Suicide is the act of putting an end to one’s life willingly. It is strange to note that in a developed country like the United States, people of all ages and all sexes increasingly resort to suicide. Risk factors for suicide can be based on several categories such as demographics, characteristics and behaviors, life experiences, mental illnesses and psychodynamic formulations. Suicides may sometimes be precipitated due to a lethal combination of these various risk factors. A police officer who is depressed and who has a drinking problem kills himself with his service revolver. This self-destructive event has been precipitated due to 5 risk factors: sex, occupation, depression, alcohol, and gun availability. Research shows that substance abuse can cause self-destructive behaviors in all stages of their use: intoxication, withdrawal, and chronic usage. A person with chronic alcohol and drug use is often forced to counter many losing situations in life either in the domestic realm or in the workplace – and these situations in turn increase their risk of suicide.Statistics and some important findings:Suicide is among the leading causes of death in the United States, ranking 10th to 12th annually, depending on the year (Blow et al, 2004). Numerous studies show that the co-occurrence of substance use disorders and depression heightens suicide risk. There is compelling evidence indicating that adequate prevention and treatment of depression, alcohol and substance abuse can reduce suicide rates. Moreover, school-based interventions involving crisis management, self-esteem enhancement and the development of coping skills and healthy decision making have been demonstrated to reduce the risk of suicide among the youth. Some important facts proven through scientific studies are:· Alcohol abusers have higher rates of both attempted and completed suicide than non-abusers (Lester, 2000).· Twenty to 50 percent of the people who die by suicide have substance abuse problems. Depression is the only psychiatric problem with a more pronounced association with suicide (Murphy, 2000).· Youth who have a recent history of using alcohol or illicit drugs are more likely to be at risk of suicide than other youth. Youth who used any illicit drug other than marijuana were almost three times more likely to be at risk of suicide (Substance Abuse and Mental Health Services Administration, 2003).· Fifteen percent of all alcohol-dependent people die by suicide. This is a loss of 7,000 to 13,000 people every year (Sadock & Sadock, 2002).Alcohol and other drug abuse are often sought as a way of escaping from the daily problems that a person encounters. It may also be related to emotional trauma, psychological stress, and other mental health problems (Merikangas et al., 1998). Such substance abuse causes a deterioration of judgment capacity and leads to impulsive behavior. A person at risk of suicide who might not have made an attempt while sober may do so while intoxicated. Research indicates that alcohol is associated with impulsive suicides, especially those involving firearms (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). This may also be true of other drugs that impair judgment. Age is an additional risk factor in the case of substance abuse. People in middle or late adolescence and the elderly are especially at risk of suicide. Alcohol-involved youth who exhibit signs of impulsiveness or irritability are at higher risk of suicide than other youth (Connor, Meldrum, Wieczorek, Duberstein, & Welte, 2004).Literature review:It has been found through studies that a depressed person commonly becomes acutely suicidal after a few drinks. In a study by Cornelius et al (1996), many of his research subjects reported drinking very heavily of the day of their suicide attempt. The study found that recent heavy alcohol use increases the probability of acting on a suicidal thought but there is no evidence that alcohol induces that suicidal tendency. Another study by Cornelius et al (1998) aimed at finding the link between depressed users of cocaine and suicide. It was found that suicidal ideation was more prevalent in alcoholics who used cocaine. These studies indicate that substance abuse can aggravate existing risk factors like depression and lead to suicide.Apart from alcohol and other intoxicating drugs, it has been found that even prescription drugs can sometimes lead to suicidal tendencies. A February 17, 2005 issue of the BMJ included 3 papers dealing with research on adult antidepressant use and suicidality (Cipriani et al, 2005). The first two papers were based on systematic reviews of data from controlled trials of antidepressants in adults (Fergusson, et al, 2005 and Gunnell, et al, 2005). The third paper reported on a nested case-control study (Martinez, et al, 2005).· Research shows that about 15% of patients with unipolar depression eventually commit suicide. This is attributed to treatment of unipolar disorder with antidepressant drugs such as selective serotonin reuptake inhibitors (SSRIs). Fergusson et al conducted an experimental study in which he studied the effect of SSRIs on patients with depression. Fergusson et al (2005) found that the odds of suicide attempts in users of SSRIs increased double times compared to those treated on placebos and other treatments. However, there was no difference in suicide attempts among users of SSRIs and tricyclic andidepressants.· The Gunnell, et al (2005) found no evidence for an increased risk of completed suicide, a slight chance for self harm behavior among users of SSRIs compared to those on placebos and inconclusive evidence of an increased risk of suicidal thoughts· According to Martinez et al (2005), in comparison with users of tricyclics, users of SSRIs were not at increased risk of suicide or non-fatal self harm. However, in patients aged 18 or less, weak evidence indicated a higher risk of non-fatal self harm in those prescribed SSRIs.The first two studies focused on self harm behavior and suicidal thoughts. However, there was greater access to data in the case of Gunnell et al than Fergusson et al but no patient level data. The study by Martinez et al examined self harm behavior and suicide in adult and pediatric patients with depression who were treated with either an SSRI or TCA. This study is limited by the fact that there was no placebo group for comparison.In March 2004 the U.S. Food and Drug Administration (FDA) warned physicians and patients regarding increased risk of suicide with 10 newer antidepressant drugs. Historically, the link between prescription drugs for depression and suicide was first scientifically explored by Martin Teicher, a psychiatrist from Harvard Medical School, along with several colleagues. In his paper he described 6 adult patients with depression who developed suicidal tendencies as a result of being treated with Prozac (fluoxetine) (Teicher, et al, 1990). This created a great uproar and Lilly, the manufacturer of Prozac, conducted more research on Prozac to ensure its safety. More recently there have been a number of studies looking at US trends in absolute suicide rates in relation to trends in antidepressant prescribing. Grunebaum, et al, 2004 looked at the period 1985 to 1999 and found an overall decrease in the suicide rate of 13.5% at the same time that antidepressant prescribing increased 4-fold, with the increase due mostly to SSRI prescribing. More recently, Milane, et al, 2006 have studied the prescription pattern of fluoxetine and suicide years between the years 1988 and 2002. They have noted a decline in suicide rates since the introduction of this SSRI. They even conclude that about 33,600 lives have been saved by the introduction of fluoxetine into the US market. This is further reaffirmed by Dr. Julio Licinio of the University of Miami: “Our findings certainly suggest that the introduction of SSRIs has contributed to reduction of suicide rates in the United States; ….. Most people who commit suicide suffer from untreated depression” (Reuters, 2006). Though there are varied viewpoints, there needs to be awareness that some antidepressant drugs can cause increase in suicidal thought in some patients.This confusing picture on antidepressants is clarified by a new study in the Archives of General Psychiatry. According to a research based on the medical records of 4,419 Medicaid patients who had been hospitalized for severe depression researchers at the Columbia University, it has been found that use of antidepressants including Wellbutrin, Effexor and SSRIs, such as Prozac, Paxil and Zoloft was significantly linked to suicide and suicide attempts in young patients (Song, 2006). In adults, however, no such link emerged. The study revealed that children and teens aged 6 to 18, who took antidepressants, were 52% more likely to attempt suicide than their peers who weren’t taking medication (Song, 2006). They were also 15 times more likely to succeed in their attempts (Song, 2006). This explains that age is also a vital factor in triggering suicidality and stresses the fact that giving antidepressants to children is a risky act.The availability of drugs to children also contributes to overall suicide rate due to differential action of drugs in children. A little-known hallucinogenic leaf called Salvia that is legal in most of the USA is the target of new calls for a ban after the suicide of a teenager who smoked it (Dorell, 2006). Use of drugs such as LSD can also lead to suicide. Martin H. Keeler in his case report describes the case of a 20 year old college undergraduate who completely disrobed and jumped from a window to his death under the influence of self-administered LSD (Keeler, 1967). When a boy has strong tendencies to self-destruction, they are held in check in the normal state of mind. However, due to intoxication of the mind by LSD, there has been a major disintegration of psychological controls and hence he took the jump from the window.The following statistics have been quoted by Richard McKeon (2005):· 37% of people who die by suicide have measurable blood alcohol at the time of death.· 40% of people who attempt suicide have measurable blood alcohol at the time of death· ~7% of people who are alcohol-dependent will die by suicide.· People who are alcohol-dependent are at higher risk for suicide if they also have depression. 50-75% of people who are alcoholic-dependent and who die by suicide also suffer from depression.· Number of substances used was more predictive of suicidal behavior than the types of substances used. (Analysis of U.S. National Co morbidity Study (1990-2), Borges et al., Am J Epidemiol. 2000). This finding is supported by a study by Tanskanen et al (2004) who have found that clustering of the heavy use of alcohol, cigarettes and coffee leads to increased risk of suicide (Tanskanen et al, 2004).· 27-50% of adolescents who die by suicide have a substance abuse disorder.· Rates of suicidal behavior are increasing among adolescents with substance abuse disorders.· Adolescents who die by suicide are more likely to use a firearm than another method if they have alcohol in their blood at the time of death.· Even those in drug recovery programs remain at risk. For example, persons in opiate dependency programs, especially those with chronic pain, those with the availability of firearms, those using other street drugs, and those new to the program are at particular risk (Thompson, 2006).Conclusion:Thus, we find that substance abuse which is an umbrella term denoting both alcohol and drug abuses can be a crucial factor in suicides. It becomes more dangerous when a substance abuser is there are further compounding factors such as mental depression, young age, and prior history of drinking or drug abuse. Sometimes even unknowingly a person can acquire suicidal tendencies due to medications. Hence, the need of the hour is to develop suicide prevention strategies right from the school stage. Self-esteem, knowledge of the value of life, courage in the face of difficulties and overall positive approach to life should be inculcated in the children. This would lead to a society that is free from the evils of substance abuse.