Substance Use & Misuse, 46:1690–1699, 2011

Copyright

C 2011 Informa Healthcare USA, Inc.
ISSN: 1082-6084 print / 1532-2491 online
DOI: 10.3109/10826084.2011.605414

ORIGINAL ARTICLE

Substance Use/Abuse and Suicidal Behavior in Young Adult Women:

A Population-Based Study

Maud Sundin1 , Fredrik Spak2 , Lena Spak2 , Valter Sundh3 and Margda Waern1
1
Department of Psychiatry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of
Gothenburg, Gothenburg, Sweden; 2 Department of Social Medicine, University of Gothenburg, Gothenburg, Sweden;
3
Department of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden

use is also increasing (CAN, 2007). There is evidence

Associations between substance use variables and sui-
cidal behavior were analyzed in an urban population
sample from (“the Women and Alcohol in Gothen-
burg” study). In Phase I, 20-year-old women (n =
2,069) completed a screening questionnaire. Interviews
were carried out with a stratified sample (n = 560).
Data, collected in 1995 and 2000, were analyzed us-
ing logistic regression to generate odds ratios. Drug
use, but not risky alcohol consumption, was associated
with suicidal thoughts after adjusting for current de-
pression. Study limitations and implications for suicide
prevention are discussed. The study was funded by the
Swedish Research Council and the Alcohol Research
Council of Sweden.
Keywords alcohol, substance use, suicidal thoughts, suicide
attempt, young women
INTRODUCTION
Sweden has seen a dramatic drop in the overall suicide
rate during the past two and a half decades (National Pre-
vention of Suicide and Mental Ill-Health, 2010). How-
ever, the trend has not been as favorable for young women.
There was no reduction in suicide rates for women aged
15–24 years during this time period, and a dramatic in-
crease in suicide attempts was observed in this age group
(Karolinska Institute’s Public Health Academy, 2009).
One explanation for this distressing development may be
the increase in alcohol use observed in young women
during this time period. Over the last 10 years, young
girls/women have increased their consumption more than
boys/men. Also, women’s share of alcohol-consumption-
related inpatient care and alcohol-consumption-related
deaths is on the rise in Sweden (CAN, 2007). Illicit drug
that increasing rates of alcohol/intoxicant consumption
are paralleled by increasing rates of attempted (Rossow,
Groholt, & Wichstrom, 2005) and completed (Mann, Zal-
cman, Smart, Rush, & Suurvali, 2006) suicide. Female
suicidal behavior is growing more similar to that of males,
with increasing use of violent suicide methods (Beautrais,
2003). In a recent European study (Värnik et al., 2009),
hanging was the main method among young women in all
participating countries. Rates of hanging were observed
to be particularly high in both genders in northern Eu-
rope, and the authors suggested that this might indicate
converging gender behavior.
While the relationship between alcohol use disorder
(AUD) and suicidal behavior is well documented (Sher,
2006; Wilcox, Conner, & Caine, 2004), most of the evi-
dence stems from studies based on clinical cohorts. A re-
cent mixed-age population-based study carried out by the
Office of Applied Studies, Substance Abuse and Mental
Health Services Administration (2009) revealed that per-
sons who fulfilled criteria for a substance use disorder had
a more than three-fold increase in odds of having seriously
considered suicide. Population studies with diagnostic in-
formation focusing specifically on young women who are
transitioning into young adulthood are lacking. This age
group is of interest as this is the stage of life at which al-
cohol consumption peaks (CAN, 2007). Alcohol is often
consumed prior to attempted suicide in teens and young
adults (Hawton & Harris, 2007), and risks associated with
problematic alcohol consumption need to be clarified us-
ing operationalized measures.
There is increasing evidence for a link between drug
use and suicidal behavior in adolescents (Wilcox, 2004).
However, results of population studies regarding cannabis
use and suicidal behavior are mixed (Borges, Walters,

The study was funded by grants from the Alcohol Research Council of Sweden and the Swedish Research Council grant number
K2004-21PD-15102-01A. This is a FAS-Epilife collaboration.
Address correspondence to Margda Waern, Department of Psychiatry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy,
University of Gothenburg, Gothenburg SE 413 45, Sweden; E-mail: margda.waern@neuro.gu.se

1690
 SUBSTANCE USE AND SUICIDALITY IN YOUNG WOMEN
& Kessler, 2000; Bovasso, 2001; Hallfors, 2004; Kung,
Pearsson, & Liu, 2003; Macleod et al., 2004). Population-
based studies that examine suicidal behavior in young
adult women with problematic use of substances other
than alcohol are needed.
We wanted to investigate relationships between alcohol
and other substances, and suicidal thoughts and attempts
in a population-based sample of 20-year-old women who
participated in the “Women and Alcohol in Gothenburg”
study. We hypothesized that we would find associations
between AUD/high alcohol consumption (HAC)/heavy
episodic drinking (HED) and suicidal behavior. We also
wanted to test associations between intake of illicit drugs
and suicidal behavior in these young women. Relation-
ships between nonprescription use of licit drugs and sui-
cidal behavior were also examined.
METHOD
Design and Sample
The study is a part of a larger longitudinal population-
based study, “Women and Alcohol in Gothenburg” (Spak
& Hällström, 1995), that was initiated in 1985 in Gothen-
burg, Sweden’s second largest city. The current study
population included all 20-year-old women born in 1975
and in 1980 living in western and central Gothenburg.
According to the Gothenburg City Office, the study area
had 200,803 inhabitants in 1995 (104,704 women) and
205,553 inhabitants in 2000 (106,323 women). There
were no exclusion criteria.
In Phase 1, which took place in 1995 for those born in
1975 and in 2000 for those born in 1980, all women in the
study population (total N = 2,069) were sent a 13-item
self-report instrument, SWAG (Screening Women in
Gothenburg). This instrument, which contains a modified
version of CAGE (Ewing, 1984), has been shown to
have good psychometric properties in both clinical and
epidemiological settings (Spak & Hällström, 1996). In-
trascale reliability, measured with Cronbach’s alpha, was
0.90. Each endorsed item gave one point (maximum pos-
sible score 13 points). There were no questions on suici-
dality in this phase. The response rate for the initial postal
questionnaire was 75.5% for both birth cohorts combined.
There was no formal attrition analysis. However, for a
previous study wave, analysis of case record data did
not show any significant difference in the prevalence of
alcohol-consumption-related diagnoses in participants
and nonparticipants (Spak & Hällström, 1995).
A stratified random sample of Phase 1 respondents was
invited to participate in face-to-face interviews in Phase
2 (n = 901). The stratified random sample included three
groups: 100% of the women who received a score of at
least 5 points on the screening instrument (n = 372), a ran-
dom 22.5% of those scoring between 1 and 4 points (n =
201), and a random 77.8% of those who scored 0 points (n
= 228). Female AUD is a low prevalent condition, and the
stratification was made for two reasons: firstly, to collect
a large enough sample of women with alcohol problems
to enable statistical analyses, and secondly, to reduce
1691
costs by interviewing a selected subsample rather than the
entire Phase 1 sample. The fractions were chosen to yield
sufficient numbers of women with AUD and still keep the
total number of interviews manageable. In order to better
understand the effect of Phase 1 attrition, a random 25%
of those who did not respond to the original screening
questionnaire (n = 100) were also sent an invitation.
After the initial mailed invitation to the face-to-face
interview, nonresponders were sent up to two written re-
minders, and if necessary, they were also telephoned. The
response rate for Phase 2 was 65.2% for those who had
taken part in Phase 1 and 40% for nonparticipants in Phase
1. Respondents who did not accept full interviews were of-
fered short interviews (n = 104), but this article is based
on data for those who took part in the full face-to-face in-
terview (278 women born in 1975 and 284 women born
in 1980).
Assessments
Almost all of the interviews took place in the homes
of the participants. A few women requested alternative
settings (our office at the Department of Social Medicine
or the participant’s workplace). The structured inter-
view covered sociodemographic, psychological, and
behavioral parameters, including drug use/abuse (Spak
& Hällström, 1995). The interviewers (n = 11) had
several years of clinical experience and were trained in
DSM-III-R (Diagnostic and Statistical Manual of Mental
Disorders) diagnostics for substance use disorders. This
DSM version was employed as the current study is part
of a larger longitudinal study and because it was the
version in use at the time of project initiation. We chose
to employ this version in later waves for comparability.
Clinical examinations were performed until sufficient
interrater reliability was achieved, which was defined as
complete diagnostic agreement to the unit digit (i.e., 30x,
where x is the unit digit). The structured diagnostic instru-
ment CIDI-SAM (Composite International Diagnostic
Interview-Substance Abuse Module; Robins, Cottler, &
Babor, 1986) was included in the protocol. For cases in
which interview diagnoses and CIDI-SAM diagnoses
differed, all available information was weighted together
to form a final diagnosis, which was used in the analyses
(Spak & Hällström, 1995). Interviewers were also trained
in the use of the MINI (Mini-International Neuropsy-
chiatric Interview; Sheehan et al., 1998), which was
utilized to diagnose other (nonsubstance use) psychiatric
disorders. Personality disorders were not diagnosed in
the current study, as time was a limiting factor.
In order to enhance statistical power, diagnoses of alco-
hol abuse and alcohol dependence were merged into one
category, AUD. HAC was defined as an average daily use
of more than 20 g of ethanol measured over the last month
of drinking during the past year, and HED denoted use of
60 g of ethanol (five drinks) on one drinking occasion.
HED frequency measures were: (1) at least once a month,
and (2) at least once a week during the past year.
The young women were asked whether they had
used illicit drugs and/or prescription drugs in a
1692 M. SUNDIN ET AL.
TABLE 1. Prevalence of suicidal thoughts and attempts in two cohorts of 20-year-old women
Total (N = 560)
Cohort 1 (n = 278) 20 years old in 1995
Cohort 2 (n = 282) 20 years old in 2000
a
Unweighted numbers.
b
Weighted percentages.
non-prescribed manner. For substances other than
alcohol (see Appendix), the frequency measures were:
(1) more than once during the past year, and (2) more
than five times during lifetime. Use/abuse of benzodi-
azepines and opiates also comprised legally prescribed
medication, as it is often difficult to distinguish between
use and misuse of such drugs in persons with problematic
drug-use-related behaviors.
Suicidal ideation and suicide attempts were assessed
according to Meehan, Lamb, Salzman, and O’Carrol
(1992), using the following questions: Suicidal ideation:
Have you EVER had thoughts of taking your life, even if
you would not really do it? Have you EVER thought about
specific ways to take your life even if you would not really
do it? A woman was considered to have lifetime suicidal
ideation if she answered affirmatively to either question.
The women were also asked whether they had had such
thoughts during the PAST 12 MONTHS, and those with a
positive response were considered to have past-year suici-
dal thoughts. Lifetime suicide attempt was recorded when
a woman answered “yes” to the following question: Have
you EVER made an attempt to take your own life? And a
woman was considered to have a past-year suicide attempt
if she gave an affirmative response to the question: Dur-
ing the PAST 12 MONTHS, have you made an attempt to
take your own life?
Statistical Analysis
As the material was oversampled with individuals
who indicated possible alcohol problems on the postal
screening questionnaire, all prevalence rates, p-values,
and odds ratios (ORs) with confidence intervals (CIs) are
weighted based on the sampling fractions in the different
SWAG-score classes (see above). SUDAAN 9.0 software
(Research Triangle Institute, 1997) was used, with
chi-square test for data analyzed in 2 × 2 tables and the
logistic procedure for data analyzed in k × 2 tables, where
k > 2. No imputation procedure was used for missing
values. Missing values are reflected in the n’s of each
analysis. Subgroups with a specific alcohol or drug vari-
able were compared with all others. As suicidal thoughts
and attempts were more common in the later-born cohort,
this cohort was introduced as a control variable in all of
the regression analyses (Model 1). In Model 2, associa-
tions were statistically controlled with multiple logistic
Suicidal thoughts Suicide attempts
Past year Lifetime Past year Lifetime
na (%)b na (%)b na (%)b na (%)b
98 (15.4) 282 (49.7) 13 (2.2) 44 (8.1)
41 (10.4) 141 (48.3) 4 (0.6) 25 (8.9)
57 (22.4) 141 (51.5) 9 (4.4) 19 (7.1)
regression for both cohort and major depression (single or
recurrent episode) in accordance with DSM-III-R (296.2x
or 296.3x). In the final set of analyses, binary logistic
regression models were employed to analyze trend
associations with number of different substances used.
Ethics
The study was approved by the Ethics Committee for
Medical Research at the University of Gothenburg.
RESULTS
Half of the young women in this population-based study
had suicidal thoughts at some point during their lives,
and 8% had made at least one suicide attempt (Table
1). Fewer reported past-year ideation and attempts. There
were significant differences between the two birth co-
horts regarding past-year suicidal thoughts and attempts.
Twenty-year-olds who were interviewed in the year 2000
were more likely to report past-year suicidal thoughts (OR
= 2.5, 95% CI = 1.4–4.4, p = .002) and attempts (OR =
7.5, 95% CI = 2.1–16.4, p = .03) than their counterparts
who were interviewed in 1995.
The two cohorts were combined for further analyses,
and regression models were therefore controlled for birth
cohort. One fifth of the women who fulfilled criteria
for AUD during the past year reported having suicidal
thoughts (Table 2). Similar proportions were noted in
those with risky alcohol consumption patterns (HAC or
HED at least once a month during the past year). None
of the abovementioned variables conferred increased risk
for past-year suicidal thoughts, however. One third of
those with illicit drug use during the past year reported
past-year suicidal thoughts. A similar proportion was
observed among women who used cannabis, which was
the illicit drug most commonly used. Past-year illicit
drug use in general, and cannabis use in specific, was
associated with a more than three-fold risk for past-year
suicidal thoughts. A third of those with nonprescription
benzodiazepine use during the past year reported suicidal
thoughts; this was associated with a four-fold risk for
past-year suicidal thoughts. Nonprescription opiate use
during the past year conferred a near four-fold risk
for suicidal thoughts during this time period. Risk was
elevated in women who reported use of any illegal drug
 SUBSTANCE USE AND SUICIDALITY IN YOUNG WOMEN 1693

TABLE 2. Associations between different types of substance use and past-year suicidal thoughts in 20-year-old women (N = 560)

Model 1a Model 2b

n (%)c OR (95% CI) LRCd (df) R2e OR (95% CI) LRCd (df) R2e

Past year
AUDf 19 (20.5) 1.2 (0.5–2.8) 31.47 (2) 0.0547 0.8 (0.3–2.0) 74.16 (3) 0.1242
HEDg 46 (20.2) 0.9 (0.4–1.9) 31.41 (2) 0.0546 0.8 (0.3–1.8) 74.65 (3) 0.1250
HACh 23 (22.0) 1.5 (0.8–3.0) 35.02 (2) 0.0607 1.6 (0.8–3.1) 77.62 (3) 0.1296
Any illegal drug 35 (33.7) 2.9 (1.5–5.5) 57.22 (2) 0.0973 2.5 (1.2–5.0) 91.40 (3) 0.1508
Cannabis 28 (34.9) 3.0 (1.5–5.9) 53.44 (2) 0.0912 2.6 (1.3–5.5) 90.38 (3) 0.1493
Benzodiazepine 9 (35.0) 4.2 (1.5–11.7) 36.95 (2) 0.0640 4.0 (1.5–10.8) 78.57 (3) 0.1311
Opiates 15 (27.6) 4.1 (1.7–10.1) 53.79 (2) 0.0917 3.8 (1.3–11.5) 92.99 (3) 0.1532
Lifetimei
Any illegal drug 20 (33.0) 2.1 ( >1.0–4.3) 39.71 (2) 0.0687 1.8 (0.8–3.9) 78.67 (3) 0.1315
Cannabis 17 (32.9) 2.1 ( <1.0–4.4) 37.85 (2) 0.0656 1.8 (0.8–3.8) 77.21 (3) 0.1292
Benzodiazepines 10 (33.0) 4.2 (1.6–11.0) 47.02 (2) 0.0808 2.9 ( <1.0–8.6) 81.94 (3) 0.1366
Opiates 17 (26.9) 2.0 (0.9–4.3) 39.10 (2) 0.0677 1.8 (0.7–4.4) 78.81 (3) 0.1317
a
Model 1 adjusted for birth cohort.
b
Model 2 adjusted for birth cohort and depression.
c
Weighted percentages.
d
LRC = Model’s likelihood ratio chi-square.
R = Cox–Snell R2 for binary logistic models.
e 2
f
Alcohol use disorder.
g
Heavy episodic drinking.
h
High alcohol consumption.
i
Use of specified substance five times or more during lifetime.

at least five times during lifetime and in those who used
benzodiazepines at least five times during lifetime.
As subgroups with a specific alcohol/drug variable
were compared with all others, there was a risk for
confounding comparisons as the reference group could
include women with other types of substance use. We
therefore investigated the effects of an alternative contrast
category free from any form of substance use problem
(no lifetime diagnosis of AUD, no lifetime illicit drug
use, and no use of benzodiazepines or opiates more
than five times during lifetime). This procedure did not
change the above associations in any substantial manner
(results not shown). When depression was included in the
logistic models, past-year illicit drug use in general and
cannabis use in specific as well as nonprescription use of
benzodiazepines and opiates, all remained independently
associated with past-year suicidal thoughts.
Table 3 shows that over three quarters of all of the 20-
year-olds who fulfilled criteria for AUD during the past
year reported that they had had suicidal thoughts at some
point during lifetime. A three-fold increased risk for life-
time suicidal thoughts was observed in young women with
AUD. The association was no longer significant, however,
after depression was taken into consideration. Neither
HED nor HAC was related to lifetime suicidal thoughts.
Over two thirds of the women who had used cannabis dur-
ing the past year reported suicidal thoughts at some point
during lifetime, and past-year cannabis use was associated
with lifetime suicidal thoughts even after depression was
taken into consideration. Lifetime use of any illegal drug
was associated with lifetime suicidal thoughts, as was life-
time use of cannabis and of benzodiazepines, but only the
association with any illegal drug remained significant af-
ter adjustment for depression.
One quarter of the young women with AUD had made
a suicide attempt at some point (Table 4). The disorder
was associated with a more than four-fold increase in risk
for lifetime suicide attempt. Neither HAC nor HED was
associated with attempted suicide. An association was ob-
served between past-year nonprescription use of benzodi-
azepines and lifetime suicide attempts, and a six-fold in-
crease in odds of attempted suicide was observed after the
models were adjusted for depression.
We examined whether risk for suicidal thoughts and
attempts increased with increasing number of substances
used during the past year. We found associations between
numbers of different substances and both past-year and
lifetime suicidal thoughts (Table 5). The models showed
that the odds for suicidal thoughts approximately doubled
for each additional substance used. Results remained sig-
nificant also after adjustment for depression. An indepen-
dent association between number of substances and sui-
cide attempt could not be shown.
DISCUSSION
Risk of lifetime suicidal thoughts was increased more than
threefold and risk of lifetime suicide attempts more than
fourfold in 20-year-olds with AUD. Illicit drug use and
nonprescribed use of bensodiazepines and opiate drugs,
but neither AUD nor risky drinking, were associated
with suicidal thoughts after current depression was taken
into account. Before results are discussed in detail, some
methodological considerations require attention.
1694 M. SUNDIN ET AL.

TABLE 3. Associations between different types of substance use and lifetime suicidal thoughts in 20-year-old women (N = 560)

Model 1a Model 2b

n (%)c OR (95% CI) LRCd (df) R2e OR (95% CI) LRCd (df) R2e

Past year
AUDf 58 (78.3) 3.4 (1.5–7.7) 24.64 (2) 0.0430 2.5 (<1.0–6.4) 107.18 (3) 0.1742
HEDg 119 (54.0) 1.0 (0.6–1.7) 1.44 (2) 0.0026 0.9 (0.5–1.6) 96.65 (3) 0.1585
HACh 53 (45.8) 0.8 (0.5–1.4) 3.09 (2) 0.0055 0.8 (0.4–1.4) 98.16 (3) 0.1608
Any illegal drug 74 (67.2) 2.2 (1.2–4.0) 20.28 (2) 0.0356 1.8 (<1.0–3.5) 106.32 (3) 0.1729
Cannabis 61 (68.6) 2.3 (1.2–4.3) 17.66 (2) 0.0310 2.0 (>1.0–4.0) 106.70 (3) 0.1735
Benzodiazepine 18 (74.8) 1.8 (0.6–5.5) 2.64 (2) 0.0047 1.7 (0.6–5.1) 97.00 (3) 0.1590
Opiates 33 (64.1) 2.1 (0.8–5.6) 8.84 (2) 0.0157 1.8 (0.6–5.5) 100.77 (3) 0.1647
Lifetimei
Any illegal drug 47 (68.1) 2.4 (1.2–4.7) 18.06 (2) 0.0318 2.1 (>1.0–4.4) 107.48 (3) 0.1749
Cannabis 41 (64.5) 2.1 (>1.0–4.4) 11.87 (2) 0.0210 1.8 (0.8–4.1) 102.40 (3) 0.1674
Benzodiazepines 17 (56.1) 3.1 (1.1–8.5) 13.77 (2) 0.0243 2.1 (0.6–6.9) 100.73 (3) 0.1649
Opiates 32 (55.7) 1.5 (0.7–3.1) 6.41 (2) 0.0114 1.3 (0.6–2.9) 98.62 (3) 0.1617
a
Model 1 adjusted for birth cohort.
b
Model 2 adjusted for birth cohort and depression.
c
Weighted percentages.
d
LRC = Model’s likelihood ratio chi-square.
R = Cox–Snell R2 for binary logistic models.
e 2
f
Alcohol use disorder.
g
Heavy episodic drinking.
h
High alcohol consumption.
i
Use of specified substance five times or more during lifetime.

A main strength of this study is its two-stage design. tify young women who fulfilled criteria for AUDs who
Participants are diagnostically well characterized on the had not yet been diagnosed within the health care system.
basis of structured face-to-face interviews carried out by One shortcoming is the cross-sectional nature of the data;
trained clinicians. This approach made it possible to iden- specific time points are lacking for substance exposure

TABLE 4. Associations between different types of substance use and lifetime suicide attempts in 20-year-old women (N = 560)

Model 1a Model 2b

n (%)c OR (95% CI) LRCd (df) R2e OR (95% CI) LRCd (df) R2e

Past year
AUDf 15 (25.3) 4.7 (1.7–13.1) 24.26 (2) 0.0426 3.2 (0.9–11.0) 56.68 (3) 0.0968
HEDg 20 (9.9) 0.7 (0.3–2.0) 2.30 (2) 0.0041 0.6 (0.2–1.7) 47.60 (3) 0.0819
HACh 10 (10.0) 1.3 (0.4–3.7) 1.58 (2) 0.0028 1.2 (0.4–3.9) 44.36 (3) 0.0766
Any illegal drug 12 (8.3) 1.0 (0.5–2.3) 0.91 (2) 0.0016 0.7 (0.3–1.7) 44.72 (3) 0.0771
Cannabis 8 (7.4) 0.9 (0.4–2.1) 1.00 (2) 0.0018 0.7 (0.3–1.7) 45.06 (3) 0.0777
Benzodiazepine 5 (15.0) 6.8 (2.1–22.7) 9.72 (2) 0.0173 6.9 (2.1–22.2) 52.35 (3) 0.0897
Opiates 3 (2.7) 0.4 (0.1–1.6) 3.61 (2) 0.0065 0.2 (0.1–1.3) 49.45 (3) 0.0849
Lifetimei
Any illegal drug 7 (8.2) 2.4 (0.8–6.9) 7.91 (2) 0.0141 1.9 (0.5–6.6) 47.62 (3) 0.0821
Cannabis 6 (8.8) 2.8 (0.9–8.4) 9.76 (2) 0.0174 2.2 (0.6–8.0) 49.12 (3) 0.0846
Benzodiazepines 7 (23.1) 2.1 (0.7–6.1) 3.48 (2) 0.0062 1.2 (0.4–3.8) 43.96 (3) 0.0760
Opiates 4 (6.3) 2.3 (0.8–6.6) 8.55 (2) 0.0153 1.9 (0.6–6.3) 48.30 (3) 0.0832
a
Model 1 adjusted for birth cohort.
b
Model 2 adjusted for birth cohort and depression.
c
Weighted percentages.
d
LRC = Model’s likelihood ratio chi-square.
R = Cox–Snell R2 for binary logistic models.
e 2
f
Alcohol use disorder.
g
Heavy episodic drinking.
h
High alcohol consumption.
i
Use of specified substance five times or more during lifetime.
 SUBSTANCE USE AND SUICIDALITY IN YOUNG WOMEN
TABLE 5. Associations between number of substances used during the past year, and suicidal thoughts and attempts in 20-year-old women
(N = 560). Unweighted numbers and weighted percentages
Suicidal thoughts (past year)
Number of substances n (%)
0 (n = 414) 55 (12.6)
1 (n = 91) 22 (18.2)
2 (n = 44) 15 (38.8)
≥3 (n = 11) 6 (54.6)
Model 1a
ORb (95% CI) 1.9 (1.3–2.6)
LRCc (df) 60.65 (2)
R2d 0.1028
Model 2e
ORb (95% CI) 1.7 (1.2–2.4)
LRCc (df) 92.14 (3)
R2d 0.1520
a
Model 1 adjusted for birth cohort.
b
Odds ratios and 95% confidence intervals (CIs) showing risk associated with each additional substance used during the past year (including
past-year alcohol use disorder).
c
Model’s likelihood ratio chi-square.
d
Cox–Snell R2 for binary logistic models.
e
Model 2 adjusted for birth cohort and depression.
and suicidal behavior. These phenomena may or may
not have coexisted simultaneously. MINI (Sheehan et al.,
1998) does not distinguish between substance-induced
and substance-independent depression. Conclusions
regarding causality cannot be drawn. Another limitation
is that alcohol abuse and dependence are combined into a
single category. This procedure, necessitated by the sam-
ple size, may affect results, as the literature suggests that
associations with suicidal behavior may differ in abuse
and dependence (Wilcox, 2004). Another methodological
consideration is that substance use categories also include
those with occasional substance misuse and those who
used prescription drugs in a nonprescribed manner. It is
difficult to delineate the latter type of behavior from abuse,
especially in the context of a population-based study.
Some persons acquire prescriptions for benzodiazepines
or opiates from several different doctors simultaneously
and others mix legally and illegally acquired substances.
Regarding diagnostics, the lack of information regarding
personality disorders is clearly a limitation. The identi-
fication of women diagnosed with borderline personality
disorder would be particularly relevant in this context, as
both self-harm and substance use are included in criteria
for this disorder. However, personality disorder diagnos-
tics were deemed to be beyond the scope of this study due
to time constraints and difficulties in obtaining reliable
data in the context of a single interview with a nonclinical
sample. Another limitation is the sample size, which
necessitated the merging of data from two birth cohorts
of 20-year-old women. This approach is not optimal as
proportions with suicidal ideation and attempts differed
between the two cohorts. We therefore controlled for birth
cohort in all regression analyses. Further, it should be
1695
Suicidal thoughts (lifetime) Suicide attempts (lifetime)
n (%) n (%)
181 (45.3) 22 (6.8)
58 (62.7) 14 (15.0)
33 (70.9) 4 (6.1)
10 (90.9) 4 (36.4)
1.8 (1.3–2.6) 1.5 (>1.0–2.3)
38.16 (2) 8.54 (2)
0.0659 0.0152
1.6 (1.1–2.3) 1.3 (0.8–2.0)
116.57 (3) 45.88 (3)
0.1879 0.0791
pointed out that these young women were born only five
years apart and resided in the same geographical area.
Major differences in associations between substance use
variables and suicidal behavior would not be expected,
as there were no major societal changes during that short
period that would be expected to affect associations.
Some analyses in the current study yielded large ORs
but CIs were wide. Examples include the observations of
nonsignificant trends despite robust point estimates when
the models for AUD and lifetime suicidal ideation and at-
tempts were adjusted for depression.
Findings
In the current study, one fifth of the 20-year-old women
with AUD reported past-year suicidal thoughts. The pro-
portion was strikingly similar to that previously observed
in an older population sample of adult women aged 25–65
years residing in the same study area (Waern, Spak, &
Sundh, 2002). While the risk of lifetime suicidal thoughts
was increased more than threefold and the risk of lifetime
suicide attempts more than fourfold in the 20-year-olds
with AUD, we could not show an independent associa-
tion after adjustment for depression. This might in part be
attributed to low study power, or may reflect that the as-
sociation between AUD and suicidal ideation is mediated
via depression. It is possible that depressed young women
in the current study were more likely to remember and re-
port lifetime suicidal ideation than those who were not de-
pressed (Goldney, Winefield, Winefield, & Saebel, 2009),
and this might affect results.
Our data do not support the hypothesized association
between risky alcohol consumption patterns and suicidal-
ity. One reason for this might be related to the fact that
1696 M. SUNDIN ET AL.
intensive consumption has increased in Sweden with in-
creasing total consumption (CAN, 2007) and the defini-
tions of HAC and HED employed here may actually de-
fine drinking patterns within the norm rather than deviant
behaviors. As suggested by Rossow et al. (2005), the im-
pact of a specific substance on self-harm might be related
to how marginal or widespread its use is.
Cannabis use was associated with a threefold risk
of past-year suicidal thoughts in these young women.
The association was independent of depression. While
it is difficult to make direct comparisons with studies
employing other categories for frequency of substance
use, we note that Hallfors (2004) reported an almost nine-
fold increase in risk for suicidal ideation in adolescent
boys and girls with frequent marijuana use, and Bovasso
(2001) observed a five-fold risk associated with cannabis
abuse in adults. Borges and colleagues (2000) found that
marijuana use without abuse and dependence was asso-
ciated with a more than two-fold risk of suicide attempts
in 15- to 24-year-old men and women. A recent clinical
study showed that suicidal ideation and behavior were
common among adolescent and young adult patients
with cannabis dependence (Arendt, Sher, Fjordback,
Brandholt, & Munk-Jorgensen, 2007). However, not all
studies point to an association between cannabis and
suicidal behavior (Macleod et al., 2004), and a number
of related factors need to be taken into consideration
(Beautrais, Joyce, & Mulder, 1999). These include both
precursors and consequences of substance use disorder
that are known to be associated with suicidal behavior,
including childhood factors, physical ill-health, comorbid
psychiatric conditions, and interpersonal conflict and
separation. A larger sample size would be required to
tease out the independent contributions of these variables.
In the current study, nonprescription use of benzodi-
azepines was associated with increased risk of suicidal
thoughts and attempts, and these associations were inde-
pendent of depression. Findings concerning suicide at-
tempts pointed in the same direction. Benzodiazepines
might have disinhibiting effects similar to that of alco-
hol (Gillet, Polard, Maudit, & Allain, 2001). Both short-
(Gardner & Cowdry, 1985) and long-acting (Ben-Porath
& Taylor, 2002) benzodiazepines appear to be related
to aggressive behaviors, even in clinically relevant doses
(Berman, Jones, & McCloskey, 2005). There may be po-
tential risks of prescribing benzodiazepines for depressed
patients (Youssef & Rich, 2008).
The risk of suicidal ideation in these young women
doubled for each additional intoxicant used. An associ-
ation was also observed between number of substances
used and lifetime suicide attempt. A “dose–response”
relation between number of substances used and suici-
dal behavior has been demonstrated in a general popu-
lation sample aged 15–54 years even in the absence of
abuse/dependence (Borges et al., 2000). In the current
study, we observed that the association between number
of substances and risk of suicidal ideation was indepen-
dent of depression, which underlines the importance of a
thorough examination of substance use history in young
women who present with self-harm, even in those who do
not appear depressed.
The etiology of suicidal behavior is complex and mul-
tidetermined. Interactions among substance use, depres-
sion, personality disorders, and suicidal behavior are
demonstrated in psychiatric patients (Corbitt, Malone,
Haas, & Mann, 1996). Larger studies would be neces-
sary to elucidate possible interactions in population-based
samples. Recurrent self-destructive behaviors have ad-
dictive characteristics, and the relationship between sub-
stance use and suicidal behavior is probably bidirectional
(Goldston, 2004). It is possible that some individuals may
have a genetic predisposition toward both substance use
and suicidal behavior that is independent of depression.
Behavioral disinhibition appears to be highly heritable
(Young, Stallings, Corley, & Krauter, 2000). Both genetic
and early life experience impact on neurobiological mat-
uration (Tarter, Kirisci, Reynolds, & Mezzich, 2004), and
neurobehavioral disinhibition has a direct effect on both
substance use and suicidal behavior.
Generalizability
The study was conducted in western and central Gothen-
burg, corresponding to the geographical area served by
Sahlgrenska University Hospital. The hospital delivers
both in- and outpatient specialized care to all persons liv-
ing in the uptake area. Thus, study participants identi-
fied with problematic alcohol use could be easily referred
for treatment. According to the Statistical Yearbook for
Gothenburg for the years 1996 and 2001–2002, rates of
morbidity and suicidal behavior in the study area were
similar to those of the city at large, suggesting that results
from our study can be generalized to the city of Gothen-
burg as a whole. Findings might not be representative
for the country as a whole as rates of alcohol consump-
tion, illicit drug use (CAN, 2007), and attempted suicide
(National Prevention of Suicide and Mental Ill-Health,
2010) are higher in young women residing in urban ar-
eas. The study focuses on young adult women only and
results cannot be extrapolated to other age groups or to
males. The literature suggests gender differences regard-
ing alcohol/suicide-related outcomes (Wilcox, 2004), and
the role of depression might be stronger in women than in
men in this age group (Kung et al., 2003).
A stronger association between alcohol consumption
and suicide rates has been observed in countries where
drinking to intoxication is more common, just as there
seems to be a stronger association between alcohol and
violence in these countries (Rossow, 2000). Concerning
consumption of illegal drugs, our results cannot be di-
rectly extrapolated to other settings. Rates of illicit drug
use are relatively low in Sweden in comparison with other
western countries.
Implications for Suicide Prevention
A consultation-liaison psychiatrist in emergency medical
services often meets young women who have attempted
suicide in connection with intake of alcohol, sleeping
 SUBSTANCE USE AND SUICIDALITY IN YOUNG WOMEN 1697

pills (prescribed or not), analgesics, and/or illicit drugs.
Our results underline the need for new strategies to re-
duce suicidal behavior in young women problematic use
of illicit drugs and nonprescription use of sedatives and
analgesics. Social connectedness, confidence in problem-
solving, and an internal locus of control constitute protec-
tive factors1 for serious suicide attempts in young adults
(Donald, Dower, Correa-Velez, & Jones, 2006). Examples
of promising treatments include dialectic behavioral ther-
apy (Linehan et al., 1999), cognitive behavioral treatment
(Esposito-Smythers, Spirito, Uth, & Lachance, 2006), and
motivational interviewing, which can be applied both for
substance use (Miller & Rollnick, 1991) and suicidal be-
havior (Britton, Williams, & Conner, 2008). The latter
treatment approach is well suited to the primary care set-
ting. General practitioners must be prepared to talk about
substance use and suicidality with their young patients,
and also in the absence of a diagnosis of substance use
disorder. Training programs can provide strategies for the
identification and treatment of substance use disorders and
can increase awareness of the need for assessments of
suicidal ideation and past history of attempts, which can
signal future risk of suicidal behavior. Primary preven-
tive techniques such as interventions designed to limit the
availability of substances are also called for.
Declaration of Interest
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the
article.
depresion fuera incluida en el modelo. Limitaciones e im-
plicaciones del estudio relacionadas con la prevención del
suicidio son discutidas. El estudio fue financiado por el
Consejo Nacional de Investigaciones y por el Consejo de
Investigaciones sobre Alcohol en Suecia.
RESUMEN
L’usage de drogues et de comportements suicidaires
chez les jeunes femmes adultes: Une étude de
population
Le lien entre les variables de substances consommées
et les comportements suicidaires a été analysé dans un
échantillon de population urbaine provenant de l’étude
sur les femmes et l’alcooleffectuée à Göteborg (Suède).
Lors de la Phase I, des femmes de 20 ans (n = 2,069)
ont rempli un questionnaire de filtrage. Des entretiens ont
été effectués avec un échantillon stratifié (n = 560). Les
données collectées en 1995 et en 2000 ont été analysées
avec une régression logistique permettant de générer
des ratios inattendus. Après un ajustement correspon-
dant aux dépressions courantes, c’est la consommation de
stupéfiants qui est associée aux pensées suicidaires, et non
la consommation d’alcool à risque. Les limites d’étude
et les implications dans la prévention des suicides y sont
commentées. Cette étude est financée par le Conseil na-
tional suédois pour la recherche scientifique et le Conseil
suédois de recherche sur l’alcoolisme.

THE AUTHORS
RÉSUMÉ
Maud Sundin, MD, is a Senior
Uso de drogas y conductas suicidas en mujeres jóvenes Consultant in psychiatry at
adultas: Un estudio poblacional the Substance Use Clinic at
Sahlgrenska University Hospital
La asociación entre el uso de drogas y conductas suici- in Gothenburg. Her areas of
das fueron analizadas en una muestra poblacional del es- interest include substance use
tudio Mujeres y Alcohol en Gotemburgo, Suecia. En la disorders, liaison psychiatry,
fase I, mujeres de 20 años de edad (n = 2,069) comple- personality disorders, and
taron una encuesta de sondeo. Posteriormente, se procedió suicidal behavior.
a entrevistar una muestra estratificada (n = 560). Los odd
ratios fueron calculados usando regresión logı́stica de la
información, recolectada entre 1995 y 2000. El consumo
de drogas, pero no el consumo de riesgo de alcohol, fue
asociado con tendencias suicidas aún después de que la Fredrik Spak, MD, Ph.D.,
is an Associate Professor at
1
The reader is reminded that the concept of “risk” and “protective” the unit of Social Medicine
factors is often noted in the literature without adequately noting their at the Sahlgrenska Academy,
dimensions (linear, nonlinear), their “demands,” the critical necessary University of Gothenburg.
conditions (endogenously as well as exogenously, from a micro to a His research interests include
macro level), which are necessary for either of these posited processes the epidemiology of alcohol
to operate (begin, continue, become anchored and integrate, change as use disorders, with a special
de facto realities change, cease, etc.) or not to, and whether their under-
focus on women, and the
pinnings are theory driven; empirically based; individual and/or sys-
temic stake holder bound; based upon “principles of faith”; historical
implementation of secondary
observation, precedents, and traditions that accumulate over time; per- prevention programs. He is a
ceptual and judgmental constraints; “transient public opinion”; or what. Senior Consultant in psychiatry
This is necessary to clarify whether these terms are not to remain as yet and social medicine and is
additional shibboleths in a field of many stereotypes. Editor’s note. involved in prevention programs in primary care.
1698 M. SUNDIN ET AL.
Lena Spak, MD, Ph.D.,
is a Child and Adolescent
Psychiatrist at Queen Silvia
Children’s Hospital in
Gothenburg, and a Guest
Teacher and Researcher at
the unit of Social Medicine
at the Sahlgrenska Academy,
University of Gothenburg. Her
research focus is on women
and alcohol, and especially on
the association between early
background factors and later
alcohol abuse and dependence among women.
Valter Sundh, M.Sc., is a Senior
Biostatistician at the Department
of Social Medicine and Public
Health at Sahlgrenska Academy,
University of Gothenburg, with a
special emphasis on longitudinal
population studies.
Margda Waern, MD, Ph.D.,
is a Professor of psychiatry
at the Section for Psychiatry
and Neurochemistry at the
Sahlgrenska Academy,
University of Gothenburg. Her
research focus is on suicidology.
She is also a senior consultant
in psychiatry at Sahlgrenska
University Hospital.
GLOSSARY
Alcohol use disorder (AUD): It comprises the diagnosis
Alcohol Dependence and Alcohol Abuse according to
the DSM-IV definitions.
HAC: It is defined as the average weekly alcohol intake
exceeding 20 glasses per day. The frequency was mea-
sured over the last 30 days.
HED: It is defined as an alcohol intake at “one occasion”
of at least five glasses containing 12 glasses of ethanol
in one day. Frequency was measured over the last
12 months.
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APPENDIX
Use/abuse of illicit drug was defined in our 1995 in-
terview as intake of marijuana/cannabis, cocaine, am-
phetamine, khat, other stimulants, heroin, LSD, ecstasy,
other psychedelic drugs and/or inhalants. In 2000 this def-
inition was extended to GHB and/or anabolic steroids at
least once during the last year. Barbiturates and inhalants
were omitted as specified alternatives but could be added
and specified under the heading “other drugs”. Use/abuse
of cannabis was intake of any cannabinoid preparation
and use/abuse of benzodiazepines, intake of benzodi-
azepines and/or related drugs, zopiclone and zolpidem and
use/abuse of opiates, intake of opiates.
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