Prevention of alcohol-related suicide: a rapid review

Figures & data

Table 1. Search strategy.

Main search
General search	((alcohol OR ethanol) AND suicide AND  (policy OR policies OR intervention OR prevent*))
Alcohol policy searches
Alcohol taxation & pricing	((alcohol OR ethanol) AND suicide AND (pricing OR price* OR tax OR taxation OR taxes))
Minimum legal drinking age	((“Minimum Legal Drinking Age” OR “Drinking Age”) AND suicide)
Alcohol availability	(((alcohol AND outlet*) OR (“Alcohol availability”) OR (“availability of alcohol”)) AND suicide)
Alcohol marketing	((“alcohol marketing” OR “alcohol advertising”) AND suicide)
Alcohol control	(“alcohol control” AND suicide)
Wet & dry policies	(wet AND dry AND suicide)

Figure 1. PRISMA flow chart for this rapid review. *Studies where alcohol use was only a secondary outcome of the study and was not part of the intervention, population or the suicide outcome (e.g. alcohol-related suicide), were screened out after data extraction. **Other reasons for exclusion included: Study protocol without data (n = 3), article not written in English (n = 1), intervention is not relevant (n = 1), study was retracted (n = 1), unable to differentiate alcohol from other drugs (n = 1).

Table 2. Inclusion and exclusion criteria.

Inclusion criteria

Exclusion criteria

Original peer reviewed research A policy, community intervention, clinical intervention or other prevention strategy is evaluated Alcohol is included in the design of the study through one of the following: (a) Including alcohol in the intervention (e.g. an alcohol policy) (b) Including alcohol in the outcome (e.g. alcohol use was a secondary outcome of the study in addition to suicide*; alcohol-related suicide deaths and/or attempts as an outcome, etc.) (c) Including alcohol in the study population (e.g. study population was patients with alcohol use disorder, etc.) Includes any quantitative measure of suicide death or attempt as the outcome variable Written in English Study design is one of the following (a) A randomized controlled experiment (b) A quasi-experimental design (c) Ecological study Published between 1990 and Fall 2020

Review, systematic review, meta-analysis commentary, case study, letter, news article No intervention, policy or structural-level change was evaluated Alcohol is not included in the intervention, in any outcome, nor is it a defining feature of the study population. Studies where alcohol is only measured at baseline and is not a defining feature of the study population were excluded. Does not include a quantitative measure of suicide death or attempt as an outcome. Studies that only described deliberate self-harm or parasuicide, without specifying suicidal intent, were excluded. Not written in English Study design does not provide comparisons pre/post intervention, between intervention groups or between populations Published before Jan 1, 1990

*Studies screened in with this criterion were ultimately excluded after data extraction was completed.

Table

Author, year	Location, year(s)	Suicide attempt or death; Role of alcohol	Design	Study population	Intervention	Main outcomes [both suicide and alcohol outcomes, if relevant]
ALCOHOL CAMPAIGNS & MULTIPLE INTERVENTIONS
Wasserman, 1992	US, 1910–1920	Deaths; Intervention and outcome	Time series	General population	Prohibition	Decrease in access to alcohol and associated decline in alcohol consumption was associated with a reduction in national suicide deaths (estimated OLS coefficient = 2.25, p < 0.05).
Law and Marks (2020)	US, 1900–1920	Deaths; Intervention and outcome	Quasi-experiment with regression analysis	General population	Prohibition	Prohibition was associated with significantly fewer deaths due to alcoholism; however, deaths rates due to suicide did not fall significantly as state-years became drier. Prohibition was estimated to reduce suicide deaths by 2.5–3.7 per 100,000 (p < 0.10).
Markowitz et al., 2003	US, 1976–1999	Deaths; intervention	Negative binomial regression	General population aged 10–24 years	A variety of laws were examined including beer taxation, percent of the population living in dry counties (for beer), alcohol outlet density, and drunk-driving prevention laws.	A 10% increase in tax on beer was associated with a statistically significant 2.4–5% decrease in male suicide deaths (depending on age group). A 10% increase in alcohol availability was associated with a statistically significant 1% increase in male suicide deaths among those aged 15–19 years. Among males aged 20–24, 0.08 BAC and zero-tolerance drunk driving laws were associated with a significant decrease in suicide deaths by 6.5% and 7.7% respectively. Zero tolerance laws were also associated with a 10.9% decrease in female suicide deaths among those aged 15–19.
Choi et al., 2020	US, 2012–2016	Deaths; intervention	Longitudinal, ecological	General population	Index of alcohol regulation, including laws related to alcohol availability, taxation, and mandatory server training.	More alcohol regulation was associated with significantly fewer firearm-related suicide deaths (β = −0.43 to −0.44 (depending on model), p < 0.001).
Nemtsov, 2003	Russia, 1965–1999	Deaths; intervention and outcome	Time series	General population aged 15 to 85+	Campaign launched in June 1985, that had a 62% cut-back in authorized sale of liquor and anti-alcoholic pressure from authorities.	Suicide deaths declined sharply from 37.9 to 23.1 per 100,000 (a 39.1% decrease) from 1984 to 1986, after the initiation of an anti-alcohol campaign. There was also a decline in alcohol consumption. After this time period, suicide deaths increased slowly as alcohol consumption increased.
Wasserman et al., 1994	USSR, 1984–1990	Deaths; intervention and outcome	Time series	General population of males	Restrictive alcohol policy enacted in June 1985 during perestroika. Decrease in alcohol production and retail outlets for alcohol.	Both alcohol consumption and suicide mortality declined (e.g. in 1986 the suicide rate was 41% lower than that in 1984), with notable regional variation. In most republics, more than 50% of suicide deaths were attributable to alcohol.
Wasserman et al., 1998	USSR, 1984–1990	Deaths; Intervention and outcome	Time series	General population of females	Restrictive alcohol policy enacted in June 1985 during perestroika. Decrease in alcohol production and retail outlets for alcohol.	Suicide deaths among females decreased by approximately 20% in the study period. In the whole USSR, alcohol explained on average 27% of the suicide deaths.
Razvodovsky, 2007, 2009	Belarus, 1979–2007	Death; intervention, outcome	Time series (ARIMA)	General population	Anti-alcohol campaign of 1985–1988 limiting availability and manufacturing of alcohol.	From 1984 to 1986, BAC-positive suicide deaths declined by 54.2%, while BAC-negative suicide deaths declined by 7.1%. There was a statistically significant association between alcohol poisoning mortality and suicide mortality.
Vaarnik et al. (2007)	Estonia, 1981–1992	Deaths; intervention, outcome	Retrospective study	General population	Anti-alcohol campaign of 1985, including restrictions on production, sales, raising taxes, propaganda, and penalties.	During the anti-alcohol campaign, there was a 39.2% (p = 0.012) and 41.4% (p = 0.075) decline in BAC positive suicide deaths among males and females respectively. During the same time, the annual per capita alcohol consumption declined from 10.9 to 6.6.
Sauliune et al., 2012	Lithuania, 2006–2009	Deaths; intervention, outcome	Time series	General population aged 15–64 years	Multiple changes in alcohol policy from 2007–2009, including banning daytime TV and radio alcohol advertisements, raising excise taxes, reducing selling hours, and greater controls on drunk driving.	The Years of Potential Life Lost as a result of alcohol-related suicide increased by 16.3% among males, despite the campaign. The overall suicide rate also tended to increase during the 2006–2009 study period.
Pridemore et al., 2013	Russia, 2000–2010	Deaths; intervention	Time series (ARIMA)	General Population aged 15+ years	January 2006 law regulating production and sale of alcohol products, with resultant increasing retail prices.	The ARIMA analysis revealed a statistically significant, immediate and permanent, 9.2% decrease (Ln ω0 = −0.096; p = 0.01) in male suicide deaths due to the policy implementation, with no significant effect on female suicide deaths.
Pridemore & Snowden, 2009	Slovenia, 1997–2005	Deaths; intervention	Interrupted time series (ARIMA)	General population	January 2003 Act which set a minimum legal drinking age of 18, limited where alcohol could be sold, limited hours of sale, mandated workplaces be alcohol free and no longer allowed alcohol in vending machines.	The 2003 policy had no significant association with suicide deaths in females, but it was associated with a significant, 10% reduction (ω0 = −3.62; p = 0.033) in suicide deaths among males compared to preintervention levels.
Zupanc et. al., 2013	Central and Northwest Slovenia, 2000–2007	Deaths; intervention, outcome	Time series	Suicide decedents who underwent autopsy	January 2003 Act, including the prohibition of selling of alcohol to and drinking of alcohol among intoxicated individuals and those under age 18. The Act also included restrictions on alcohol availability and advertising at certain locations (e.g. educational institutions).	There were no significant differences in the proportion of suicide deaths that were BAC-positive in the three periods studied 2000–2002, 2003, 2004–2007 (i.e. before, during and after the act’s implementation). However, the mean BAC level of suicide decedents was significantly (p < 0.05) higher in the period before the act’s implementation (2000–2002) than after (2004–2007).
Lester 1993	US, 1973	Deaths; intervention	Ecological study	General population	State variation in alcohol availability measures including proportion of the population living under prohibition, state taxes on alcohol, retail outlets per capita, minimum purchasing age, and other measures.	Correlation analysis showed suicide rates were significantly and negatively associated with restrictions on alcohol (r = −0.30, p < 0.05). However, a measure of liberal availability (as opposed to restriction) of alcohol was not as strongly associated with suicide rates.
Andreasson et al., 2006	Sweden, 1994–2002	Deaths; intervention, outcome	Time series (ARIMA)	General population	Changes in Sweden’s alcohol policy since joining EU. Monopolies on alcohol were eliminated in 1995, and limits on the private import of alcohol were essentially removed in 2004.	Over the course of the period studied, suicide deaths showed a decrease, while estimated total alcohol consumption showed an increase.
LOCAL RESTRICTIONS ON ALCOHOL SALES
Berman et al., 2000	US (Alaska), 1980–1993	Deaths; intervention	Quasi-experimental	Alaskan Natives	Comparing villages that adopted a state local option law restricting alcohol (i.e. changed from being “wet” to being “dry” or “damp”) compared to villages that did not adopt such law (i.e. remained “wet”) during the study period.	There was no decrease in suicide deaths in areas with more restrictive measures (i.e. “dry” communities). However, there was a statistically significant decrease in suicide deaths in villages adopting less restrictive alcohol controls (i.e. “damp” communities), compared to “wet” villages (a 56 per 100,000 decrease, p < 0.05).
Wood & Gruenewald, 2006	US (Alaska), 1991–2000	Deaths and attempts; intervention	Retrospective study	General population aged 15+ years	Alaska Native Village-level variation in local alcohol prohibition. 68 villages were always “dry,” 53 always “wet,” and 11 changed policies at least once during the study period.	There was no significant difference in the age-adjusted rate of intentional self-harm injury for wet versus dry Alaska Native villages.
Berman, 2014	US (Alaska), 1980–2007	Deaths; intervention	Poisson regression	Alaska Native males aged 15–34 years	Variation in local alcohol control, including dry status and other local alcohol regulations, among 178 rural Alaska communities.	Suicide rates were higher in communities that prohibited the importation of alcohol, but the effect was not significant after controlling for other community-based factors.
Joubert, 1994	US (Alabama), 1978–1988	Deaths; intervention	Quasi-experimental	General population	Local prohibition of alcohol, comparing “dry” to “wet” counties.	Dry counties had significantly higher mean suicide rates than wet counties (p < 0.05).
ALCOHOL PRICING/TAXATION
Skog, 1993	Denmark, 1911–1924	Deaths; intervention, outcome	Time series	General population	Increase in alcohol taxation in 1916–1917 due to shortage of alcohol in World War I.	Suicide deaths declined by 19% overall from 1911–1915 to 1916–1920. This decline was particularly profound (56% decline) for suicide deaths where “alcohol abuse” was recorded (“alcoholic” suicide deaths). There was no notable change for suicide deaths not involving “alcohol abuse.” There was also a decrease in per capita alcohol consumption, with a r = 0.95 correlation between alcohol consumption and “alcoholic” suicide deaths. For every litre that per capita alcohol consumption decreased, total suicide mortality decreased 2.5%.
Razvodovsky, 2019	Russia, 2000–2015	Deaths; intervention	Time series	General population	Between 2000 and 2015, the mean retail price of vodka increased by 6.7 times, wine by 3 times, and beer by 3 times.	During the study period, the male suicide rate decreased by a factor of 2.3 from 70.3 to 30.0 per 100,000; the female rate decreased by a factor of 1.9, from 10.6 to 5.7 per 100,000. There were significant negative correlations between the price of all types of alcohol beverages and suicide deaths in both males and females (correlations ranging from r = −0.92 to −0.96, all at a significance of p < 0.000), with suicide deaths being more sensitive to vodka pricing than beer or wine pricing.
Sloan et al., 1994	US, 1982–1988	Deaths; intervention, outcome	Time series	General population aged 25–64 years	State- and year-based variation in alcohol pricing.	Alcohol prices had a statistically significant, negative association with suicide deaths when time and state variables were included (regression coefficient: −0.039 to −0.040 (depending on model), p < 0.05).
Son & Topyan, 2011	US, 1995–2004	Deaths; intervention, outcome	Time series	General population aged 25–64 years	State-level excise tases on wine, beer, and spirits.	The associations between excise taxes on spirits and beer and suicide rate were not statistically significant. However, the association between excise taxes on wine and suicide rates was negative and statistically significant (regression coefficient: −1.220, p < 0.05). During the study period, real tax rates for alcohol declined significantly, with overall alcohol consumption per person increasing by 2.4% (from 3.40 to 3.48 gallons).
Yamasaki et al., 2005	Switzerland, 1965–1994	Deaths; intervention	Time series	General population	Changes in taxes on alcohol over time, as measured by the sum of specific taxes on alcohol products.	Taxes on alcohol were significantly and positively related to the male age-standardized suicide rate (partial regression coefficient: 0.042, p < 0.001), with no effect on female suicide rates.
Puljula et al., 2013	Finland (Northern Ostrobothia), 1999–2007	Deaths; intervention, outcome	Logistic regression	Individuals with acute moderate-to-severe traumatic brain injury and/or those who died on scene	Alcohol taxes were reduced by one third and EU traveller allowances increased in 2004.	Alcohol consumption increased 25%, however alcohol-related suicide deaths that involved traumatic brain injury were 50% less frequent in 2007 vs 1999.
PHYSICAL AVAILABILITY OF ALCOHOL
Ramstedt, 2002	Sweden, 1973–1981	Attempts; intervention, outcome	Time series (ARIMA)	General population aged 10+ years	From July 1977 medium beer was taxed as strong beer and only allowed for sale in 300 retail alcohol monopoly stores, with no one under 20 years permitted to purchase.	There was a non-significant, weak trend for hospitalizations due to attempted suicide to stop increasing as medium strength beer was removed. Hospitalizations due to alcoholism, alcohol psychosis or alcohol intoxication significantly declined only among those aged 10–19 years as medium strength beer was removed.
Lester (1999a)	Iceland, 1984–1994	Deaths; intervention	Ecological	General population	After March 1989, Iceland permitted strong beer to be sold. Other studies reported this policy change was associated with decreased consumption of spirits.	With the allowance of strong beer, the overall suicide rate had a statistically significant decline from 15.08 to 11.98 per 100,000 per year (one- tailed p < 0.05). The female suicide rate declined significantly from 7.40 to 4.44 (p < 0.05), but the decrease for the male suicide rate was non-significant.
Lester (1995)	US, 1974	Deaths; intervention, outcome	Ecological	General population	State-level variation in an index of alcohol availability. The index includes MLDA, limitations on off- and on-premise sales, outlet density, and other limitations on sales.	A positive association was noted between the index of alcohol availability and alcohol consumption. Suicide rates were strongly and positively correlated with alcohol consumption (Pearson r = 0.43, p < 0.01), and positively, but not significantly, associated with the alcohol availability index (Pearson r = 0.19).
Lester (1999b)	US (Idaho, Iowa, Maine, Montana, New Hampshire, and West Virginia), unspecified year	Deaths; intervention	Ecological	General population	Retail state monopolies on wine sales were removed, which was associated with increased wine consumption.	After the monopolies on wine sales were removed, four states had an increase in the suicide rate (mean increase per 100,000 per year of 1.24 in Iowa, 1.50 in Idaho, 1.06 in Maine, and 0.52 in West Virginia), while two had a decrease in the suicide rate (−0.44 in Montana and −1.56 in New Hampshire)
Zalcman & Mann, 2007	Alberta, 1976–1999	Deaths; intervention	Time series (ARIMA)	General population aged 15+ years	Privatization of alcohol sales with three stages. Stage 1 (1985): Privately owned wine stores were opened. Stage 2 (1989): Privately owned beer stores were opened. Spirits and wine were sold in hotels in rural areas. Stage 3 (1994): All liquor stores were privatized.	Stage 1 and 2 were associated with statistically significant (p < 0.01) increased suicide rates for both males (ω = 0.42 and ω = 0.16, respectively) and females (ω = 0.30 and ω = 0.41). Stage 3 was associated with a significant increase in the suicide rate for males (ω = 0.17, p < 0.01), but not females.
Johnson et al., 2009	US (California), 1995–2000	Deaths and attempts; intervention	Ecological	General population aged 15+ years	The number of active alcohol outlets per zip code, including off-premise outlets, restaurants, and bars/pubs.	Densities of local bars and off-premise outlets were significantly and positively related to suicide deaths (b = 7.600, p = 0.016; b = 3.547, p = 0.022, respectively), while local restaurant densities had a significant, negative association with suicide deaths (b= −3.348, p = 0.003). Densities of local bars were significantly and positively associated with suicide attempts (b = 8.157, p = 0.004), while local restaurants had a significant, negative association with suicide attempts (b= −2.205, p = 0.029). Local off-premise densities had no significant association with suicide attempts.
Escobedo & Ortiz, 2002	US (New Mexico), 1990–1994	Deaths; intervention, outcome	Linear regression	General population	Liquor outlet density.	There was a statistically significant, positive association between liquor outlet density and suicide rates (adjusted regression coefficient: 0.23 (p = 0.03)). Suicide rates were 80% and 60% higher for the second and third tertiles of alcohol outlet density, respectively, compared to the first tertile.
Giesbrecht et al., 2015	US (14 states), 2003–2011	Deaths; intervention, outcome	Multi-level logistic regression models	General population	County-level variations in on and off-premise alcohol outlet density.	Among male suicide decedents, both on- and off-premise alcohol outlet density were positively associated with blood alcohol content positivity (AOR = 1.05, p < 0.01 and AOR = 1.08, p < 0.01, respectively), while only on-premise alcohol outlet density was associated with BAC ≥ 0.08 (AOR = 1.05, p < 0.01) in adjusted models. There was also a significant interaction between off-premise alcohol outlet density and American Indian/Alaska Native race (AOR = 1.36, p < 0.01).
Malaga et al., 2012	Peru (Lima), 2005–2008	Deaths; intervention, outcome	Ecological	General population	Reduction in hours of sale of alcohol in La Victoria district in Lima in January 2007. A nearby district, Cercado de Lima, not undergoing such policy change, was used as the control group.	Suicide deaths in La Victoria declined by 35% compared to a 13% increase in Cercado, but this difference was non-significant. Despite the decline in suicide deaths in La Victoria, the proportion of suicide decedents positive for alcohol increased.
Wilkins et al., 2019	Australia, Canada & US, 2011	Deaths; Intervention	Ecological	General population	State/province-level variation in alcohol outlet density.	Alcohol outlet density was not significantly associated with suicide deaths.
Branas et al., 2011	US (Philadelphia), 2003–2006	Deaths and attempts; Intervention	Case-control	General population aged 21+ years	Density of on- and off-premise alcohol outlets.	There was no statistically significant relationship between alcohol outlet density and intentional self-inflicted gun injuries, including gun suicide deaths.
MINIMUM LEGAL DRINKING AGE (MLDA) AND OTHER UNDERAGE DRINKING POLICIES
Callaghan, Sanches, Gatley, et al., 2013	Canada (Ontario), 2002–2007	Deaths; intervention, outcome	Regression- discontinuity analysis	General population aged 16–22 years	Minimum legal drinking age of 19 in Ontario.	Compared to those slightly below the MLDA, individuals just older than the MLDA showed a significant, 51.8% (p = 0.01) increase in emergency department visits classified as suicide deaths related to alcohol. Among young women crossing the MLDA threshold, there was a statistically significant, 91.8% increase in such suicide deaths (p < 0.01).
Callaghan, Sanches, & Gatley, 2013	Canada (excluding Quebec), 1997–2007	Attempt; intervention	Regression-discontinuity analysis	General population aged 15–22 years	Minimum legal drinking age threshold for each jurisdiction.	At the MLDA threshold, the rate of hospital admission for self-inflicted injuries rose significantly by 9.6% (p = 0.029), compared to the hospitalization rate just before the MLDA.
Carpenter & Dobkin, 2011	US, 1975–2003	Deaths; intervention, outcome	Fixed effects and regression discontinuity	General population aged 15–29 years	Minimum legal drinking age.	The fixed effects model estimated that an increase in the proportion of young adults who can legally drink was associated with a statistically significant, 10% increase in suicide deaths (p < 0.01). The regression-discontinuity model estimated that suicide deaths increased by 20.3% at the MLDA of 21, which was statistically significant (p < 0.01). The proportion of young adults who could drink legally was also associated with significant increases in a variety of measures of alcohol consumption.
Carpenter, 2004	US, 1981–1998	Deaths; intervention	Negative binomial regression	General population aged 15–29 years	State-level variation in adoption of zero tolerance (i.e. zero blood alcohol content) drunk driving laws for drivers under 21 years.	Adoption of zero tolerance laws was associated with a 10.3% decline in male suicide deaths among those aged 15–17 (p < 0.10) and a 7.7% decline among males aged 18–20 years (p < 0.05). There was no significant effect noted for older males or female suicide deaths.
Jones et al., 1992	US, 1979–1984	Deaths; intervention	Logistic regression	General population aged 15–24 years	State-level variation in legal drinking age.	At a given age, suicide death rates were 9.7% higher among those who could legally drink as compared to those who could not. This difference was statistically significant (OR = 1.097; p < 0.05).
Birckmayer & Hemenway, 1999	US states (48 states), 1970–1990	Deaths; intervention	Time series	General population aged 15–23 years	Raising of the minimum legal drinking age.	When controlling for other factors, states with an MLDA of 18 years had an 8% higher suicide rate among 18–20 year-olds than states with a 21-year MLDA. This difference was significant (p < 0.01).
Carpenter & Dobkin, 2009	US, 1997–2004	Deaths; intervention, outcome	Regression discontinuity	General population aged 19–22 years	Minimum legal drinking age.	At the MLDA, age 21, the suicide death rate increased by more than 16%. Measures of alcohol consumption also increased at the MLDA, including a 21% increase in the number of recent drinking days.
Grucza et al., 2012	US, 1990–2004	Deaths; intervention	Quasi-experimental	General population of individuals born between 1949 and 1972	Minimum legal drinking age laws, specifically whether individuals were legally permitted to consume alcohol before age 21.	Being exposed to a lower MLDA was associated with a significant, 12% increased risk of suicide death among women (OR = 1.12, p = 0.0003). For men, there was borderline significance for a decreased risk of suicide death with a more permissive MLDA.
Carpenter & Dobkin, 2017	US (Arizona, New Jersey, New York, Texas, Wisconsin), 1990–2010	Attempts; intervention	Regression discontinuity	General population aged 19–22 years	Minimum legal drinking age.	There were no significant increases in self-inflicted injuries in relation to the MLDA.
Matsubayashi & Yoshikawa, 2018	Japan, 1974–2014	Deaths; intervention, outcome	Regression discontinuity	General population aged 18–21 years	Minimum legal drinking age of 20 years.	The rate of suicide deaths did increase between 18 and 22 years of age, but it was uninterrupted at 20-year age point.
MODELLING STUDIES
Holder et al., 1995	Sweden & Norway, n/a	Deaths; Intervention and outcome	Multiplicative modelling	General population	Partial or complete elimination of the national alcohol retail monopolies, as well as low to substantial drops in alcohol prices.	All scenarios examined were projected to lead to increased per capita levels of alcohol consumption. Suicide deaths in Sweden were projected to increase by 100 (9%) to 638 (57%) for men, and 30 (7%) to 170 (37%) for women at 1 and 5 L increases in per capita alcohol consumption, respectively. In Norway, the projected increase was from 50 (10%) to 280 (57%) deaths for men, and 10 (6%) to 40 (23%) deaths for women, for 1 and 5 L per capita increase in consumption, respectively.
Norstrom et al. (2010)	Sweden, n/a	Deaths; intervention and outcome	Multiplicative modelling	General population	The effects of two scenarios were projected. The first scenario involved replacing the present retail monopoly with private stores that primarily sell alcohol. The second involved making alcohol available in grocery stores.	Scenario 1 was projected to yield a 17% and scenario 2 a 37.4% increase in alcohol consumption, respectively. Under the conditions of the first scenario, there was a projected 15.0% increase for men and 11.9% increase for women in suicide deaths. Under the second scenario, there was a projected 36.3% increase for men, and 28.1% increase for women in suicide deaths.

Table

Author, year	Location, year(s)	Suicide attempt or death; Role of alcohol	Design	Study population	Intervention	Main outcomes [both suicide and alcohol outcomes, if relevant]
Kelley et al., 2017	US, 2013–2016	Attempts; population, intervention and outcome	Bivariate analyses	American Indian individuals (mostly from Northern Plains Tribes) with substance use, recruited from tribal chemical dependency programs, social service agencies, tribal health programs or through self-referral.	Transitional Recovery and Culture Program, which uses Peer Recovery Support (PRS) to enhance recovery from substance use and related disorders.	From baseline to 6 month follow up, there was no significant difference in suicide attempts not due to alcohol or drug use. There were significant decreases in past 30-day alcohol use.
Cwik et al., 2016	US (Arizona), 2001–2012	Attempts and deaths; intervention and outcome	Ecological	White Mountain Apache Tribe	White Mountain Apache Suicide Surveillance and Prevention System, a comprehensive suicide prevention intervention, including dissemination of information on resources and hotlines, suicide prevention conferences, and educational workshops such as the Applied Suicide Intervention Skills Training (ASIST) and life skills curriculum. A brief intervention program was also implemented for youth with suicidal ideation and attempts, as well as youth who were in the surveillance system for binge drinking.	The Apache suicide death rate declined from 40.0 to 24.7 per 100,000, a 38.3% decrease. Annual suicide attempts also declined from 75 to 35, a 53.3% decrease.
Brown & Block, 2001	US (Portland, Oregon), 1995–2000	Attempts; intervention and outcome	Randomized controlled trial	Adolescent females aged 14–17 years with a history of being a victim of sexual, emotional or physical abuse and having at least two other psychosocial risk factors	Project Chrysalis, a multi-faceted intervention that primarily consisted of school-based support groups facilitated by school counsellors and local therapists. The program also included educational sessions about alcohol and other drug prevention.	Both the intervention and control group had declines in suicide attempts at the first follow up point compared to baseline, however this difference was greater among those in the Project Chrysalis program. The significance of these differences was not reported. At the second follow up time point, there was a significant, negative association between time in case management and the likelihood of trying alcohol.
Fekkes et al., 2016	Netherlands; unspecified year	Attempts; intervention and outcome	Cluster randomized controlled trial	Students aged 13–16 years	Skills for Life program, a classroom-based, two-year intervention consisting of 25 lessons designed to enhance social, emotional and moral skills. As part of the intervention, skills are also developed for situations involving substance use.	Significantly fewer students in the experimental group reported using alcohol compared to the control group, but there were no significant differences in the risk of past year suicide attempts.
Machado et al., 2018	Brazil, 2008–2012	Attempts and deaths; intervention and outcome	Mixed ecological design	General population	Municipal coverage of a network of community mental health care units (CAPS) which are the primary health care resource for people with persistent, severe mental health disorders. One of the sub-types of CAPS, CAPS I, which are the smallest units, have a patient population that includes those with disorders related to alcohol use.	Increased CAPS coverage was associated with significantly fewer hospitalizations for both attempted suicide (RR = 0.89, p < 0.05) and alcohol problems (RR = 0.88, p < 0.05), but not for suicide deaths.
Mann et al., 2006	Canada (Ontario), 1968–1991	Deaths; intervention	Time series (ARIMA)	General population aged 15+ years	Alcoholics Anonymous (AA) membership per 100,000 adults aged 20 years and older	AA membership rates had a significant, negative association with overall (b = −0.002, p < 0.05) and female (b = −0.003, p < 0.10) suicide death rates.
Mann et al., 2008	Canada (Manitoba), 1976–1997	Deaths; intervention	Time series (ARIMA)	General population aged 15+ years	Alcoholics Anonymous (AA) membership per 100,000 adults aged 20 years and older	There was a significant, negative association between the rate of AA membership and the rate of suicide deaths overall (b = −0.04, p = 0.02) and among females (b = −0.02, p = 0.01).

Table

Author, year	Location, year(s)	Suicide attempt or death; R ole of alcohol	Design	Study Population	Intervention; sample size^1	Main outcomes [both suicide and alcohol outcomes, if relevant]
INTERVENTIONS FOCUSING ON SUICIDAL POPULATIONS WITH ALCOHOL USE
McManama O'Brien et al., 2018	US; 2014–2018	Attempt; population, intervention & outcome	RCT	Adolescents hospitalized following suicide attempt or ideation, endorsing past month alcohol use	Alcohol and Suicide Intervention for Suicidal Teens (ASIST) [individual and family counselling using motivational interviewing] vs control; n = 50	Suicide attempts were non-significantly less frequent in the intervention group compared to the control. Days of alcohol use and quantity of alcohol use were also non-significantly lower in the intervention group compared to the control group, after controlling for baseline.
Esposito-Smythers et al., 2011	US; 2004–2007	Attempt; population, intervention & outcome	RCT	Adolescents at risk of suicide with comorbid alcohol and/or cannabis use disorder	Integrated outpatient cognitive behavioral (I-CBT) intervention vs enhanced treatment as usual (E-TAU); n = 40	The I-CBT group had significantly fewer suicide attempts over 18 months (5.3% vs 35.3%, p = 0.023) and significantly fewer heavy drinking days relative to E-TAU.
Morley et al., 2014	Australia; unspecified	Attempt; population, intervention & outcome	RCT	Adults with alcohol or other drug misuse and a suicide attempt in the last 3 months or current suicidal ideation	Opportunistic cognitive behavioural (OCB) intervention vs treatment as usual (TAU); n = 185	Substantial reductions in suicide attempts occurred in both the OCB group and the TAU group. Alcohol consumption also significantly decreased across the 6-month study period regardless of the treatment group.
INTERVENTIONS FOCUSED ON TREATING ALCOHOL USE DISORDER (AUD)/RELATED CONDITIONS
Therapy-Based interventions
Nadkarni et al., 2017	India; 2013–2016	Attempt; population, intervention & outcome	RCT	Adult men scoring 12–19 on AUDIT	Enhanced usual care (EUC) plus Counselling for Alcohol Problems (CAP) vs EUC alone; n = 378	Suicide attempts were non-significantly lower in the EUC plus CAP group. EUC plus CAP had a significantly higher proportion of individuals with no drinking and higher remission rates. EUC plus CAP also had non-significantly higher mean alcohol consumed among drinkers.
Kristenson et al., 2002	Sweden; 1975–1991	Death; population, intervention & outcome	RCT	Males aged 45–49 with heavy alcohol consumption and gamma-glutamyltransferase levels in the highest decile	Brief intervention vs control; n = 667	There were significantly fewer alcohol-related deaths in the intervention group. Among all alcohol-related deaths, there was one suicide death and it occurred in the intervention group.
Timko et al., 2019	USA; Unspecified	Attempt; population, intervention & outcome	RCT	Patients entering a psychiatry unit undergoing detoxification for alcohol and/or opioid dependence	Enhanced Telephone Monitoring (ETM) [connects patients to addiction treatment and/or mutual help] plus usual care (UC) vs UC alone; n = 298	Suicide attempts were non-significantly lower in the ETM group at 3-month follow up, and non-significantly higher at 6-month follow up. Both number of drinking days and alcohol addiction severity index were significantly decreased in the ETM group compared to UC alone at 3-month follow up, but significance was lost at 6-month follow up.
Gregory et al., 2008, 2010	USA; 2004–2008	Attempt & death; population, intervention & outcome	RCT	Adults with Borderline Personality Disorder and active alcohol abuse or dependence	Dynamic deconstructive psychotherapy (DDP) vs treatment as usual/optimized community care (TAU/OCC); n = 30	Suicide attempts were significantly less frequent in the DDP group compared to the TAU/OCC group during the 6 to 12-month treatment period (p = 0.013). Throughout the study period there were no reported suicide attempts in the DDP group. One participant died by suicide in the TAU group at 9 months. The DDP group also had significant improvement in heavy drinking behavior over the 30-month study period, and significantly less heavy drinking than the TAU/OCC group at 12 months.
van den Bosch et al., 2005	Netherlands; Unspecified	Attempt; population & outcome	RCT	Women with borderline personality disorder who were clinically referred from addiction treatment and psychiatric services	52 weeks of Dialectical Behavioural Therapy (DBT) vs treatment as usual (TAU); n = 58	Suicide attempts were lower in the group receiving DBT (effect approaching significance, p = 0.064). The DBT group also had a significantly greater decrease in alcohol consumption, sustained for 6-months after treatment cessation, relative to TAU.
Pharmaceutical interventions
Laaksonen et al., 2008	Finland; 2000–2005	Death; population, intervention & outcome	RCT	Patients with alcohol dependence	Randomization to either take Naltrexone, Disulfiram or Acamprosate; n = 243	Only one suicide death was observed, and it was in the Acamprosate group. On multiple alcohol measures, disulfiram was significantly better than naltrexone and acamprosate during weeks 1–12; this significance only persisted for certain measures from weeks 13 to 52.
ECOLOGICAL STUDIES EXAMINING A CLINICAL INTERVENTION
Moustgaard et al., 2014	Finland; 1995–2007	Death; outcome	Longitudinal Study	General population (adults)	Antidepressant usage (assessed via sales)	Although the increased proportion of antidepressant users may have prevented non-alcohol related suicide deaths among men, alcohol-related suicide deaths were not related to regional antidepressant sales.
Nettelbladt et al., 2007	Sweden; 1947–1997	Death; outcome	Prospective Cohort Study	General population	Introduction of tricyclic antidepressants in 1962 in Sweden	As antidepressants were introduced over the course of the study period, a shift from depressive disorders to other psychiatric disorders and alcohol use disorder (alone, not comorbid) associated with suicide occurred.
Bellanger et al., 2007	France, 1996–1999	Death; intervention	Ecological	General population	Alcohol withdrawal drug prescription rates	The prescription of drugs for alcohol withdrawal was positively associated with suicide mortality in females.

¹ Refers to the number of participants randomized in randomized controlled trials. Sample sizes not reported for non-RCT studies.

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