking, alcohol and drugs use. Intervention programs to prevent/control those risky behaviors as well as further attention on the association between physical fighting and victimization at school through longitudinal research are warranted.
doi:10.1186/1745-0179-4-16
PMCID: PMC2423367  PMID: 18510746
21.  Correlates of Suicide Ideation and Attempt among Youth Living in the Slums of Kampala 
While suicidal behavior is recognized as a growing public health problem world-wide, little is known about the prevalence and risk factors for suicidal behaviors among street and slum youth in Africa, and in Uganda, specifically. The number of youth who live on the streets and in the slums of Kampala appears to be growing rapidly, but their mental health needs have not been documented, which has hampered resource allocation and service implementation. This study of youth, ages 14–24, was conducted in May and June of 2011, to assess the prevalence and correlates of suicidal behavior. Participants (N = 457) were recruited for a 30-minute interviewer-administered survey through eight drop-in centers operated by the Uganda Youth Development Link for youth in need of services. Bivariate and multivariate logistic regression analyses were computed to determine associations between psychosocial correlates and suicide ideation and suicide attempt. Reporting both parents deceased Adj.OR = 2.36; 95% CI: 1.23–4.52), parental neglect due to alcohol use (Adj.OR = 2.09; 95% CI: 1.16–3.77), trading sex for food, shelter or money (Adj.OR = 1.95; 95% CI: 1.09–3.51), sadnesss (Adj.OR = 2.42; 95% CI: 1.20–4.89), loneliness (Adj.OR = 2.67; 95% CI: 1.12–6.40) and expectations of dying prior to age 30 (Adj.OR = 2.54; 95% CI: 1.53–4.23) were significantly associated with suicide ideation in multivariate analyses. Parental neglect due to alcohol use (Adj.OR = 2.04; 95% CI: 1.11–3.76), sadness (Adj.OR = 2.42; 95% CI: 1.30–7.87), and expectations of dying prior to age 30 (Adj.OR = 2.18; 95% CI: 1.25–3.79) were significantly associated with suicide attempt in multivariate analyses. Given the dire circumstances of this vulnerable population, increased services and primary prevention efforts to address the risk factors for suicidal behavior are urgently needed.
doi:10.3390/ijerph9020596
PMCID: PMC3315266  PMID: 22470312
suicidal ideation; suicide attempt; street youth; homeless youth; vulnerable youth; adolescents; sadness; loneliness; parental neglect; trading sex; Africa; Uganda; Kampala
22.  At-School Substance Use as a Marker for Serious Health Risks 
Academic pediatrics  2015;15(1):41-46.
Objectives
At-school substance use is associated with increased rates of violence and delinquency. However, whether at-school substance use is a useful marker for other serious health risks and whether this association varies by gender or substance is still unclear.
Methods
We analyzed data from the national 2011 Youth Risk Behaviors Survey of 15,698 9th-12th grade students. Multivariate regressions controlling for age and race evaluated whether at-school marijuana and alcohol users were more likely than out-of-school users to exhibit 9 serious health risks (exposure to intoxicated driving, fighting, carrying a weapon at school, substance use with intercourse, experiencing intimate partner violence, being forced to have intercourse, experiencing depression, suicidal ideation and attempting suicide). We included interaction terms to determine whether this association varied by gender or substance.
Results
At-school alcohol and marijuana use were both associated with increased odds of all 9 serious health risks. The association between at-school substance use and both fighting and being forced to have sex was higher for boys than for girls. Associations did not vary significantly by substance. Specificity of at-school substance use for serious health risks ranged from 0.93-0.96, and positive predictive values ranged from 0.23-0.69, well above the ranges for both out-of-school use and non-use.
Conclusions
Students found using alcohol or marijuana at school should be immediately and carefully screened for other serious health risks that pose significant present dangers, as this may represent a critical opportunity to identify troubled youth.
doi:10.1016/j.acap.2014.06.022
PMCID: PMC4273105  PMID: 25528124
school health; alcohol use; marijuana use; gender
23.  Alcohol Consumption at Midlife and Successful Ageing in Women: A Prospective Cohort Analysis in the Nurses' Health Study 
PLoS Medicine  2011;8(9):e1001090.
Using the Nurses' Health Study, Qi Sun and colleagues examine whether moderate alcohol intake is associated with overall health and well-being among women who survive to older age.
Background
Observational studies have documented inverse associations between moderate alcohol consumption and risk of premature death. It is largely unknown whether moderate alcohol intake is also associated with overall health and well-being among populations who have survived to older age. In this study, we prospectively examined alcohol use assessed at midlife in relation to successful ageing in a cohort of US women.
Methods and Findings
Alcohol consumption at midlife was assessed using a validated food frequency questionnaire. Subsequently, successful ageing was defined in 13,894 Nurses' Health Study participants who survived to age 70 or older, and whose health status was continuously updated. “Successful ageing” was considered as being free of 11 major chronic diseases and having no major cognitive impairment, physical impairment, or mental health limitations. Analyses were restricted to the 98.1% of participants who were not heavier drinkers (>45 g/d) at midlife. Of all eligible study participants, 1,491 (10.7%) achieved successful ageing. After multivariable adjustment of potential confounders, light-to-moderate alcohol consumption at midlife was associated with modestly increased odds of successful ageing. The odds ratios (95% confidence interval) were 1.0 (referent) for nondrinkers, 1.11 (0.96–1.29) for ≤5.0 g/d, 1.19 (1.01–1.40) for 5.1–15.0 g/d, 1.28 (1.03–1.58) for 15.1–30.0 g/d, and 1.24 (0.87–1.76) for 30.1–45.0 g/d. Meanwhile, independent of total alcohol intake, participants who drank alcohol at regular patterns throughout the week, rather than on a single occasion, had somewhat better odds of successful ageing; for example, the odds ratios (95% confidence interval) were 1.29 (1.01–1.64) and 1.47 (1.14–1.90) for those drinking 3–4 days and 5–7 days per week in comparison with nondrinkers, respectively, whereas the odds ratio was 1.10 (0.94–1.30) for those drinking only 1–2 days per week.
Conclusions
These data suggest that regular, moderate consumption of alcohol at midlife may be related to a modest increase in overall health status among women who survive to older ages.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
People have always drunk alcoholic beverages but throughout history there have been arguments about the risks and benefits of beer, wine, and spirits. It is clear that excessive alcohol use—heavy drinking (an average of more than two drinks per day for men or more than one drink per day for women; in the US, a “drink” is defined as 15 g of alcohol or, roughly speaking, a can of beer or a small glass of wine) or binge drinking (five or more drinks on a single occasion for men; 4 or more drinks at one time for women)—is harmful. It causes liver damage and increases the risk of developing some types of cancer. It contributes to depression and violence and interferes with relationships. And it is often implicated in fatal traffic accidents. However, in contrast to these and other harms associated with excessive alcohol use, moderate alcohol consumption seems to reduce the risk of specific diseases such as heart disease, stroke, and cognitive decline (deterioration in learning, reasoning, and perception).
Why Was This Study Done?
Although people who drink moderate amounts of alcohol have a reduced risk of premature death compared to abstainers or heavy drinkers, it is not known whether moderate alcohol consumption is associated with overall health among ageing populations. In many countries, elderly people are an increasingly large part of the population, so it is important to know how moderate alcohol consumption affects their well-being. In this study, the researchers examine the effect of alcohol consumption at midlife on successful ageing among the participants of the Nurses' Health Study. The researchers study the effect of midlife alcohol consumption because the chronic conditions that affect elderly people develop slowly and it is likely that factors in earlier life determine health in later life. Successful ageing is defined as being free of major chronic diseases such as cancer and heart disease, and having no major cognitive impairment, physical impairment, or mental health problems. The Nurses' Health Study enrolled 121,700 female registered nurses in 1976 to investigate the long-term effects of oral contraceptive use but has provided insights into many aspects of health and disease.
What Did the Researchers Do and Find?
The researchers assessed the alcohol consumption of the study participants at midlife (average age 58 years) from food frequency questionnaires completed in 1980 and 1984. Successful ageing for 13,984 participants who survived past 70 years was assessed by analyzing biennial health status questionnaires and cognitive function test results. One tenth of the women achieved successful ageing. After allowing for other factors that might affect their health such as smoking, women who drank light or moderate amounts of alcohol had a modestly increased chance of successful ageing compared to nondrinkers. For example, compared to nondrinkers, women who drank 5–15 g of alcohol per day (between one-third and one drink per day) had about a 20% higher chance of successful ageing. Independent of total alcohol intake, women who drank alcohol regularly had a better chance of successful ageing than occasional drinkers. Thus, compared to nondrinkers, women who drank five to seven days a week had nearly a 50% greater chance of successful ageing whereas women who drank only one or two days a week had a similar likelihood of successful ageing.
What Do These Findings Mean?
These findings suggest that regular, moderate consumption of alcohol at midlife may be related to a modest increase in overall health among women who survive to older ages. Because this is an observational study, it is possible that the women who drank moderately share other unknown characteristics that are actually responsible for their increased chance of successful ageing. Moreover, because all the study participants were women and most had European ancestry, these findings cannot be applied to men or to other ethnic groups. Nevertheless, these findings provide support for the 2010 US Department of Agriculture dietary guidelines, which state that consumption of up to one alcoholic drink per day for women and up to two alcoholic drinks per day for men may provide health benefits. Importantly, they also suggest that drinking alcohol regularly in moderation rather than occasional heavy drinking may be associated with a greater likelihood of successful ageing.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001090.
The US National Institute on Alcohol Abuse and Alcoholism has detailed information about alcohol and its effects on health, including a fact sheet on women and alcohol and a booklet entitled Alcohol, a woman's health issue
The US Centers for Disease Control and Prevention has a website on alcohol and public health
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including how to calculate consumption
The Nutrition Source, a website maintained by the Department of Nutrition at Harvard School of Public Health, has an article entitled Alcohol: balancing risks and benefits
MedlinePlus provides links to many other resources on alcohol and on seniors' health
Details of the Nurses' Health Study are available
The 2010 US Department of Agriculture dietary guidelines are available
doi:10.1371/journal.pmed.1001090
PMCID: PMC3167795  PMID: 21909248
24.  Using New and Emerging Technologies to Identify and Respond to Suicidality Among Help-Seeking Young People: A Cross-Sectional Study 
Background
Suicidal thoughts are common among young people presenting to face-to-face and online mental health services. The early detection and rapid response to these suicidal thoughts and other suicidal behaviors is a priority for suicide prevention and early intervention efforts internationally. Establishing how best to use new and emerging technologies to facilitate person-centered systematic assessment and early intervention for suicidality is crucial to these efforts.
Objective
The aim of this study was to examine the use of a suicidality escalation protocol to respond to suicidality among help-seeking young people.
Methods
A total of 232 young people in the age range of 16-25 years were recruited from either a primary mental health care service or online in the community. Each young person used the Synergy Online System and completed an initial clinical assessment online before their face-to-face or online clinical appointment. A suicidality escalation protocol was used to identify and respond to current and previous suicidal thoughts and behaviors.
Results
A total of 153 young people (66%, 153/232) reported some degree of suicidality and were provided with a real-time alert online. Further levels of escalation (email or phone contact and clinical review) were initiated for the 35 young people (15%, 35/232) reporting high suicidality. Higher levels of psychological distress (P<.001) and a current alcohol or substance use problem (P=.02) predicted any level of suicidality compared with no suicidality. Furthermore, predictors of high suicidality compared with low suicidality were higher levels of psychological distress (P=.01), psychosis-like symptoms in the last 12 months (P=.01), a previous mental health problem (P=.01), and a history of suicide planning or attempts (P=.001).
Conclusions
This study demonstrates the use of new and emerging technologies to facilitate the systematic assessment and detection of help-seeking young people presenting with suicidality. This protocol empowered the young person by suggesting pathways to care that were based on their current needs. The protocol also enabled an appropriate and timely response from service providers for young people reporting high suicidality that was associated with additional comorbid issues, including psychosis-like symptoms, and a history of suicide plans and attempts.
doi:10.2196/jmir.7897
PMCID: PMC5529742  PMID: 28701290
suicidal ideation; mental health; primary health care; telemedicine; health services
25.  Suicidal Behaviour and Related Risk Factors among School-Aged Youth in the Republic of Benin 
PLoS ONE  2014;9(2):e88233.
Introduction
Research on factors associated with suicidal ideation and suicide attempts has been conducted largely in developed countries. Research on West African countries in particular is lacking.
Methods
Data were obtained from the Global School-based Health Survey conducted in Benin in 2009. This was a cross-sectional study of three grades, spanning Junior and Senior High, which sampled a total of 2,690 adolescents. Data on the occurrence of demographic, psycho-social and socio-environmental risk factors were tested using multinomial logistic regression for their association with suicidal ideation and suicide attempts.
Results
The survey indicated that 23.2% had thought about suicide and 28.3% had made a suicide attempt in the previous year. Anxiety, loneliness, being bullied, alcohol misuse, illicit drug use, and lack of parental support were independently related to the ideation outcomes, suicidal ideation without planning and suicidal ideation with planning. Multinomial regression analysis, using one suicide attempt and multiple suicide attempts as outcomes, revealed that female sex, anxiety, loneliness, being physically attacked, and illicit drug use were associated these outcomes.
Discussion
The prevalence of suicide attempts reported in the survey is relatively high. It is possible that there are cultural factors that could explain this finding. Our research indicates that many factors are related to the occurrence of suicidal ideation and suicide attempts among youth in Benin. Illicit drug use and violence in particular are associated with a high rate of suicide attempts in Benin. Measures to address these issues may reduce the risk of self-inflicted violence.
doi:10.1371/journal.pone.0088233
PMCID: PMC3914941  PMID: 24505443

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