Dose-response relationship between alcohol and suicide

University College London (UCL) requires Adult Psychiatric Morbidity Survey (APMS) data to investigate if there is a dose-response relationship between weekly alcohol consumption and suicidal/self-harm behaviours in the general population.

A link between alcohol misuse and suicidal behaviours is well-established. Alcohol use disorder (AUD) and acute use of alcohol prior to attempt (AUA) are particularly significant risks to suicidal behaviours. There is little research exploring the relationship between alcohol consumption on self-harm and suicidality at a population-level with previous research showing inconsistent results.

The data is being processed in line with EU GDPR Article 6 (1) (e) “for the performance of a task carried out in the public interest” and EU GDPR Article 9 (2) (j) “processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1)”. Approximately 800,000 people die by suicide worldwide each year with approximately 6,000 suicidal deaths in the UK. It is in public interest to conduct research to identify trends and risk factors for suicidal and self-harming behaviours to inform policy and practice and potentially inform interventions for these at-risk groups to lessen the societal burden of suicide and self-harm. Participants have willingly participated in the Adult Psychiatric Morbidity Survey (APMS) knowing their data will be used for research purposes and consenting to this. All APMS 2014 data is pseudonymised, protecting the identities of participants.

The APMS data will achieve the aim as statistical analyses (logistic regression) will be carried out to test the association between alcohol use and self-harm and suicidality. Alcohol use has been collected in APMS using The Alcohol Use Disorder Identification Test (AUDIT) score, this is a 10-item questionnaire measuring harmful alcohol use including specific questions on units of alcohol consumed and drinking days. A weekly measure of alcohol consumption will be created based on the responses to these questions. Total AUDIT scores will also be used to analyse the relationship between alcohol consumption and self-harm & suicidality.

This research will be undertaken as part of a PhD research on alcohol and substance use as a risk factor for suicide and self-harm across the lifespan, funded by the National Institute for Health and Care Research (NIHR) School for Public Health Research. This will be the first in a series of studies unpacking the relationship between alcohol consumption and self-harm/suicidality at a population health level. Depending on the results observed in this study, it is expected that future longitudinal research will be conducted using UK GP records (The Health Improvement Network – THIN / Clinical Practice Research Datalink - CPRD).

The data subjects for this study are UK residents aged over 16 years living in private households who have completed the APMS survey. There is no control group.

The APMS data is a nationally representative sample of the UK general population. Due to the rare outcomes of self-harm/suicidality UCL need a sufficiently large sample to get meaningful results for the research question, so the full 2014 APMS sample is required. Individuals’ responses within APMS are pseudonymised. No linkages are requested at this time. Any intention to link will be subject to a new application with NHS England.

University College London (UCL) are the sole Data Controller who also process data.

Amazon Web Services (AWS) is a processor acting under the instructions of UCL. AWS’ role is limited to secure back-up of data stored in UCL’s Data Safe Haven.

UCL uses offsite data centre services provided by VIRTUS data centre. VIRTUS does not have access to the data.

NIHR School for Public Health Research are funding the PhD project for which this research project is being conducted.

This request is for the APMS 2014 dataset to flow out of NHS England. Some of this relates to health-related data given that some screening questionnaires were used in the conduct of the survey. Once this agreement is active the actual flow of data will be from the UK Data Service (UKDS) who will grant system access to pseudonymised APMS data to the University College London. There are no subsequent flows of data.

Data will be stored and upheld in line with UCL’s Data Protection Policy. It will be marked as highly confidential and only be accessed by the principal research team through the UCL Safe Haven source. The principal research team consist of a PhD student and senior researchers (including professor, senior clinical lecturer). All are substantive employees of UCL.

Amazon Web Services provides cloud hosting services to UCL and will store the data as contracted by UCL.

UCL uses offsite data centre services provided by VIRTUS data centre.

Logistic regression will be carried out on the data for the main statistical analyses. All statistical testing will be conducted using Stata version 16. All files, including coding instructions, will be deleted upon conclusion of this agreement.

All APMS participants data will be included in the research. No linkage to other sources will be conducted. APMS Data are pseudonymised.

There will be no requirement or attempt to re-identify individuals.

The 2014 APMS dataset (English adult population (aged 16 and over) is held on behalf of NHS England by the UK Data Service (UKDS) (www.ukdataservice.ac.uk) and UKDS are responsible for dissemination under direction by NHS England. UCL will get the whole dataset; there is no facility to select individual variables.

UCL will be able to download the dataset from UKDS for the period specific within the data sharing agreement (DSA) and they must securely destroy all local copies of the dataset when the DSA expires and notify the Data Access Request Service (DARS) in line with standard procedures. This 2014 version of the dataset available via DARS has been redacted on Disclosure Control Procedure advice to minimise the likelihood of individuals being able to identify anyone taking part in the survey.

NHS England reminds all organisations party to this agreement of the need to comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract i.e.: employees, agents and contractors of the Data Recipient who may have access to that data).

The dissemination plan for the research paper reporting findings of this APMS analysis was to submit this to an academic peer-reviewed journal specialising in psychiatry/public health, such as the BMJ or Journal of Affective Disorders. This paper was submitted and accepted for publication in BJPsych Open in November 2022. The paper is open access and available to view here: https://www.cambridge.org/core/journals/bjpsych-open/article/alcohol-use-and-its-association-with-suicide-attempt-suicidal-thoughts-and-nonsuicidal-selfharm-in-two-successive-nationally-representative-english-household-samples/A0BDB904D24BBEDFE4320FA16569D671

As this is a core component of the PhD thesis, which has yet to be submitted, The study team will expand in much greater detail on this research study in the draft thesis, and report much more detailed findings. It is possible that the PhD examiners may suggest reanalyses of the data, for which the requirement would be to re-submit within 3 months of the viva exam. For this the study team would need access to the dataset in order to run the new Stata commands and report findings in the edited draft.

The final approved thesis will be uploaded and freely available via http://discovery.ucl.ac.uk/ upon completion of the PhD.

Other aspects of the dissemination plan for this APMS analysis were to present findings at an academic conference for those with an interest in suicide/self-harm/mental health. Results have been presented at four conferences to date:

Public Health Research and Science Conference in May 2021 (https://www.phe-events.org.uk/hpa/frontend/reg/tAgendaWebsite.csp?pageID=411333&eventID=930&mode=)

Society for the Study of Addiction Annual Conference in November 2021 (https://www.addiction-ssa.org/author-publications/alcohol-use-and-its-association-with-suicide-attempt-suicidal-thought-and-self-harm-in-two-successive-nationally-representative-english-household-samples/),

Royal College of Psychiatrists International Congress in June 2022 (https://www.rcpsych.ac.uk/events/congress/programme)

European Psychiatric Association’s Section of Epidemiology & Social Psychiatry Conference in September 2022 (https://www.psychepi.org/congress/wp-content/uploads/sites/2/2022/09/EPA-Section-20th-Congress-Full-Programme-v1.7.pdf).

The study team also plans to submit a poster to the IASR/AFSP conference in October 2023 and for any other relevant conferences.

Given the clinical and public health importance of the study findings, The study team is discussing with the NIHR School for Public Health Research the potential to create a public health resource to inform clinicians and policy makers of the study findings, created on conclusion of the PhD. This will include recommendations for practitioners, policy makers and the public with respect to the improved knowledge of the links between alcohol consumption and self-harm/suicidality. The public resource summarising the outputs and key findings should assist clinicians with the recognition of at-risk individuals and populations so they can be offered the necessary support and appropriate targeted interventions can be designed for these groups. The core research team work clinically in primary and secondary healthcare settings and have direct links with the NIHR School for Public Health Research and The UK Health Security Agency (UKHSA). The study team will work with these organisations to plan the distribution and dissemination of this work to maximise its impact, while being mindful of the sensitive nature of this subject.

Findings of this APMS study have already been disseminated via Twitter with the assistance of UCL Media Relations in preparing a press release for the BJPsych Open paper published in November 2022. The reach of this messaging was amplified through the RCPsych and through voluntary sector organisations such as Samaritans, Addaction and Rethink Mental Illness.

Pending outputs are the PhD thesis (expected submission by end of autumn 2023, with possible corrections after this date before the thesis will be available to the public), and any public health / clinical materials/resources summarising key PhD findings.

APMS low numbers and suppression:

In order to protect patient confidentiality in publications resulting from analysis of APMS data users must:

• guarantee that any outputs made available to anyone other than those with whom this agreement is made, will meet required standards, including the guarantee, methods and standards contained in the Code of Practice for Official Statistics (http://www.statisticsauthority.gov.uk/assessment/code-of-practice/index.html) and the ONS Statistical Disclosure Control (https://gss.civilservice.gov.uk/statistics/methodology-2/statistical-disclosure-control/) for tables produced from surveys;

• apply methods and standards specified in the Microdata Handling and Security Guide to Good Practice (http://www.data-archive.ac.uk/media/132701/UKDA171-SS-MicrodataHandling.pdf) for disclosure control for statistical outputs.

The study results have shed light on the complex relationship between alcohol consumption and self-harm/suicidality and have great potential to inform practice and policy regarding suicide prevention/self-harm management. Alcohol misuse and suicide prevention are two key public health priorities. Quantifying the risk of alcohol use on self-harm and suicidality is in the public interest. Currently the results of this population-based study indicate that there is a relationship between increasing alcohol use and self-harm/suicidality and identify particular at-risk subgroups. This information this will inform health and social care workers on the importance of assessing self-harm/suicide risk among patients who regularly consume alcohol, even if their alcohol use is not traditionally classed as ‘problematic’. However, it is possible that the PhD examiners will identify aspects of the analysis that could be developed further, with specific implications for patients, clinicians, and public health practitioners. The study team would need access to the data in order to respond to their suggestions, both improving the outputs from this study and fulfilling the requirements of the doctoral school in responding to suggested corrections.

Once the project has been finalised through the process of PhD corrections, recommendations to clinicians will include actions relating to the regular assessment of alcohol consumption as an important part of suicide prevention in primary care. This will also be useful information to disseminate to the public in a sensitive manner, to highlight the health risks of alcohol misuse. There is wide public awareness of the guidelines regarding the maximum units of alcohol recommended for men and for women to reduce health risks. However, these focus on physical health, specifically the risks of accidents, injuries, cancer, heart disease, alcohol-related chronic diseases, and increased all-cause mortality. There is a need for population-based research to develop guidelines on safe levels of drinking in relation to mental health. The current study proposes to focus on suicide and self-harm, as a marker of mental distress.

Each death by suicide costs the UK £1.7million in economic losses (Knapp et al, 2011). As this estimate uses 2008 prices, the current cost would be much higher than this. It is estimated that 60 people are affected by each death by suicide (Berman, 2011), and that 10% of those affected will subsequently attempt suicide themselves (Pitman et al, 2016). Due to the detrimental effect of self-harm and suicidality to both the individual and their family, friends and acquaintances, in addition to the economic burden, UCL's research is of public interest. The final outputs of this research will increase understanding of the causes of this personal and economic burden and provide new evidence for public health policy makers.

A public resource summarising the outputs and key findings will be completed toward the conclusion of the PhD in the autumn of 2023 and the results of this specific study will feed into that. This will include recommendations for practitioners, policy makers and the public with respect to the improved knowledge of the links between alcohol consumption and self-harm/suicidality. The public resource summarising the outputs and key finding should assist clinicians with the recognition of at-risk individuals and populations so they can be offered the necessary support and appropriate targeted interventions can be designed for these groups. The core research team work clinically in primary and secondary healthcare settings, and have direct links with the NIHR School for Public Health Research and Public Health England. The research team will work with these organisations to plan the distribution and dissemination of this work to maximise its impact, while being mindful of the sensitive nature of this subject.

Results to date have been presented at the Public Health England conference in May 2022, Society for the Study of Addiction Conference in October 2022, the Royal College of Psychiatrists Conference in June 2023, and the European Psychiatric Association’s Section of Epidemiology & Social Psychiatry Conference in September 2022.

An initial paper has been accepted and published in the BJPsych Open with associated press coverage (https://www.cambridge.org/core/journals/bjpsych-open/article/alcohol-use-and-its-association-with-suicide-attempt-suicidal-thoughts-and-nonsuicidal-selfharm-in-two-successive-nationally-representative-english-household-samples/A0BDB904D24BBEDFE4320FA16569D671).

This project is in support of a PhD research study, which is still ongoing. The study team anticipates the PhD examiners to submit their report in late 2023, following which the study team will need to respond to corrections (potentially including a reanalysis of the APMS data).

Initial findings from this study were published in the BJPsych Open, a peer-reviewed journal in November 2022. This attracted a lot of interest, and the study team will capitalise on in this in further publications arising from this project. The study team anticipates further benefits once the dissemination of this work has been completed. The study team estimates that these will be completed upon conclusion of the PhD project at the end of 2023.