Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2021 Jan 1.
Published in final edited form as: Gen Hosp Psychiatry. 2019 Dec 18;62:79–86. doi: 10.1016/j.genhosppsych.2019.12.002

Short-term Risk of Suicide Attempt Associated with Patterns of Patient-Reported Alcohol Use Determined by Routine AUDIT-C Among Adults Receiving Mental Healthcare

Julie E Richards 1,2, Susan M Shortreed 1, Greg E Simon 1,3, Robert B Penfold 1,2, Joseph E Glass 1, Rebecca Ziebell 1, Emily C Williams 2,4
PMCID: PMC7047881  NIHMSID: NIHMS1547152  PMID: 31874300

Abstract

Objective:

To evaluate the association between alcohol use routinely reported during outpatient mental healthcare visits and short-term risk of subsequent suicide attempt.

Methods:

Using a longitudinal retrospective-cohort design, electronic health records identified adult outpatient visits to a mental health provider (1/1/2010–6/30/2015) at Kaiser Permanente Washington with a documented Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]. Suicide attempts within 90 days of AUDIT-C documentation were defined using death certificate cause-of-death and diagnosis codes (non-lethal). Visit-level analyses used generalized estimating equations to account for correlation between multiple AUDIT-Cs for individuals. Separate models evaluated the association between (1) level of consumption and (2) frequency of heavy drinking episodes and suicide attempts, adjusted for visit year, demographics, depressive symptom, and suicidal ideation.

Results:

Of 59,382 patient visits, 0.62% (N=371) were followed by a suicide attempt within 90 days. Patients reporting high-level alcohol use were 1.77 times (95% CI, 1.22–2.57) more likely to attempt suicide than those reporting low-level use. Patients reporting daily or almost daily heavy drinking episodes were 2.33 times (95% CI, 1.38–3.93) more likely to attempt suicide than those reporting none.

Conclusions and Relevance:

The AUDIT-C is a valuable tool for assessing patterns of patient-reported alcohol use associated with subsequent suicide attempt.

Keywords: Suicide prevention, mental health, AUDIT-C, alcohol use disorder

1. INTRODUCTION

Suicide is the 10th leading cause of death in the U.S. [1], and alcohol use is an important risk factor for suicide attempt. About a quarter of suicide deaths are directly attributable to alcohol [2], which is often used at the time of suicide attempts (both non-lethal and deaths) [3–11]. Alcohol use disorders are strongly associated with suicidal behavior [12–16], especially among people with serious mental illnesses [17–19]. However, prior research on this topic also has limited applicability to suicide prevention in clinical settings because the data were collected retrospectively from coroner reports [9, 20, 21] or self-reported from suicide attempt survivors [5–7, 10, 22, 23]. Such data cannot be used to identify patients at high risk of suicide prior to an attempt.

In response to recommendations from the U.S. Preventive Services Task Force [USPSTF] [24] and initiatives focused on integrating behavioral health in primary care [25], healthcare systems are increasingly implementing population-based screening for unhealthy alcohol use. Screening tools like the Alcohol Use Disorders Identification Test-Consumption [AUDIT-C] assess patterns of alcohol use, such as average consumption and frequency of heavy drinking episodes, that are associated with increased risk for adverse outcomes [26–29]. Prior cross-sectional research among Veterans has identified associations between alcohol consumption reported via AUDIT-C and both suicidal ideation and past attempts [30–32]. It remains unknown, however, whether routine use of screening instruments like the AUDIT-C, can identify patients at higher risk of subsequent suicide attempt [33]. Healthcare settings may also enable opportunities for suicide prevention, because research demonstrates approximately half of individuals who die by suicide visit their healthcare provider in the month prior to suicide death [34, 35]. This may be particularly relevant to mental health providers who often see a population of patients at higher suicide risk than the general population [35, 36].

No prior research has examined the short-term risk of suicide attempt associated with patterns of alcohol use measured using routine alcohol screening in a general population of patients receiving outpatient mental healthcare. Therefore, we evaluated the associations between patterns of alcohol use reported via AUDIT-C at an outpatient mental health visit and risk of documented suicide attempt over the following 90 days.

2. METHODS

2.1. Data Source

The study utilized de-identified electronic health record (EHR), insurance claims, health system enrollment, and state death certificate data from Kaiser Permanente [KP] Washington, a large regional healthcare system serving approximately 700,000 patients. These data included patient sociodemographic information, inpatient and outpatient visit diagnoses [37], as well as the 3-item AUDIT-C [29, 38] routinely used at KP Washington since 2010. The AUDIT-C has been extensively validated as a screen for the spectrum of alcohol use disorders in diverse adult patient populations (age 18+) [28, 29, 38–48]. The KP Washington Institutional Review Board approved this analysis.

2.2. Study Population & Analytic Sample

The analytic sample included all adult patients who: 1) received care from a KP Washington mental health provider between 1/1/2010 and 6/30/2015, 2) had a documented AUDIT-C, and 3) were enrolled for at least 90 days after completing the AUDIT-C (i.e., did not disenroll or die from causes other than suicide) (Figure 1). When patients had multiple recorded AUDIT-Cs, we further limited our sample to only visits with AUDIT-Cs recorded at least 9 months apart, starting with the first observed AUDIT-C. We did this to be consistent with the prior-year timeframe of the AUDIT-C, while maximizing our sample of patient visits, as well as to approximate annual screening practices in large heath systems, like the Veterans Health Administration [VA] and KP Washington, where patient appointments are often not exactly one year apart [26, 49]. Sensitivity analyses (described below) explored the impact of this study design on results.

Figure 1:

Figure 1:

Open in a new tab

Adult Outpatient Mental Health Visits with AUDIT-C Documentation and Outcome Data Availability in the Following 90-days During the Study Period

2.3. Measures

Two patterns of alcohol use were derived from the AUDIT-C based on extensive prior research [50–57]. First, levels of alcohol consumption were measured categorically based on gender-specific AUDIT-C cut-points of the total score (0–12) of the three items—nondrinking: score 0; low-level: score 1–2 or 1–3 (women, men); moderate-level: score 3–7 or 4–7 (women, men), and high-level: score 8–12 (both women and men) [58]. Second, frequency of heavy drinking episodes was measured categorically based on responses to the third AUDIT-C question, which asks how often patients consume six or more drinks on one occasion, with response options: “never,” “less than monthly,” monthly,” “weekly,” and “daily or almost daily” [53, 56].

Our primary outcome—suicide attempts—within 90 days of the index visit were ascertained from state death certificate cause-of-death codes and EHR diagnostic codes. Suicide deaths and non-fatal attempts were combined due to the small number of deaths. We selected 90 days to operationalize the definition of “short-term risk” to maximize the likelihood of observing a suicide attempt soon after a healthcare visit based on prior research [34, 59]. Following common recommendations [60, 61], all deaths with an ICD-10 cause-of-death code of intentional self-harm (X60–X84) or injury/poisoning with undetermined intent (Y10–Y34) were considered probable suicide deaths. Similarly, based on prior research at KP Washington [62], all non-fatal attempts were identified using ICD-9 cause-of-injury codes for intentional self-harm (E950–E958) or undetermined intent (E980–E989). Cause-of-death and cause-of-injury codes of undetermined intent were included, based on a prior chart review study, to increase the probability of ascertaining probable suicide attempts [59].

Covariates included demographic characteristics measured via chart documentation, specifically age (continuous), sex (male/female), and race/ethnicity (white, black, Asian, Hispanic, other, unknown), to control for demographic characteristics known to be differentially associated with alcohol use and suicide attempt [33, 63]. Additionally, we measured depression severity and suicidal ideation—both of which are known to be associated with suicide attempt [59, 64, 65]—using the nine item Patient Health Questionnaire [PHQ-9] [66–68] reported at the same index visit as the AUDIT-C. The PHQ-8 (responses to the first eight questions) is a valid diagnostic and severity measure for depressive disorders in population-based studies [69] and was used as a categorical measure of depressive symptom severity—minimal or no depressive symptoms: score 0–4; mild symptoms: score 5–9; moderate symptoms: score 10–14; moderately severe symptoms: score 15–19; and severe symptoms: score 20–24 [69, 70]. Suicidal ideation was measured categorically using responses to the ninth PHQ-9 question, which asks about “thoughts that you would be better off dead, or of hurting yourself” in the prior two weeks and results in the following responses: “not at all,” “several days,” “more than half the days” and “nearly every day” [64, 65]. Finally, history of mental health and medical comorbidity was measured using ICD-9 diagnostic codes documented in the 0–365 days prior to alcohol screening. Diagnoses for depression, anxiety, or serious mental illness (bipolar, schizophrenia, other psychosis or personality disorders), and suicide attempts were used to control for history of mental health comorbidity. The Charlson comorbidity index, a disease-specific summary measure commonly used in health services research [37, 71], was used to control for history of medical comorbidity associated with mortality. Additionally, an alcohol use disorder diagnosis indicator documented in the 0–365 days prior to screening was used for descriptive purposes but was not considered a potential confounder due to strong correlation with AUDIT-C assessment [39].

2.4. Statistical Analysis

Patient-level descriptive analyses using data from the first visit in study period were conducted to describe patient characteristics and compare the sample to the overall patient population receiving mental healthcare during the study period. Visit-level analyses were conducted to understand the association between patterns of alcohol use measured using the AUDIT-C and subsequent short-term risk of suicide. Specifically, we fit generalized estimating equations [GEE] to evaluate the association between: (1) level of alcohol consumption and (2) frequency of heavy drinking and suicide attempt within the subsequent 90 days [72, 73]. GEE models were used to account for correlation resulting from including multiple visits for individual patients. Four models were fit for each predictor (8 total models); all included an indicator for visit year to account for changes in AUDIT-C administration practices over time and then added covariates in blocks to evaluate how the association between alcohol use and risk changed as we adjusted for more covariates. The first model (Model A) was only adjusted for visit year. The second (Model B) was additionally adjusted for demographic risk factors, to inform clinical care in the scenario when additional information about depression symptom severity and medical history are not available to clinicians at the time of AUDIT-C assessment. The third model (Model C), considered our primary model, was additionally adjusted for depressive symptom severity and frequency of suicidal ideation. This model was considered primary because it best replicates routinely recommended mental healthcare, including assessment of both depression severity and suicidal ideation [68, 74]. The fourth model (Model D) was further adjusted for additional mental health comorbidity and physical comorbidity to replicate the scenario when mental health and medical history are known by providers at the time of alcohol screening. Low-level drinking (not nondrinking) was used as the reference group in models assessing consumption levels because the past-year timeframe of the AUDIT-C does not distinguish lifetime abstinence from ceasing drinking due to alcohol-related problems or illness [75], and prior research has demonstrated a non-linear relationship between levels of alcohol use and mental health [76] and mortality [77, 78]. In models assessing frequency of heavy drinking episodes, report of “never” having a past-year heavy drinking episode was used as the reference group. In all models, standard errors were calculated using the robust sandwich estimator with an independence working correlation structure.

Sensitivity analyses were conducted to examine the impact of assumptions related to including repeated visits for the same person in the analyses and the timing between multiple recorded AUDIT-Cs. Specifically, we repeated all analyses restricted to the first AUDIT-C recorded for each individual during our study years, because prior research had demonstrated answering questions about drinking may alter subsequent self-reported behavior [79]. Secondly, we used all patient visits with AUDIT-Cs available at least 90 days apart (rather than 9 months apart), to maximize the number of index visits observed with a 90-day follow-up window to observe suicide attempt outcomes. All analyses were performed using Stata/MP 15.1 [80].

3. RESULTS

3.1. Patient Characteristics

Our patient sample included 44,106 individuals, and majority were women (63.7%), and white race/ethnicity (77.9%). Based on data from the first visit, the mean age of the sample was 43.3 years (range 18–90, SD=16.7), and the majority had a past-year depressive disorder (71.0%) and/or anxiety disorder (58.4%) (Table 1). At the time of initial visits, most patients reported low-level (38.6%) or moderate-level (34.5%) alcohol consumption and no heavy drinking (65.1%) in the past year (Figure 2). Patients reporting high-level alcohol use were more likely to be male, younger, to report moderate to severe depressive symptoms, to indicate some frequency of thoughts about self-harm on the PHQ-9 ninth question, and to have past-year diagnoses for depression, suicide attempt and/or alcohol use disorder (Table 1). Similar patterns were seen across heavy drinking frequency (Supplement Table S1). Demographic and clinical characteristics among patients eligible for the study were similar to those in the overall patient population who received care from a mental health provider without a documented AUDIT-C (Supplement Table S2).

Table 1:

Characteristics of Adult Mental Health Patients Assessed for Unhealthy Alcohol Use (N=44106), Across Levels of Reported Alcohol Consumption

Level of Alcohol Use Based on Alcohol Use Disorder Identification Test Consumption (AUDIT-C) Scores
Total Sample N=44106 Nondrinking (Score 0) N=9762 Low-Level Alcohol use (Score 1–2 Women, Score 1–3 Men) N=17038 Medium-Level Alcohol use (Score 3–7 Women, Score 4–7 Men) N=15200 High-Level Alcohol use (Score 8–12) N=2106
Age (Mean, SD) 43.3 (16.7) 48.0 (18.3) 44.0 (16.1) 40.1 (15.6) 38.8 (14.2)
Male (N, %) 16028 (36.3%) 3358 (34.4%) 6406 (37.6%) 5051 (33.2%) 1213 (57.6%)
Race/Ethnicity (N, %)
 White, non-Hispanic 34367 (77.9%) 7339 (75.2%) 13272 (77.9%) 12134 (79.8%) 1622 (77.0%)
 Black, non-Hispanic 1983 (4.5%) 499 (5.1%) 760 (4.5%) 609 (4.0%) 115 (5.5%)
 Asian 1965 (4.5%) 591 (6.1%) 766 (4.5%) 548 (3.6%) 60 (2.8%)
 Hispanic 1503 (3.4%) 333 (3.4%) 603 (3.5%) 494 (3.3%) 73 (3.5%)
 Other 2689 (6.1%) 643 (6.6%) 1025 (6.0%) 880 (5.8%) 141 (6.7%)
 Unknown 1599 (3.6%) 357 (3.7%) 612 (3.6%) 535 (3.5%) 95 (4.5%)
*Level of Depressive Symptoms (PHQ-8) (N, %)
 Minimal or None (Score 0–4) 8373 (19.0%) 1841 (18.9%) 3510 (20.6%) 2813 (18.5%) 209 (9.9%)
 Mild (Score 5–9) 11075 (25.1%) 2192 (22.5%) 4473 (26.3%) 4008 (26.4%) 402 (19.1%)
 Moderate (Score 10–14) 10324 (23.4%) 2188 (22.4%) 3914 (23.0%) 3707 (24.4%) 515 (24.5%)
 Moderately Severe (Score 15–19) 8400 (19.0%) 1946 (19.9%) 3044 (17.9%) 2881 (19.0%) 529 (25.1%)
 Severe (Score 20–24) 5290 (12.0%) 1366 (14.0%) 1886 (11.1%) 1621 (10.7%) 417 (19.8%)
*Frequency of Self-Harm Thoughts (PHQ-9 Q9) (N, %)
 Not at all (Score 0) 32220 (73.1%) 6930 (71.0%) 12811 (75.2%) 11257 (74.1%) 1222 (58.0%)
 Several days (Score 1) 7033 (15.9%) 1543 (15.8%) 2555 15.0%) 2436 (16.0%) 499 (23.7%)
 More than half (Score 2) 2348 (5.3%) 560 (5.7%) 814 (4.8%) 791 (5.2%) 183 (8.7%)
 Nearly every day (Score 3) 1821 (4.1%) 494 (5.1%) 629 (3.7%) 535 (3.5%) 163 (7.7%)
Mental Health Diagnoses, Prior Year (N, %)
 Anxiety disorder 25766 (58.4%) 5876 (60.2%) 9793 (57.5%) 8834 (58.1%) 1263 (60.0%)
 Depressive disorder 31294 (71.0%) 6918 (70.9%) 11946 (70.1%) 10785 (71.0%) 1645 (78.1%)
 †Serious mental illness diagnosis 6202 (14.1%) 2008 (20.6%) 2353 (13.8%) 1569 (10.3%) 272 (12.9%)
 Prior suicide attempt 530 (1.2%) 136 (1.4%) 164 (1.0%) 171 (1.1%) 59 (2.8%)
‡Charlson Score 0.5 (1.2) 0.8 (1.5) 0.5 (1.2) 0.3 (0.8) 0.3 (0.9)
Alcohol Use Disorder Diagnosis 1709 (3.9%) 189 (1.9%) 182 (1.1%) 592 (3.9%) 746 (35.4%)
Open in a new tab

Time-varying information defined at the time of the first outpatient mental health visit during the study period.

*

Recorded via self-report on the PHQ-9 about the prior two weeks during same visit as AUDIT-C; PHQ8 score missing for 644 individuals & PHQ-9 Q9 missing for 684 individuals, so columns for these variable do not total 100% across alcohol consumption categories.

†

Diagnosis of bipolar, schizophrenia, other psychosis or personality disorders.

‡

Missing for 2467 individuals without ambulatory or inpatient encounters in which to observe comorbidities during 365 days prior to the first visit.

Figure 2:

Figure 2:

Open in a new tab

Patterns of Patient-Reported Alcohol Use Via AUDIT-C Among Adult Patients Receiving Outpatient Mental Healthcare

3.2. Association Between Patterns of Alcohol Use and Risk of Suicide Attempt

Among all patient visits included in the primary analysis (n=59,382), 371 (0.62%) had a documented suicide attempt (352 non-fatal, 19 deaths) within 90 days (Table 2). Results of all GEE models are presented in Table 2 and described below, with a focus on results from our primary models (Model C).

Table 2:

Counts of suicide attempts observed within 90-days following the index visits with a documented AUDIT-C and PHQ-9 (Primary Model C)

Visits N=59,382 Suicide Attempts N=371
Alcohol Consumption Level† Count N %
 Nondrinking 11632 78 0.67%
 Low-Level 25442 142 0.56%
 Moderate-Level 19873 113 0.57%
 High-Level 2435 38 1.56%
Heavy Episodic Drinking Frequency†† Count N %
 Never 40572 222 0.55%
 Less than monthly 12343 80 0.65%
 Monthly or More 6790 69 1.02%
Open in a new tab
†

AUDIT-C: Nondrinker=score 0; Low-Level= Score 1–2 Women, 1–3 Men; Moderate-Level=Score 3–7 Women, 4–7 Men; High -Level=Score 8–12 Women & Men

††

AUDIT-C Question 3: Never=Score 0, Less than monthly=Score 1, Monthly or More=Score 2–4

Levels of Alcohol Consumption

Levels of alcohol consumption were associated with documentation of a suicide attempt in Models A-C but not D (Results of Global Wald tests, Model A: p<0.0001, Model B: p<0.0001, Model C: p=0.0075, Model D: p= 0.0835). In the primary model (Model C), risk of suicide attempt was increased for those reporting high-level alcohol use (OR 1.77, 95% CI, 1.22–2.57), relative to those reporting low-level alcohol use, but did not differ for those with moderate-level (OR: 0.93, 95% CI 0.72–1.17) or no alcohol use (OR 1.12, 95% CI 0.84–1.49; Model C, Table 2). Results of the other models (Model A, B and D) were similar, though the risk of suicide attempt associated with high-level consumption was stronger in the analyses unadjusted (Model A) and adjusted for demographic characteristics only (Model B) and attenuated when restricted to patients with known prior-year mental health and medical comorbidity (Model D).

Frequency of Heavy Drinking Episodes

Frequency of heavy drinking episodes was also associated with documentation of a suicide attempt in Models A-C but not D (Results of Global Wald tests: Model A: p<0.0001, Model B: p<0.0001, Model C: p=0.0236, Model D: p=0.4430). In the primary model (Model C), risk of suicide attempt was increased for those reporting heavy drinking episodes “daily/almost daily” (OR 2.33, 95% CI 1.38–3.93) relative d to those reporting none. No differences in risk were observed for those reporting heavy drinking episodes “weekly” (OR 1.21, 95% CI, 0.78–1.89) “monthly” (OR 1.09, 95% CI 0.73–1.89) or “less than monthly” (OR 0.94, 95% CI 0.72–1.23) relative to those reporting none. In unadjusted analyses, all levels of heavy drinking frequency of monthly or more were significantly associated with risk of suicide attempt; a frequency of more than monthly remained significant in analyses adjusted for demographic characteristics (Model B); and no level of heavy drinking frequency was significant in the model restricted to patients with known prior year mental health and medical comorbidity (Model D).

Sensitivity Analyses

Both sets of sensitivity analyses (Supplement Tables S3, S4) were similar to main analyses, except that increased risk of suicide attempt among those reporting “daily/almost daily” heavy drinking episodes compared to those reporting none remained significant in Model D, both in the analysis restricted to the first for each patient (OR, 1.96; 95% CI, 1.06–3.62) and in the analysis including all visits for the same person at least 90 days apart (OR, 1.86; 95% CI, 1.08–3.21).

4. DISCUSSION

This large study of adult patients who completed an AUDIT-C during visits with a mental health provider found high levels of self-reported alcohol use documented in the EHR were associated with higher short-term risk of documented suicide attempt. These findings remained significant even after adjustment for multiple factors that predict suicide risk and may also be associated with alcohol use. After adjusting for demographics, depressive symptoms and suicidal ideation, patients reporting high-level alcohol use were 1.77 times more likely to attempt suicide within 90 days than those reporting low-level use. Similarly, patients reporting daily/almost daily heavy drinking episodes were 2.33 times more likely to attempt suicide within 90 days than those reporting no heavy drinking episodes. These results suggest the AUDIT-C is a valuable tool for identifying risk of suicidal behavior, even after assessing depressive symptoms with the PHQ-9, recommended for routine depression monitoring [68] and detection of suicidal ideation [74].

The present study builds on, and extends, prior research studying alcohol use and suicide attempts. The longitudinal design and use of EHR and death certificate data reduce biases present in previous case-control studies [11] or studies that rely on self-reported suicide attempt. This is also the first study to investigate the utility of using the AUDIT-C collected as part of mental healthcare to identify prospective risk of suicide attempt. Moreover, findings from the present study have direct applicability to clinical settings where the AUDIT-C is used routinely, including in the VA [26], the nation’s largest healthcare system, responsible for providing care to a population at high risk of suicide [81, 82].

This study has several limitations. First, the study sample included patients seeking mental healthcare, who had a high rate of suicide attempts and deaths; additional research is needed to extend findings in other settings. Second, KP Washington provides comprehensive care for a population of insured patients; these findings should be confirmed in settings where medical history may be limited. Third, the AUDIT-C asks about alcohol use in the year prior to assessment, which may not accurately capture current alcohol use, particularly because drinking patterns can vary substantially over time [83]. Fourth, reliance on EHR documentation could have resulted in some suicide attempts being missed or misclassified (e.g. for individuals who did not seek care following a suicide attempt). Fifth, PHQ-9 and prior-year diagnoses information were not available on everyone in our sample. We used complete case analyses and no strong differences were observed between those included and excluded from our analyses, but unobserved differences may remain. Lastly, due to small numbers, we did not examine suicide death separately from suicide attempt. Future research in larger populations should consider these outcomes separately, as research has demonstrated that alcohol intoxication may be differentially associated with more lethal suicide methods, particularly firearms [21].

Despite these limitations, this study provides a valuable addition to the literature on alcohol use and suicide risk and findings may be used to augment existing suicide prevention interventions. For example, the Zero Suicide framework, which supports systematic identification of patients at risk of suicide [84] may be enhanced by encouraging healthcare organizations to integrate screening practices for high risk patterns of alcohol use into existing practices used to identify patients with depressive symptoms and suicidal ideation. Alcohol screening information could also be integrated into more complex risk prediction algorithms being developed to identify and intervene with patients at high risk of suicide [62, 85], like the VA where these algorithms are now being deployed to identify veterans at high-risk of suicide and engage them in appropriate care pathways [86]. Moreover, offering patients identified at risk of suicide evidence-based treatment options for unhealthy alcohol use / alcohol use disorders (e.g., repeated brief interventions, pharmacotherapy, psychotherapy) [87–90] may be beneficial for patients reporting high-level alcohol consumption and frequent heavy drinking.

Conclusions

In this large population of adults receiving mental healthcare, high-level alcohol use and heavy drinking more than monthly were associated with significantly increased risk of suicide attempt within 90 days. Findings suggest the AUDIT-C can serve as a screening measure that might enhance healthcare organization practices to systematically identity suicide risk. Future research should examine the effects of integrating routine alcohol use screening and follow-up care for positive screening into care pathways designed to provide high-quality care for patients at-risk of suicide, which some have argued is often a “missed opportunity” in suicide prevention [91].

Supplementary Material

1

Table 3:

Estimated Risk of Suicide Attempt by Reported Level of Alcohol Consumption and Frequency of Heavy Episodic Drinking, within 90 Days of AUDIT-C Assessments at Least 9 Months Apart

A: *Unadjusted Model B: †Additionally Adjusted for Demographics C: ‡Additionally Adjusted for Depressive Symptoms and Thoughts of Self-harm D: Additionally Adjusted for ‡‡Mental Health Diagnoses and Medical Comorbidity
N visits=60,273 (44106 patients) N visits=60,273 (44106 patients) N visits=59,382 (43537 patients) N visits=56,731 (41644 patients)
OR 95% CI p-value OR 95% CI p-value OR 95% CI p-value OR 95% CI p-value
1: Level of Alcohol Consumption**
 Nondrinking 1.25 (0.94–1.65) 0.118 1.32 (1.00–1.74) 0.054 1.12 (0.84–1.49) 0.430 1.02 (0.76–1.37) 0.908
 Low-level ref ref ref Ref
 Moderate-level 1.03 (0.80–1.32) 0.837 0.95 (0.74–1.22) 0.677 0.93 (0.72–1.19) 0.556 0.96 (0.74–1.26) 0.786
 High-level 2.87 (2.00–4.12) <0.001 2.59 (1.80–3.74) <0.001 1.77 (1.22–2.57) 0.002 1.61 (1.08–2.40) 0.018
2: Frequency of Heavy Episodic Drinking
 Never ref ref ref ref
 Less Than Monthly 1.20 (0.93–1.55) 0.171 0.98 (0.75–1.28) 0.879 0.94 (0.72–1.23) 0.670 0.98 (0.74–1.30) 0.892
 Monthly 1.47 (1.00–2.16) 0.049 1.16 (0.78–1.71) 0.47 1.09 (0.73–1.61) 0.681 1.18 (0.78–1.78) 0.446
 Weekly 1.92 (1.25–2.97) 0.003 1.58 (1.02–2.46) 0.042 1.21 (0.78–1.89) 0.392 1.23 (0.77–1.99) 0.389
 Daily or Almost Daily 3.88 (2.32–6.49) <0.001 3.62 (2.16–6.07) <0.001 2.33 (1.38–3.93) 0.002 1.63 (0.90–2.96) 0.108
Open in a new tab

OR=odds ratio

*

All analyses adjusted for assessment year

†

Adjusted for gender, age, race/ethnicity (including unknown category)

‡

Additionally adjusted for depressive symptoms (PHQ-8 score) & suicidal ideation measured (PHQ-9 ninth question)

‡‡

Additionally adjusted for mental health diagnoses recorded in the past year, including depressive disorders, anxiety disorders, serious mental illness (bipolar, schizophrenia, other psychosis or personality disorders), suicide attempt, as well as Charlson comorbidity index score

**

AUDIT-C: Nondrinking=score 0; Low-Level= Score 1–2 Women, 1–3 Men; Moderate-Level=Score 3–7 Women, 4–7 Men; High -Level=Score 8–12 Women & Men

Acknowledgements:

This study was supported by the Kaiser Permanente Washington Health Research Institute, Seattle WA, the National Institute of Mental Health (U19 MH092201), the National Institute on Alcohol Abuse and Alcoholism (K01AA023859) and the United States Department of Veterans Affairs Health Services Research and Development (HSR&D) Program Development Fund Career Development Award (CDA #12-276).

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

REFERENCES

  • [1].Centers for Disease Control & Prevention: National Center for Injury Prevention and Control. Fatal Injury Reports, National, Regional and State, 1981 – 2017, Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA: Centers for Disease Control & Prevention, 2019. [Google Scholar]
  • [2].Centers for Disease Control & Prevention. Alcohol-related disease impact (ARDI). Atlanta, GA: CDC; 2013. [Google Scholar]
  • [3].Cherpitel CJ, Borges GL and Wilcox HC. Acute alcohol use and suicidal behavior: a review of the literature. Alcohol Clin Exp Res 2004;28:18S–28S. [DOI] [PubMed] [Google Scholar]
  • [4].Kaplan MS, Giesbrecht N, Caetano R, Conner KR, Huguet N, McFarland BH, et al. Acute alcohol consumption as a contributing factor to suicidal behavior. Am J Public Health 2013;103:e2–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [5].Bagge CL, Lee HJ, Schumacher JA, Gratz KL, Krull JL and Holloman G, Jr. Alcohol as an acute risk factor for recent suicide attempts: a case-crossover analysis. J Stud Alcohol Drugs 2013;74:552–8. [DOI] [PubMed] [Google Scholar]
  • [6].Borges G, Cherpitel CJ, MacDonald S, Giesbrecht N, Stockwell T and Wilcox HC. A case-crossover study of acute alcohol use and suicide attempt. J Stud Alcohol 2004;65:708–14. [DOI] [PubMed] [Google Scholar]
  • [7].Lejoyeux M, Huet F, Claudon M, Fichelle A, Casalino E and Lequen V. Characteristics of suicide attempts preceded by alcohol consumption. Arch Suicide Res 2008;12:30–8. [DOI] [PubMed] [Google Scholar]
  • [8].Borges G and Loera CR. Alcohol and drug use in suicidal behaviour. Curr Opin Psychiatry 2010;23:195–204. [DOI] [PubMed] [Google Scholar]
  • [9].Caetano R, Kaplan MS, Huguet N, McFarland BH, Conner K, Giesbrecht N, et al. Acute alcohol intoxication and suicide among United States ethnic/racial groups: findings from the national violent death reporting system. Alcohol Clin Exp Res 2013;37:839–46. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [10].Powell KE, Kresnow MJ, Mercy JA, Potter LB, Swann AC, Frankowski RF, et al. Alcohol consumption and nearly lethal suicide attempts. Suicide Life Threat Behav 2001;32:30–41. [DOI] [PubMed] [Google Scholar]
  • [11].Borges G, Bagge CL, Cherpitel CJ, Conner KR, Orozco R and Rossow I. A meta-analysis of acute use of alcohol and the risk of suicide attempt. Psychol Med 2017;47:949–957. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [12].Boenisch S, Bramesfeld A, Mergl R, Havers I, Althaus D, Lehfeld H, et al. The role of alcohol use disorder and alcohol consumption in suicide attempts--a secondary analysis of 1921 suicide attempts. Eur Psychiatry 2010;25:414–20. [DOI] [PubMed] [Google Scholar]
  • [13].Darvishi N, Farhadi M, Haghtalab T and Poorolajal J. Alcohol-related risk of suicidal ideation, suicide attempt, and completed suicide: a meta-analysis. PLoS One 2015;10:e0126870. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [14].Flensborg-Madsen T, Knop J, Mortensen EL, Becker U, Sher L and Gronbaek M. Alcohol use disorders increase the risk of completed suicide--irrespective of other psychiatric disorders. A longitudinal cohort study. Psychiatry Res 2009;167:123–30. [DOI] [PubMed] [Google Scholar]
  • [15].Sung YK, La Flair LN, Mojtabai R, Lee LC, Spivak S and Crum RM. The Association of Alcohol Use Disorders with Suicidal Ideation and Suicide Attempts in a Population-Based Sample with Mood Symptoms. Arch Suicide Res 2016;20:219–32. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [16].Wilcox HC, Conner KR and Caine ED. Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug Alcohol Depend 2004;76 Suppl:S11–9. [DOI] [PubMed] [Google Scholar]
  • [17].Oquendo MA, Currier D, Liu SM, Hasin DS, Grant BF and Blanco C. Increased risk for suicidal behavior in comorbid bipolar disorder and alcohol use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). J Clin Psychiatry 2010;71:902–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [18].Doyle M, While D, Mok PL, Windfuhr K, Ashcroft DM, Kontopantelis E, et al. Suicide risk in primary care patients diagnosed with a personality disorder: a nested case control study. BMC Fam Pract 2016;17:106. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [19].Cassidy RM, Yang F, Kapczinski F and Passos IC. Risk Factors for Suicidality in Patients With Schizophrenia: A Systematic Review, Meta-analysis, and Meta-regression of 96 Studies. Schizophr Bull 2017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [20].Kaplan MS, McFarland BH, Huguet N, Conner K, Caetano R, Giesbrecht N, et al. Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System. Inj Prev 2013;19:38–43. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [21].Conner KR, Huguet N, Caetano R, Giesbrecht N, McFarland BH, Nolte KB, et al. Acute use of alcohol and methods of suicide in a US national sample. Am J Public Health 2014;104:171–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [22].Borges G and Rosovsky H. Suicide attempts and alcohol consumption in an emergency room sample. J Stud Alcohol 1996;57:543–8. [DOI] [PubMed] [Google Scholar]
  • [23].Bryan CJ, Garland EL and Rudd MD. From impulse to action among military personnel hospitalized for suicide risk: alcohol consumption and the reported transition from suicidal thought to behavior. Gen Hosp Psychiatry 2016;41:13–9. [DOI] [PubMed] [Google Scholar]
  • [24].Moyer VA and Preventive Services Task F. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. preventive services task force recommendation statement. Ann Intern Med 2013;159:210–8. [DOI] [PubMed] [Google Scholar]
  • [25].Gerrity M. Evolving Models of Behavioral Health Integration: Evidence Update 2010–2015. Milbank Memorial Fund. 2016. [Google Scholar]
  • [26].Bradley KA, Williams EC, Achtmeyer CE, Volpp B, Collins BJ and Kivlahan DR. Implementation of evidence-based alcohol screening in the Veterans Health Administration. Am J Manag Care 2006;12:597–606. [PubMed] [Google Scholar]
  • [27].Bobb JF, Lee AK, Lapham GT, Oliver M, Ludman E, Achtmeyer C, et al. Evaluation of a Pilot Implementation to Integrate Alcohol-Related Care within Primary Care. Int J Environ Res Public Health 2017;14. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [28].Bradley KA, Bush KR, Epler AJ, Dobie DJ, Davis TM, Sporleder JL, et al. Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med 2003;163:821–9. [DOI] [PubMed] [Google Scholar]
  • [29].Bush K, Kivlahan DR, McDonell MB, Fihn SD and Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998;158:1789–95. [DOI] [PubMed] [Google Scholar]
  • [30].Fuehrlein BS, Mota N, Arias AJ, Trevisan LA, Kachadourian LK, Krystal JH, et al. The burden of alcohol use disorders in US military veterans: results from the National Health and Resilience in Veterans Study. Addiction 2016;111:1786–94. [DOI] [PubMed] [Google Scholar]
  • [31].McCloud A, Barnaby B, Omu N, Drummond C and Aboud A. Relationship between alcohol use disorders and suicidality in a psychiatric population: in-patient prevalence study. Br J Psychiatry 2004;184:439–45. [DOI] [PubMed] [Google Scholar]
  • [32].Smith GW, Shevlin M, Murphy J and Houston JE. An assessment of the demographic and clinical correlates of the dimensions of alcohol use behaviour. Alcohol Alcohol 2010;45:563–72. [DOI] [PubMed] [Google Scholar]
  • [33].Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC and Lee S. Suicide and suicidal behavior. Epidemiol Rev 2008;30:133–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [34].Ahmedani BK, Simon GE, Stewart C, Beck A, Waitzfelder BE, Rossom R, et al. Health care contacts in the year before suicide death. J Gen Intern Med 2014;29:870–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [35].Luoma JB, Martin CE and Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002;159:909–16. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [36].Ribeiro JD, Gutierrez PM, Joiner TE, Kessler RC, Petukhova MV, Sampson NA, et al. Health care contact and suicide risk documentation prior to suicide death: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). J Consult Clin Psychol 2017;85:403–408. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [37].Klabunde CN, Potosky AL, Legler JM and Warren JL. Development of a comorbidity index using physician claims data. J Clin Epidemiol 2000;53:1258–67. [DOI] [PubMed] [Google Scholar]
  • [38].Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D and Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res 2007;31:1208–17. [DOI] [PubMed] [Google Scholar]
  • [39].Dawson DA, Grant BF, Stinson FS and Zhou Y. Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population. Alcohol Clin Exp Res 2005;29:844–54. [DOI] [PubMed] [Google Scholar]
  • [40].Frank D, DeBenedetti AF, Volk RJ, Williams EC, Kivlahan DR and Bradley KA. Effectiveness of the AUDIT-C as a screening test for alcohol misuse in three race/ethnic groups. J Gen Intern Med 2008;23:781–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [41].Aertgeerts B, Buntinx F, Ansoms S and Fevery J. Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population. Br J Gen Pract 2001;51:206–17. [PMC free article] [PubMed] [Google Scholar]
  • [42].Bischof G, Grothues J, Reinhardt S, John U, Meyer C, Ulbricht S, et al. Alcohol screening in general practices using the AUDIT: how many response categories are necessary? Eur Addict Res 2007;13:25–30. [DOI] [PubMed] [Google Scholar]
  • [43].Gomez A, Conde A, Santana JM and Jorrin A. Diagnostic usefulness of brief versions of Alcohol Use Disorders Identification Test (AUDIT) for detecting hazardous drinkers in primary care settings. J Stud Alcohol 2005;66:305–8. [DOI] [PubMed] [Google Scholar]
  • [44].Meneses-Gaya C, Zuardi AW, Loureiro SR, Hallak JE, Trzesniak C, de Azevedo Marques JM, et al. Is the full version of the AUDIT really necessary? Study of the validity and internal construct of its abbreviated versions. Alcohol Clin Exp Res 2010;34:1417–24. [DOI] [PubMed] [Google Scholar]
  • [45].Rumpf HJ, Hapke U, Meyer C and John U. Screening for alcohol use disorders and at-risk drinking in the general population: psychometric performance of three questionnaires. Alcohol Alcohol 2002;37:261–8. [DOI] [PubMed] [Google Scholar]
  • [46].Wu SI, Huang HC, Liu SI, Huang CR, Sun FJ, Chang TY, et al. Validation and comparison of alcohol-screening instruments for identifying hazardous drinking in hospitalized patients in Taiwan. Alcohol Alcohol 2008;43:577–82. [DOI] [PubMed] [Google Scholar]
  • [47].Gual A, Segura L, Contel M, Heather N and Colom J. Audit-3 and audit-4: effectiveness of two short forms of the alcohol use disorders identification test. Alcohol Alcohol 2002;37:591–6. [DOI] [PubMed] [Google Scholar]
  • [48].Khadjesari Z, White IR, McCambridge J, Marston L, Wallace P, Godfrey C, et al. Validation of the AUDIT-C in adults seeking help with their drinking online. Addict Sci Clin Pract 2017;12:2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [49].Glass JE, Bobb JF, Lee AK, Richards JE, Lapham GT, Ludman E, et al. Study protocol: a cluster-randomized trial implementing Sustained Patient-centered Alcohol-related Care (SPARC trial). Implement Sci 2018;13:108. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [50].Chavez LJ, Williams EC, Lapham G and Bradley KA. Association between alcohol screening scores and alcohol-related risks among female veterans affairs patients. J Stud Alcohol Drugs 2012;73:391–400. [DOI] [PubMed] [Google Scholar]
  • [51].Rubinsky AD, Kivlahan DR, Volk RJ, Maynard C and Bradley KA. Estimating risk of alcohol dependence using alcohol screening scores. Drug Alcohol Depend 2010;108:29–36. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [52].Williams EC, Bradley KA, Gupta S and Harris AH. Association between alcohol screening scores and mortality in black, Hispanic, and white male veterans. Alcohol Clin Exp Res 2012;36:2132–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [53].Williams EC, Bryson CL, Sun H, Chew RB, Chew LD, Blough DK, et al. Association between alcohol screening results and hospitalizations for trauma in Veterans Affairs outpatients. Am J Drug Alcohol Abuse 2012;38:73–80. [DOI] [PubMed] [Google Scholar]
  • [54].Williams EC, Peytremann-Bridevaux I, Fan VS, Bryson CL, Blough DK, Kivlahan DR, et al. The association between alcohol screening scores and health status in male veterans. J Addict Med 2010;4:27–37. [DOI] [PubMed] [Google Scholar]
  • [55].Harris AH, Bradley KA, Bowe T, Henderson P and Moos R. Associations between AUDIT-C and mortality vary by age and sex. Popul Health Manag 2010;13:263–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [56].Harris AH, Bryson CL, Sun H, Blough D and Bradley KA. Alcohol screening scores predict risk of subsequent fractures. Subst Use Misuse 2009;44:1055–69. [DOI] [PubMed] [Google Scholar]
  • [57].Bryson CL, Au DH, Sun H, Williams EC, Kivlahan DR and Bradley KA. Alcohol screening scores and medication nonadherence. Ann Intern Med 2008;149:795–804. [DOI] [PubMed] [Google Scholar]
  • [58].Chavez LJ, Liu CF, Tefft N, Hebert PL, Devine B and Bradley KA. The Association Between Unhealthy Alcohol Use and Acute Care Expenditures in the 30 Days Following Hospital Discharge Among Older Veterans Affairs Patients with a Medical Condition. J Behav Health Serv Res 2016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [59].Simon GE, Coleman KJ, Rossom RC, Beck A, Oliver M, Johnson E, et al. Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice. J Clin Psychiatry 2016;77:221–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [60].Bakst SS, Braun T, Zucker I, Amitai Z and Shohat T. The accuracy of suicide statistics: are true suicide deaths misclassified? Soc Psychiatry Psychiatr Epidemiol 2016;51:115–23. [DOI] [PubMed] [Google Scholar]
  • [61].Cox KL, Nock MK, Biggs QM, Bornemann J, Colpe LJ, Dempsey CL, et al. An Examination of Potential Misclassification of Army Suicides: Results from the Army Study to Assess Risk and Resilience in Servicemembers. Suicide Life Threat Behav 2017;47:257–265. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [62].Simon GE, Johnson E, Lawrence JM, Rossom RC, Ahmedani B, Lynch FL, et al. Predicting Suicide Attempts and Suicide Deaths Following Outpatient Visits Using Electronic Health Records. Am J Psychiatry 2018:appiajp201817101167. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [63].Delker E, Brown Q and Hasin DS. Alcohol Consumption in Demographic Subpopulations: An Epidemiologic Overview. Alcohol Res 2016;38:7–15. [PMC free article] [PubMed] [Google Scholar]
  • [64].Simon GE, Rutter CM, Peterson D, Oliver M, Whiteside U, Operskalski B, et al. Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death? Psychiatr Serv 2013;64:1195–202. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [65].Louzon SA, Bossarte R, McCarthy JF and Katz IR. Does Suicidal Ideation as Measured by the PHQ-9 Predict Suicide Among VA Patients? Psychiatr Serv 2016;67:517–22. [DOI] [PubMed] [Google Scholar]
  • [66].Kroenke K, Spitzer RL, Williams JB and Lowe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry 2010;32:345–59. [DOI] [PubMed] [Google Scholar]
  • [67].Siu AL, Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, Ebell M, et al. Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA 2016;315:380–7. [DOI] [PubMed] [Google Scholar]
  • [68].National Committee for Quality Assurance. Depression Screening and Follow-Up for Adolescents and Adults (DSF). HEDIS 2019 Volume 2: Technical Specifications for Health Plans. Washington, DC: National Committee for Quality Assurance, 2018. [Google Scholar]
  • [69].Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT and Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord 2009;114:163–73. [DOI] [PubMed] [Google Scholar]
  • [70].Kroenke K, Spitzer RL and Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [71].Austin SR, Wong YN, Uzzo RG, Beck JR and Egleston BL. Why Summary Comorbidity Measures Such As the Charlson Comorbidity Index and Elixhauser Score Work. Med Care 2015;53:e65–72. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [72].Zeger SL and Liang KY. An overview of methods for the analysis of longitudinal data. Stat Med 1992;11:1825–39. [DOI] [PubMed] [Google Scholar]
  • [73].Zeger SL, Liang KY and Albert PS. Models for longitudinal data: a generalized estimating equation approach. Biometrics 1988;44:1049–60. [PubMed] [Google Scholar]
  • [74].Commission Joint. Detecting and treating suicide ideation in all settings. Sentinel Event Alert 2016;56:1–7. [PubMed] [Google Scholar]
  • [75].Shaper AG, Wannamethee G and Walker M. Alcohol and mortality in British men: explaining the U-shaped curve. Lancet 1988;2:1267–73. [DOI] [PubMed] [Google Scholar]
  • [76].Rodgers B, Korten AE, Jorm AF, Jacomb PA, Christensen H and Henderson AS. Non-linear relationships in associations of depression and anxiety with alcohol use. Psychol Med 2000;30:421–32. [DOI] [PubMed] [Google Scholar]
  • [77].Connor J. The life and times of the J-shaped curve. Alcohol Alcohol 2006;41:583–4. [DOI] [PubMed] [Google Scholar]
  • [78].Kinder LS, Bryson CL, Sun H, Williams EC and Bradley KA. Alcohol screening scores and all-cause mortality in male Veterans Affairs patients. J Stud Alcohol Drugs 2009;70:253–60. [DOI] [PubMed] [Google Scholar]
  • [79].McCambridge J and Kypri K. Can simply answering research questions change behaviour? Systematic review and meta analyses of brief alcohol intervention trials. PLoS One 2011;6:e23748. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [80].StataCorp LLC. Stata/MP 15.0 for Windows. College Station, TX, 2017. [Google Scholar]
  • [81].U.S. Department of Veterans Affairs: Office of Suicide Prevention. Suicide Among Veterans and Other Americans 2001–2014. 2016. [Google Scholar]
  • [82].Nelson HD, Denneson L, Low A, Bauer BW, O’Neil M, Kansagara D, et al. Systematic Review of Suicide Prevention in Veterans. VA ESP Project #05–225 2015. [PubMed] [Google Scholar]
  • [83].Kerr WC, Fillmore KM and Bostrom A. Stability of alcohol consumption over time: evidence from three longitudinal surveys from the United States. J Stud Alcohol 2002;63:325–33. [DOI] [PubMed] [Google Scholar]
  • [84].Brodsky BS, Spruch-Feiner A and Stanley B. The Zero Suicide Model: Applying Evidence-Based Suicide Prevention Practices to Clinical Care. Front Psychiatry 2018;9:33. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [85].Kessler RC, Hwang I, Hoffmire CA, McCarthy JF, Petukhova MV, Rosellini AJ, et al. Developing a practical suicide risk prediction model for targeting high-risk patients in the Veterans health Administration. Int J Methods Psychiatr Res 2017;26. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • [86].U.S. Department of Veterans Affairs. VA REACH VET Initiative Helps Save Veterans Lives: Program Signals When More Help Is Needed for At-risk Veterans. 2017.
  • [87].Holt SR and Tobin DG. Pharmacotherapy for Alcohol Use Disorder. Med Clin North Am 2018;102:653–666. [DOI] [PubMed] [Google Scholar]
  • [88].Campbell EJ, Lawrence AJ and Perry CJ. New steps for treating alcohol use disorder. Psychopharmacology (Berl) 2018;235:1759–1773. [DOI] [PubMed] [Google Scholar]
  • [89].Bischof G, Grothues JM, Reinhardt S, Meyer C, John U and Rumpf HJ. Evaluation of a telephone-based stepped care intervention for alcohol-related disorders: a randomized controlled trial. Drug Alcohol Depend 2008;93:244–51. [DOI] [PubMed] [Google Scholar]
  • [90].Guth S, Lindberg SA, Badger GJ, Thomas CS, Rose GL and Helzer JE. Brief intervention in alcohol-dependent versus nondependent individuals. J Stud Alcohol Drugs 2008;69:243–50. [DOI] [PubMed] [Google Scholar]
  • [91].Kalk NJ, Kelleher MJ, Curtis V and Morley KI. Addressing substance misuse: a missed opportunity in suicide prevention. Addiction 2018. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS1547152-supplement-1.docx (44.2KB, docx)

RESOURCES