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Abstract
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In a follow-up study of 1289 alcoholics 6-9 years after treatment, 52 had died by violent means. Suicide and homicide were the leading causes of violent death, with deaths in fires and pedestrian accidents also occurring with some frequency.
VioLit summary:
OBJECTIVE:
The purpose of this research by Combs-Orme et al. was to examine violent deaths among alcoholics some years after they had been released from treatment programs.
METHODOLOGY:
The authors employed a quasi-experimental cross-sectional study with a non-probability sample of 1,289 alcoholics selected from a private psychiatric hospital, from the medical and surgical unit of a private general hospital, from a psychiatric outpatient center and from a public acute-care alcoholism treatment ward, all associated with Washington University Medical School. Individuals with a record of excessive drinking within the previous six months and with at least two symptoms of, or problems caused by, alcohol were included in the study, which examined subjects six to nine years after release from treatment. Mortality data were collected from the Missouri and Illinois Departments of Vital Statistics, as well as from a search for subjects via use of hospital, police and driving records, and contacts with subjects' relatives, friends, neighbors and employers. Causes of death were coded according to the International Classification of Diseases, with circumstances of death being determined via examination of medical examiner or coroner reports on death certificates. Expectations of death rates for each category were calculated with death rates for St. Louis, adjusted for age, sex and race. Analysis included examination of frequencies and estimates of excess mortality ratios (calculated by dividing the number of deaths observed by those expected).
FINDINGS/DISCUSSION:
The authors found that 283 individuals from their sample had died. This mortality rate of 22% was 3.1 times greater than that expected according to the St. Louis death rates. Of these deaths, 52 (18%) involved death by violent means. Ten of the subjects, primarily White males, had committed suicide, accounting for 3.5% of the total number of deaths. This overall rate was 6.5 times that expected. However, when controlling for race, it was found that White suicides were 7.3 times the expected rate, whilst Black suicides were 4.6 times the expected rate. Suicides by women were 13.5 times the St Louis rates, and for men the excess mortality ratio was 5.3. These findings were thought to be consistent with previous studies that had found an increased risk for suicide in alcoholics. The second leading cause of death in this sample was homicide, with 8 deaths accounting for 3.2% of the total deaths. Whilst the excess mortality ratio for the overall sample was 0.8, that for Whites was 3.6 and for Blacks was 0.5. Again, findings were considered to be consistent with previous research showing a relationship between alcohol and homicide. The authors noted that the proportion of violent deaths associated with guns was increasing, with seven of the eight homicides being caused by guns, and only one by stabbing. Seven deaths, five of them females, were caused by fires, representing 2.4% of all deaths in the sample and an overall excess mortality ratio of 26.0. For females, the rate was actually 98.0 times that expected, but for men the ratio was only 9.2 - a finding consistent with others showing that alcoholic women were more likely to suffer fatal or nonfatal injuries in fires. Causes of alcohol-related fires were thought to include smoking, cooking fires and those caused by faulty appliances, and delayed detection of fires due to impaired sensory perception or coordination and judgement. Six fatalities (2.1% of the total) were due to pedestrian accidents, and five to automobile accidents. The greater number of pedestrian deaths than vehicular deaths was in contrast to the numbers in the general population, which indicated a greater number of vehicular than pedestrian deaths. This inconsistency was thought to be due to the lower-class nature of the sample, with fewer people owning cars and more walking. The relationship between alcohol and pedestrian death was considered to be a result of exposure to high risk situations, such as walking around at night, and to poor judgement and coordination because of the intoxication. Four of the five automobile accidents involved single vehicles - a finding consistent with others that indicate that alcoholic are more likely to be involved in single-car accidents than are non-alcoholics. The three accidental falls in the sample constituted 1.0% of the total deaths, with a rate 2.9 times the expected rate. Falls are the second leading cause of accidental death in the United States, with the relationship between alcoholism and accidental falls being explained by a reduction in coordination and judgement. Eight incidents of other accidents were found in the sample, accounting for 2.8% of the total number of deaths. These accidents included poisoning, acute alcohol toxicity and exposure, and findings were consistent with previous studies reporting a high proportion of such accidents to be associated with alcohol. Five cases of death were left with open verdicts, in which the coroner could not determine cause of death. It was thought that this lack of final decision could be due to the lower social class of these individuals, who had been patients of a public alcoholism ward, coupled with a greater likelihood of them being without family, friends or social connections who might have requested more thorough assessment. The authors concluded that violent death is one of the most dramatic outcomes of alcoholism, and is perhaps influenced by the low social class of many alcoholics, combined with stressful and hazardous environments, social isolation and lack of support.
AUTHORS' RECOMMENDATIONS:
As alcohol-related violent death was found to most greatly affect the young, the prevention of alcohol-related mortality from violent causes was advocated. The authors also suggested further study into alcohol-related violent death, to allow for public education about the relationship between the two, and to become a point of consideration in treatment. During treatment, a thorough assessment of the individual's social situation was considered vital, as were the presence of support services and aggressive follow-up. By studying the relationship between alcohol misuse and violence, prevention of all types of alcohol-related violence could be facilitated.
EVALUATION:
The authors present an informative examination of the relationship between alcoholism and violent death. However, the fairly small sample size results in a number of very low figures for particular causes of death, making it difficult to draw conclusions about incident rates. A more thorough discussion of the methodology would have been helpful, as would have a more clear and detailed examination of the findings. Whilst few firm conclusions should be drawn from this work, it seems that the study could be considered as brief and crude basis upon which to build further research into the important relationship between alcohol and violence. (CSPV Abstract - Copyright © 1992-2007 by the Center for the Study and Prevention of Violence, Institute of Behavioral Science, Regents of the University of Colorado)
KW - Missouri
KW - Illinois
KW - Death Rates
KW - Adult Suicide
KW - Adult Victim
KW - Adult Homicide
KW - Suicide Rates
KW - Homicide Rates
KW - Alcohol Use Effects
KW - Racial Differences
KW - Homicide Victim
KW - Victimization Causes
KW - Adult Substance Use
KW - Substance Use Effects
KW - Adult Victim
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