Suicide risk among cannabis, heroin and cocaine users

Vol.:(0123456789) International Journal of Mental Health and Addiction https://doi.org/10.1007/s11469-025-01460-y ORIGINAL ARTICLE Suicide Risk Among Cannabis, Heroin andCocaine Users MiguelZacaríasPérezSosa1· Diegode‑la‑Vega‑Sánchez2 · SergioSanz–Gómez3· GlennMelvin4· AnaSánchez–Gómez5· JulioA.Guija6· MariaA.Oquendo7· LucasGiner3 Accepted: 19 February 2025 © The Author(s) 2025 Abstract Individuals who use substances such as cocaine, cannabis, heroin, alcohol and nicotine are at increased risk for suicidal behavior. Our objective is to examine the relationship between substance use and suicide. An observational psychological autopsy study design was used to compare substance use in individuals who died by suicide and individuals who died by other manners. Subjects were recruited at the Medical Forensic Institute of Sevillebetween 2006 and 2018. The total sample was 593 decedents including those who had died by suicide (n = 412) and those who died suddenly from non-suicidal causes (n = 181). We determined the association between substance (cannabis, heroin, cocaine, alcohol and nicotine) use and suicide. We also analyzed the behavioral association between the use of any one of these substances (cannabis, heroin, cocaine, alcohol, and nicotine), as well as the use of more than one substance at a time and manner of death (suicide vs not suicide). We established three categories of substance use: never-used, lifetime users (prior use but not in the past month), and past month users (use within the last month). This study found that decedents who died by suicide were more likely to have substance use compared with those who died by other means. Use of cocaine, cannabis, or heroin within the last month prior to death was associated with increased risk of suicide (X2 = 13.050; df = p = 0.001). Of the substances examined, the strongest association was between past month cocaine use and suicide after adjusting for Axis I and Axis II disorders. Our study supports the relationship between the useof illicit substances and suicide. The use of substances, independent of the type, was associated with a greater risk of suicide. Cocaine use had the strongest association with suicide. Keywords Suicide· Cocaine· Cannabis· Heroin· Alcohol· Tobacco· Psychological autopsy Globally, approximately 800,000 people die by suicide every year (Suicide, 2022). In Spain, the suicide rate in 2020 was 8 suicides/100,000 habitants, compared to 10.25 in the Eurozone (Ministerio de Sanidad. Gobierno de España, 2024). According to the National Institute of Statistics, suicide continues to be the leading cause of violent death, with 3952 deaths in 2023, which is greater than the 1806 individuals who died in motor vehicle accidents (8.17/100.000 and 3.73/100.000 respectively) (INE, 2024). Risk factors for suicide Extended author information available on the last page of the article International Journal of Mental Health and Addiction include older age, male sex, low economic status, physical illness, and previous suicide attempts(Chan etal., 2016; Grunbaum etal., 2000; Hawton & van Heeringen, 2009; Hawton etal., 2013; Nock etal., 2008). However there is also a body of research identifying modifiable risk factors for suicide, including impulsiveness, aggressiveness, mental health disorders, suicidal ideation, and substance use. A comprehensive understanding ofthe relative importance of these suicide risk factors is therefore essential for effective suicide prevention strategies. In Spain, the prevalence of substance use in the past month is as follows: alcohol 63.5%, tobacco 33.9%, cannabis 10.5%, cocaine 1.4%, heroin 0.1% (Observatorio Español de las Drogas y las Adicciones, 2024). When compared to neighbouring countries, Spain is among the top countries for lifetime use of both cannabis (Spain 43.7%, EU 29.9%) and cocaine (Spain 13.3%, EU 5.4%) (Europeo, 2024).While Spain has lower suicide rates compared to other European countries, suicide remains one of the leading causes of unnatural death in the country (in 2023, 3952 suicides were recorded, equivalent to a rate of 8.17 per 100,000 inhabitants) (INE, 2024). Furthermore, although it is estimated that there was an average 20% drop in European suicide rates from 2011 to 2019, Spain was one of the European countries where the figure remained stable (Fico etal., 2023). Consequently, there is a compelling rationale for a detailed and rigorous examination of this situation. The extant literature indicates a clear association between the increased risk of suicidal ideation and suicide and the use of various substances, including heroin (Bohnert etal., 2017; Chen etal., 2010; Icick etal., 2018; Kazour etal., 2016), cocaine (Abdalla etal., 2019; Arias etal., 2016; Bohnert etal., 2017; Icick etal., 2018), and cannabis (Abdalla etal., 2019; Arias etal., 2016; Bohnert etal., 2017; Gobbi etal., 2019; Halladay etal., 2019; Lee etal., 2017). There is robust data supporting the association between substance abuse and an increased risk of suicide, with the exception of psychedelics (Hendricks etal., 2015). Moreover, the recovery process from addiction and dependence has been found to be associated with a reduced risk of suicide (Manhapra etal., 2017). Conversely, the use of legal substances such as alcohol and nicotine has been linked to an elevated risk of suicide, in addition to an increased mortality rate and patients with alcohol abuse have an increased risk of suicide, regardless of comorbidity with other mental disorders (Flensborg-Madsen etal., 2009; Amiri & Behnezhad, 2020). A recent meta-analysis revealed that the risk ratio (RR) for suicide among individuals with alcohol use, relative to non-alcohol users was found to be 1.65 (Amiri & Behnezhad, 2020). Conversely, a 2021 meta-analysis revealed that smokers, both current and past smokers in comparison to non-smokers, exhibited an elevated risk of suicidal behaviour (OR = 1.74; 95% IC 1.541.96) (Echeverria etal., 2021). In addition, the number of different substances used could affect the risk of suicide attempts (Lambert & Bonner, 1996; Landheim etal., 2006). In an epidemiological study of illicit substance use in adolescents, the European School Survey Project on Alcohol and Other Drugs, the risk of attempted suicide nearly doubled with every additional substance taken (Kokkevi etal., 2012). In contrast, to this observation, another study revealed that there was no significant distinction in the risk of suicide attempt between individuals who use a single substance and individuals who use multiple substances (Bakken & Vaglum, 2007). The majority of studies have investigated the association between illicit substance use and suicide attempts, rather than analyzing the relationship between illicit substance use and suicide. While there exist some toxicological studies on suicide, but they have not measured clinical risk factors, such as mental health disorders or prior suicide attempts. (Conner etal., 2017; Darke etal., 2010; Gibbons etal., 2005; Hadidi etal., 2009; Orpana International Journal of Mental Health and Addiction etal., 2021). Psychological autopsy studies offer the advantage of investigating not only the psychological profile of the deceased, but also enabling the identification of substance use, identifying illicit substance use, and can be strengthened by accessing toxicology results. The objective of this study is to analyze the risk of suicide associated with the use of cannabis, heroin, cocaine, alcohol and nicotine by employing a psychological autopsy methodology. We hypothesize that cannabis, heroin, cocaine, alcohol and nicotine use within the last month prior to death is associated with suicide. Methodology This study constitutes a component of an ongoing psychological autopsy project was initiated in 2006 by the Institute of Legal Medicine of Seville. The project involves the invitation of family members of individuals who have died by suicide to participate. The present study’s sample comprised 593 subjects, including 412 consecutive individuals who died by suicide and 181 non-suicide sudden death controls (natural and accidental deaths) from the province of Seville, Spain between 2006 and 2018. The total population of the province of Seville in 2024 was 1,967,746, and the suicide rate for that year was 8.28 for every 100,000 habitants of Seville (Instituto Nacional de Estadística, 2024). a forensic investigation and mandatory autopsy. Deaths occurring in prison or under police custody are excluded from the study. The cases encompassed individuals over the age of 18years residing in the province of Seville who had been certified as having committed suicide, and whose relatives had provided consent for a subsequent interview. The control group comprised individuals over the age of 18years residing in the province of Seville who had been certified as having died suddenly or accidentally (ruling out suicide), and whose relatives had consented to a subsequent interview. Psychological autopsies are a method of obtaining information about the subject through structured interviews of family members, friends, and other individuals with whom the subject had a close relationship (Beskow etal., 1990; Hawton etal., 1998). Following a detailed explanation of the study, all relatives of the deceased who wished to participate in the interview were invited to do so. Of the 1,128 suicides that occurred during the study period, the relatives of 412 (36.5% of the total) agreed to participate. The interviews were conducted 3 to 15months after the subject’s death by psychiatrists (n = 2) and psychologists (n = 2) who had undergone training by the principal investigator (LG). The Structured Clinical Interview for DSM-IV Disorders for Axis I disorder and Axis II disorders (SCIDI and SCID-II) were administered to assess DSM-IV (American Psychiatric Association, 1994) diagnoses of substance related disorders. Interviews were followed by an interdisciplinary investigator meeting involving (LG, DVS) to reach a consensus diagnosis. The study was approved by the ethics committee of the University of Seville and was carried out in accordance with the recommendations of the Declaration of Helsinki. Written informed consent was provided by all participants reporting on the deceased. Measures The SCID-I and SCID-II for DSM-IV structured interviews are diagnostic measures of DSM-IV axis I and II disorders (Williams etal., 1992). The reliability of both interviews has been demonstrated in studies employing psychological autopsy (Kelly & Mann, 1996) and the have been previously utilized by our group (Giner etal., 2013). International Journal of Mental Health and Addiction In the present study, an analysis was conducted on the influence of the use of illegal substances (including cannabis, heroin and cocaine) and legal substances (including alcohol and nicotine) using the substance abuse category of the SCID-I. This category is used to make a diagnosis of abuse in the last twelve months and can specify its presence in the last month. Three categories of use emerged from the SCID-I: no substance abuse in the last 12months, substance abuse in the last 12months, and substance abuse in the last month. The application of these categories enabled the analysis of a gradient of suicide risk according to the pattern of use, and to ascertain whether the lowest risk was for those who had not used in the last 12months, the intermediate risk was for those who had used in the last 12months, and the highest risk was for those who had used in the last month. Furthermore, a bespoke questionnaire was developed in order to analyse each of the three substances in three distinct categories: never users (those who have never used the substance), lifetime users (those who have used the substance in the past but not in the last month) and last month users (those who have used the substance in the previous month). This questionnaire provided substance-specific results over a more extended period of time (lifetime). Statistical Analysis The statistical analysis was conducted using SPSS V26.0. Descriptive statistics were estimated with mean for continuous variables and percentages for categorical variables. Pearson Chi-square (and Fisher´s test if Pearson’s Chi-squared test was not applicable) and t-test were used to compare categorical and continuous variables, respectively. The odds ratios (OR) and 95% confidence intervals were calculated for associations between suicide and categories of substance use (never-users, lifetime users, past month users). To investigate the possibility of a dose–response relationship between substance use and suicide, we employed the Mantel–Haenszel (M2) trend test using the ¡TCOR macro. Lastly, a logistic regression model to control for other variables related to suicide such as the presence of mental disorders (Axis I and Axis II disorders) or the use of the most common substances such as alcohol and tobacco, examined the relationship between substance use (independent variables) and the dependent variable being manner of death (suicide or control). Model 1 included I Axis I and Axis II, while Model II included Axis I, Axis II, alcohol and nicotine in past month. Results There were no significant sociodemographic differences between suicide and control groups (See Table 1) except that those in the control group were more likely to be employed (suicides 14.6%, controls 23.8% χ2 = 6.432 p = 0.040). Those who died by suicide were more likely than controls to have psychiatric follow-up (23.2% Vs 12%, χ2 = 9.355, p = 0.025), to have a mental health disorder (Table2), including both Axis I (85.7% Vs. 60.8%, χ2 = 45.574 p < 0.001) and Axis II disorders (64.1% Vs. 38.9%, χ2 = 32.328 p < 0.001). Similarly, suicide decedents were more likely to have substance abuse of illicit substances (13.1% Vs. 3.3%, χ2 = 13.258, p < 0.001) or dependence (8.7% Vs. 1.1%, χ2 = 12.216 p < 0.001) disorder in the previous month, and alcohol abuse (21.1% Vs. 13.9%, χ2 = 4.266, p = 0.039) or dependence (13.6% Vs. 7.7%, χ2 = 6.333, p = 0.042) in the previous month. International Journal of Mental Health and Addiction Regarding substance use (never-users, lifetime users, past month users), decedents who died by suicide and did or did not use substances in the past month differed on several variables. Compared with the never-users and lifetime users, suicide past month users were: younger (mean age 57.03, 61.413, 45.781, F = 33.274 p < 0.001), more likely to be men Table 1 Sociodemographic variables in suicide and control groups Study groups Suicides N = 412 (69.48%) Control N = 181 (30.52%) Total 593 (100.0%) df Statistics Age Mean 53.769 56.762 54.485 591 t = −1.738 p = 0.083 Sex Male 308 (74.8%) 127 (70.2%) 364 (74.1%) 1χ2 = 1.356 p = 0.244 Female 104 (25.2%) 54 (29.8%) 127 (25.9%) Has a partner Has a partner 196 (47.6%) 87 (48.1%) 235 (47.9%) 1χ2 = 0.012 p = 0.912 Offspring Yes 280 (68.3%) 133 (74.7%) 349 (71.7%) 1χ2 = 2.452 p = 0.117 Living arrangements Alone 74 (18.5%) 29 (16.5%) 82 (17.2%) 1χ2 = 0.326 p = 0.568 Employment status Employed 52 (14.6%) 36 (23.8%) 71 (17.0%) 2χ2 = 6.432 p = 0.040 Not employed with income 229 (64.1%) 85 (56.3%) 256 (61.4%) Not employed without income 76 (21.3%) 30 (19.9%) 90 (21.6%) Table 2 Diagnostic characteristics of suicides and controls * (Cocaine, cannabis, heroin) Suicides N = 412 Controls N = 181 χ2, p Mental health follow-up 82 (23.2%) 14 (12%) 9.355, p = 0.025 Axis I 353 (85.7%) 110 (60.8%) 45.574, p < 0.001 Axis II 261 (64.1%) 70 (38.9%) 32.328, p < 0.001 Lifetime substance* abuse 63 (15.3%) 13 (7.2%) 7.400, p = 0.007 Past month substance* abuse 54 (13.1%) 6 (3.3%) 13.258, p < 0.001 Lifetime substance* dependence 39 (9.5%) 4 (2.2%) 9.845, p = 0.002 Past month substance* dependence 36 (8.7%) 2 (1.1%) 12.216, p < 0.001 Lifetime alcohol abuse 110 (26.7%) 38 (21.0%) 2.185, p = 0.139 Past month alcohol abuse 87 (21.1%) 25 (13.9%) 4.266, p = 0.039 Lifetime alcohol dependence 72 (17.5%) 21 (11.6%) 3.281, p = 0.070 Past month alcohol dependence 56 (13.6%) 14 (7.7%) 6.333, p = 0.042 Lifetime tobacco consumption 293 (71.6%) 116 (64.8%) 2.746, p = 0.098 Past month tobacco consumption 214 (57.8%) 88 (50.9%) 2.231, p = 0.128 International Journal of Mental Health and Addiction (39.4%, 72.5%, 89.6%, χ2 = 65.687 p < 0.001); had fewer children (2.045, 2.213, 1.591, F = 5.374 p = 0.005); and were more likely to hold active labor jobs (12.1%, 4.8%, 25.2%, χ2 = 53.395 p < 0.001). Substance Abuse Compared to controls, subjects who died by suicide were more likely to have been using at least one substance (other than alcohol or nicotine) in the month prior to death (Z = 3.378. (p < 0.001) – see Table 3. Compared with those who never used substances, lifetime users were at no greater risk of suicide (OR = 0.832, 95% CI = 0.322–2.153), but past month users had a nearly four-fold risk of suicide (OR = 4.370, 95% CI = 1.843–10.361). The risk of suicide associated with past month use of any illicit substance was present even after adjusting for the presence of Axis I or II disorders, model I, (OR = 1.446, IC 95% = 1.934–4.588) and the presence of Axis I, Axis II, alcohol and nicotine in past month, model II, (OR = 1.49, IC 95% = 1.006–2.22). Past Month Use ofAny Illicit Substance (Cannabis, Heroin orCocaine) Los datos obtenidos con esta propuesta son muy similares a los obtenidos empelando la SCID-I. Compared to controls, subjects who died by suicide were more likely to have been using at least one substance (other than alcohol or nicotine) in the month prior to death (Z = 3.602, p < 0.001) – see Table3. Compared with those who never used substances, lifetime users were at no greater risk of suicide (OR = 1.762, 95% CI = 0.863–3.598), but past month users had a nearly three-fold risk of suicide (OR = 2.985, 95% CI = 1.553–7.739). The risk of suicide associated with past month use of any illicit substance) was present even after adjusting for the presence of Axis I or II disorders, model I, (OR = 2.010, IC 95% = 1.021–3.959) and the presence of Axis I, Axis II, alcohol and nicotine in past month, model II, (OR = 2.266, IC 95% = 1.103–4.654). Polysubstance Use (Cannabis and/orHeroin and/orCocaine) Past month useof more than one substance (other than alcohol or nicotine) in the month prior to death was only present in 27 suicides (6.55%) and 4 controls (2.21%). There was no difference in likelihood of polysubstance use in the past month between groups (OR = 2.116, 95% CI = 0.704–6.361). Cannabis Relative to controls, suicide decedents were more likely to have used cannabis in the past month (Z = 2.696, p = 0.007). Past users compared to never users were at no greater risk of suicide (OR = 1.821, IC 95% = 0.868–3.819), but past month users were at greater risk (OR = 2.276, IC 95% = 1.138–4.554). Past month use of cannabis was associated with a greater risk of suicide compared to never users and past cannabis users although after adjusting for other variables in model I (1.396, 95% CI = 0.694–2.807) and model II (OR = 1.493, 95% CI = 0.684–3.027) the difference ceased to be significant. International Journal of Mental Health and Addiction Table 3 Substance use in suicides and controls adjusted for presence of Axis I and II disorders df Pearson’s chisquared test* Lineal tendency test (M2) Adjusted model I** OR (95% C.I.) Adjusted model II*** OR (95% C.I.) Suicide Control OR Substance abuse (SCID-I) No substance abuse (12months) 346 168 1 χ2 = 13.408 (P < 0.001) Z = 3.378 (p < 0.001) 1.446 (1.934– 4.588) 1.495 (1.006–2.22) Substance abuse (in the last 12months) 15 7 1.04 (0.416–2.6) Substance abuse in the last month 51 6 4.127 (1.736– 9,809) Any substance (Cannabis or Heroin or Cocaine) Never-User 235 (71.4%) 138 (85.7%) 1 1 χ2 = 13.050 (p = 0.001) Z = 3.602 (p < 0.001) 2.010 (1.021– 3.959) 2.266 (1.103–4.654) Lifetime users 33 (10.0%) 11 (6.8%) 1.762 (0.863– 3.598) Past month users 61 (18.5%) 12 (7.5%) 2.9851 (1.553– 5.739) Cannabis Never-User 239 (75.9%) 136 (86.6%) 1 2 χ2 = 7.573 (p = 0.023) Z = 2.696 (p = 0.007) 1.396 (0.694– 2.807) 1.493 (0.684–3.027) Lifetime users 32 (10.2%) 10 (6.4%) 1.821 (0.868– 3.819) Past month users 44 (14.0%) 11(7.0%) 2.276 (1.138– 4.554) Heroin Never-User 282 (94.0%) 148 (98.0%) 1 2 p = 3.576 (p = 0.165) Z = 1.925 (p = 0.054) 2.411 (0.513– 11.329) 2.640 (0.551– 12.652) Lifetime users 4 (1.3%) 1 (0.7%) 2.099 (0.233– 18.952) Past month users 14 (4.7%) 2 (1.3%) 3.673 (0.824– 16.381) Cocaine Never-User 259 (84.9%) 147 (96.1%) 1 2 p = 13.624 (p = 0.001) Z = 3.489 (p < 0.001) 3.243 (1.096– 9.595) 3.140 (1.041–9.475) Lifetime users 12 (3.9%) 2 (1.3%) 3.405 (0.752– 15.424) Past month users 34 (11.1%) 4 (2.6%) 4.824 (1.679– 13.864) International Journal of Mental Health and Addiction Table 3 (continued) df Pearson’s chisquared test* Lineal tendency test (M2) Adjusted model I** OR (95% C.I.) Adjusted model II*** OR (95% C.I.) Suicide Control OR Alcohol Never-User 88 (22.7%) 41 (23.6%) 1 2 χ2 = 0.146 (p = 0.929) Z = 0.309 (0.757) 1.000 (0.666– 1.502) Lifetime users 35 (9.0%) 17 (9.8%) 0.959 (0.482–1.908) Past month users 264 (68.2%) 116 (66.7%) 1.060 (0.690– 1.630) Nicotine Never-User 113 (30.5%) 58 (33.5%) 12χ2 = 2.816 (p = 0.245) Z = 1.1979 (p = 0.231) 1.024 (0.692– 1.515) Lifetime users 43 (11.6%) 27 (15.6%) 0.817 (0.459– 1.454) Past month users 214 (57.8%) 88 (50.9%) 1.248 (0.835– 1.866) # OR Odds ratio; ^CI Confidence interval, *Fisher´s test if Pearson’s chi-squared Test not applicable **Model I: Axis I and Axis II, ***Model II: Axis I, Axis II, alcohol and nicotine in past month International Journal of Mental Health and Addiction Heroin Those who died by suicide tended to have used heroin in the past month (Z = 1.925, p = 0.054) compared to controls. Risk of suicide in never users did not differ from risk in past heroin users (OR = 2.099, 95% CI = 0.233–18.952). The past month use of heroin was not associated with a greater risk of suicide (OR = 3.673, IC 95% = 0.824–16.381) compared to never users and past heroin users, which did not change when adjusting with model I (OR = 2.411, IC 95% = 0.513–11.329) or II (OR = 2.640, 95% IC = 0.551–12.652). Cocaine Past month cocaine use was more common in suicides relative to controls (Z = 3.489, p < 0.001). Past cocaine users were not more likely to die by suicide relative to never users (OR = 3.405, IC 95% = 0.752–15.424). However, those who used cocaine during the month before death were more likely to have died by suicide (OR = 4.824, IC 95% = 1.679–13.864). Past month use of cocaine was associated with greater risk of suicide, compared to never users and past cocaine users which persisted after adjusting with model I (OR = 3.243, IC 95% = 1.096–9.595) or II (OR = 3.140, 95% IC = 1.041–9.475). Alcohol Past month alcohol use was not more common in suicide deaths relative to controls (Z = 0.309, p < 0.757). Past alcohol users were not more likely to die by suicide relative to never users (OR = 0.959, CI 95% = 0.482–1.908). Past month use of alcohol was not associated with greater risk of suicide (OR = 1.060, CI 95% = 0.690–1.630) compared to never users and past alcohol users, which did not change when adjusting for Axis 1 and 2 disorders (model I) (OR = 1.000, CI 95% = 0.666–1.502). Nicotine Past month nicotine use was not more common in suicides relative to controls (Z = 1.1979, p < 0.231). Past nicotine users were not more likely to die by suicide relative to never users (OR = 0.817, CI 95% = 0.459–1.454). Past month use of nicotine was not associated with a greater risk of suicide (OR = 1.248, CI 95% = 0.835–1.866) compared to never users and past nicotine users, which did not change when adjusting for Axis 1 and 2 (model I) (OR = 1.024, CI 95% = 0.692–1.515). 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Authors and Affiliations MiguelZacaríasPérezSosa1· Diegode‑la‑Vega‑Sánchez2 · SergioSanz–Gómez3· GlennMelvin4· AnaSánchez–Gómez5· JulioA.Guija6· MariaA.Oquendo7· LucasGiner3 * Diego de-la-Vega-Sánchez dv[email protected] 1 Virgen Macarena University Hospital, Seville, Spain 2 Department ofPsychiatry, School ofMedicine, Universidad de Sevilla, Virgen Macarena University Hospital, Seville, Spain 3 Department ofPsychiatry, School ofMedicine, Universidad de Sevilla, Seville, Spain 4 School ofPsychology, Faculty ofHealth, Deakin University, Burwood, Australia 5 Institute ofLegal Medicine ofSevilla, Seville, Spain 6 Institute ofLegal Medicine ofSevilla, Department ofPsychiatry School ofMedicine, Universidad de Sevilla, Seville, Spain 7 Department ofPsychiatry inthePerelman School ofMedicine attheUniversity ofPennsylvania, Philadelphia, PA, USA