European Child & Adolescent Psychiatry

, Volume 21, Issue 8, pp 443–450 | Cite as

Multiple substance use and self-reported suicide attempts by adolescents in 16 European countries

  • Anna KokkeviEmail author
  • Clive Richardson
  • Deborah Olszewski
  • João Matias
  • Karin Monshouwer
  • Thoroddur Bjarnason
Original Contribution


Substance use and suicide attempts are high-risk behaviors in adolescents, with serious impacts on health and well-being. Although multiple substance use among young people has become a common phenomenon, studies of its association with suicide attempts are scarce. The present study examines the association between multiple substance use and self-reported suicide attempts in a large multinational sample of adolescent students in Europe. Data on multiple substance use (tobacco, alcohol, tranquillizers/sedatives, cannabis, other illegal drugs) and self-reported suicide attempts were drawn from the 2007 European School Survey Project on Alcohol and Other Drugs (ESPAD). The ESPAD survey follows a standardized methodology in all participating countries. The present study is based on 45,086 16-year-old adolescents from 16 countries that had used the optional “psychosocial module” of the questionnaire, thereby including the question on suicide attempts. Logistic regression analyses were performed to examine the associations of any self-reported suicide attempt (dependent variable) with substance use controlling for country and gender. The strongest association with self-reported suicide attempts was for any lifetime tranquillizer or sedative use (odds ratio 3.34, 95 % confidence interval 3.00–3.71) followed by any lifetime use of illegal drugs other than cannabis (2.41, 2.14–2.70), 30-day regular tobacco use (2.02, 1.84–2.21), 30-day frequent alcohol use (1.47, 1.32–1.63) and any 30-day cannabis use (1.37, 1.18–1.58). The odds ratio of reporting a suicide attempt approximately doubled for every additional substance used. These findings on the association between multiple substance use, including legal drugs (tranquillizers or sedatives and tobacco), and the life-threatening behavior of suicide attempts provide important cues for shaping prevention policies.


Multiple substance use Suicide attempts Adolescents ESPAD survey 



The preparation of this paper was supported by the Stavros S. Niarchos Foundation (Greece). The authors would like to thank Salme Ahlsrom, Sabrina Molinaro, Valeria Siciliano and André Noor, members of the working group on polydrug use of the EMCDDA. Principal investigators from participating countries were as follows: Artak Mushegyan (Armenia), Alfred Uhl (Austria), Patrick Lambrecht (Belgium/Flanders), Anina Chileva (Bulgaria), Marina Kuzman (Croatia), Kyriakos Veresies (Cyprus), Anna Kokkevi (Greece), Zsuzsanna Elekes (Hungary), Thoroddur Bjarnason (Iceland), Andreea Steriu (Isle of Man), Marcis Trapencieris (Latvia), Silvia Florescu (Romania), Alojz Nociar (Slovak Republic), Eva Stergar (Slovenia), Olga Balakirova (Ukraine). The authors would like to thank them all for providing access to their national ESPAD data.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Bjarnason T, Thorlindsson T (1994) Manifest predictors of past suicide attempts in a population of Icelandic adolescents. Suicide Life Threat Behav 24:350–358PubMedGoogle Scholar
  2. 2.
    Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG (2002) Reliability of the 1999 Youth Risk Behavior Survey questionnaire. J Adolesc Health 31:336–342PubMedCrossRefGoogle Scholar
  3. 3.
    Brent D (2011) Preventing youth suicide: time to ask how. J Am Acad Child Adolesc Psychiatry 50:738–740PubMedCrossRefGoogle Scholar
  4. 4.
    Cavanagh JTO, Carson AJ, Sharpe M, Lawrie SM (2003) Psychological autopsy studies of suicide: a systematic review. Psychol Med 33:395–405PubMedCrossRefGoogle Scholar
  5. 5.
    Dawes MA, Mathias CW, Richard DM, Hill-Kapturczak N, Dougherty DM (2008) Adolescent suicidal behaviour and substance use: developmental mechanisms. Subst Abuse 2:13–28PubMedGoogle Scholar
  6. 6.
    Dishion T, Kavanagh K, Schneiger A et al (2002) Preventing early adolescent substance use: a family-centered strategy for the public middle school. Prev Sci 3:191–201PubMedCrossRefGoogle Scholar
  7. 7.
    Earleywine M, Newcomb MD (1997) Concurrent versus simultaneous polydrug use: prevalence, correlates, discriminant validity, and prospective effects on health outcomes. Exp Clin Psychopharmacol 5:353–364PubMedCrossRefGoogle Scholar
  8. 8.
    Eurostat (2009) Health statistics (causes of death). In: Youth in Europe. A statistical portrait (chap 3). Accessed 10 Dec 2011
  9. 9.
    European Monitoring Centre for Drugs and Drug Addiction (2009) Annual Report 2009. The State of the Drugs Problem in Europe. Publications Office of the European Union, LuxembourgGoogle Scholar
  10. 10.
    European Monitoring Centre for Drugs and Drug Addiction (2009) Polydrug use: patterns and responses. European Monitoring Centre for Drugs and Drug Addiction, LisbonGoogle Scholar
  11. 11.
    Evans J, Middleton N, Gunnell D (2004) Social fragmentation, severe mental illness and suicide. Soc Psychiatry Psychiatr Epidemiol 39:165–170PubMedCrossRefGoogle Scholar
  12. 12.
    Fergusson DM, Boden JM, Horwood LJ (2006) Cannabis use and other illicit drug use: testing the cannabis gateway hypothesis. Addiction 101:556–569PubMedCrossRefGoogle Scholar
  13. 13.
    Fergusson DM, Woodward LJ, Horwood LJ (2000) Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood. Psychol Med 30:23–39PubMedCrossRefGoogle Scholar
  14. 14.
    Fombonne E (1998) Suicidal behaviours in vulnerable adolescents. Time trends and their correlates. Br J Psychiatry 173:154–159PubMedCrossRefGoogle Scholar
  15. 15.
    Gore FM, Bloem PJN, Patton GC, Ferguson J, Joseph V, Coffeg C, Sawger S, Mathers CD (2011) Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet 377:2093–2102PubMedCrossRefGoogle Scholar
  16. 16.
    Gould MS, Greenberg T, Velting DM, Shaffer D (2003) Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 42:386–405PubMedCrossRefGoogle Scholar
  17. 17.
    Haw C, Hawton K (2008) Life problems and deliberate self-harm: associations with gender, age, suicidal intent and psychiatric and personality disorder. J Affect Disord 109:139–148PubMedCrossRefGoogle Scholar
  18. 18.
    Hawton K, Arensman D, Wasserman D, Hultén A, Bille-Brahe U, Bjerke T, Crepet P, Deisenhammer E, Kerkhof A, De Leo D, Michel K, Ostamo A, Philippe A, Querejeta I, Salander-Renberg E, Schmidtke A, Temesváry B (1998) Relation between attempted suicide and suicide rates among young people in Europe. J Epidemiol Community Health 52:191–194PubMedCrossRefGoogle Scholar
  19. 19.
    Hawton K, Appleby L, Platt S, Foster T, Cooper J, Malmberg A, Simkin S (1998) The psychological autopsy approach to studying suicide: a review of methodological issues. J Affect Disord 50:269–276PubMedCrossRefGoogle Scholar
  20. 20.
    Hawton K, van Heeringen K (2009) Suicide. Lancet 373:1372–1381PubMedCrossRefGoogle Scholar
  21. 21.
    Hibell B, Guttormsson U, Ahlström S, Balakireva O, Bjarnason T, Kokkevi A, Kraus L (2009) The 2007 ESPAD report: substance use among students in 35 European countries. The Swedish Council for Information on Alcohol and Other Drugs (CAN), StockholmGoogle Scholar
  22. 22.
    Hooven C, Snedker KA, Thompson EA (2011) Suicide risk at young adulthood: continuities and discontinuities from adolescence. Youth Soc. doi: 10.1177/0044118X11407526.
  23. 23.
    Jessor R, Jessor SL (1977) Problem behaviour and psychosocial development: a longitudinal study of youth. Academic Press, New YorkGoogle Scholar
  24. 24.
    King RA, Schwab-Stone M, Flisher AJ, Greenwald S, Kramer RA, Goodman SH, Lahey BB, Shaffer D, Gould MS (2001) Psychosocial and risk behaviour correlates of youth suicide attempts and suicidal ideation. J Am Acad Child Adolesc Psychiatry 40:837–846PubMedCrossRefGoogle Scholar
  25. 25.
    Kokkevi A, Rotsika V, Arapaki A, Richardson C (2012) Adolescents’ self-reported suicide attempts and their correlates across 17 European countries. J Child Psychol Psychiatry 53:381–389. doi: 10.1111/j1469-7610.2011.02457.x Google Scholar
  26. 26.
    Kokkevi A, Rotsika V, Arapaki A, Richardson C (2011) Changes in associations between psychosocial factors and suicide attempts by adolescents in Greece from 1984 to 2007. Eur J Public Health 21:694–698PubMedCrossRefGoogle Scholar
  27. 27.
    Li C, Pentz MA, Chou C-P (2002) Parental substance use as a modifier of adolescent substance use risk. Addiction 97:1537–1550PubMedCrossRefGoogle Scholar
  28. 28.
    Lynskey MT, Agrawal A, Bucholz KK, Nelson EC, Madden PAF, Todorov AA, Grant JD, Martin NG, Health AC (2006) Subtypes of illicit drug users: a latent class analysis of data from an Australian twin sample. Twin Res Hum Genet 9:523–530PubMedCrossRefGoogle Scholar
  29. 29.
    Mann JJ (2003) Neurobiology of suicidal behaviour. Nat Rev Neurosci 4:819–828PubMedCrossRefGoogle Scholar
  30. 30.
    Mayet A, Legleye S, Chau N, Falissard B (2010) The mediation role of licit drugs in the influence of socializing on cannabis use among adolescents: a quantitative approach. Addict Behav 35:890–895PubMedCrossRefGoogle Scholar
  31. 31.
    Nrugham L, Larsson B, Sund AM (2008) Specific depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence. J Affect Disord 111:83–93PubMedCrossRefGoogle Scholar
  32. 32.
    Olszewski D, Matias J, Monshouwer K, Kokkevi A (2010) Polydrug use among 15- to 16-year olds: similarities and differences in Europe. Drugs Educ Prev Pol 17:287–302CrossRefGoogle Scholar
  33. 33.
    Peter T, Roberts LW, Buzdugan R (2008) Suicidal ideation among Canadian youth: a multivariate analysis. Arch Suicide Res 12:263–275PubMedCrossRefGoogle Scholar
  34. 34.
    Renaud J, Berlim MT, McGirr A, Tousignant M, Turecki G (2008) Current psychiatric morbidity, aggression/impulsivity, and personality dimensions in child and adolescent suicide: a case–control study. J Affect Disord 105:221–228PubMedCrossRefGoogle Scholar
  35. 35.
    Riala K, Hakko H, Rasanen P (2009) Nicotine dependence is associated with suicide attempts and self-mutilation among adolescent females. Compr Psychiatry 50:293–298PubMedCrossRefGoogle Scholar
  36. 36.
    Safer DJ (1997) Self-reported suicide attempts by adolescents. Ann Clin Psychiatry 9:263–269PubMedGoogle Scholar
  37. 37.
    Substance Abuse and Mental Health Services Administration (2002) Substance use and the risk of suicide among youths. National Household Survey on Drug Abuse ReportGoogle Scholar
  38. 38.
    Taliaferro LA, Borowsky IW (2011) Perspective: physician education: a promising strategy to prevent adolescent suicide. Acad Med 86:342–347PubMedCrossRefGoogle Scholar
  39. 39.
    Von Sydow K, Lieb R, Pfister H, Hofler M, Wittchen HU (2002) What predicts incident use of cannabis and progression to abuse and dependence? A 4-year prospective examination of risk factors in a community sample of adolescents and young adults. Drug Alcohol Depend 68:49–64CrossRefGoogle Scholar
  40. 40.
    World Health Organization (2005) Mental health: facing the challenges, building solutions: report from the WHO European Ministerial Conference. World Health Organization, Regional Office for Europe, Copenhagen, p 75Google Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Anna Kokkevi
    • 1
    • 2
    Email author
  • Clive Richardson
    • 3
  • Deborah Olszewski
    • 4
  • João Matias
    • 4
  • Karin Monshouwer
    • 5
    • 6
  • Thoroddur Bjarnason
    • 7
  1. 1.Department of Psychiatry, Medical SchoolAthens UniversityAthensGreece
  2. 2.University Mental Health Research Institute (UMHRI)AthensGreece
  3. 3.Panteion University of Social and Political SciencesAthensGreece
  4. 4.European Monitoring Centre for Drugs and Drug AddictionLisbonPortugal
  5. 5.Department of Interdisciplinary Social ScienceUtrecht UniversityUtrechtThe Netherlands
  6. 6.Trimbos Institute (Netherlands Institute of Mental Health and Addiction)UtrechtThe Netherlands
  7. 7.Department of Social SciencesUniversity of AkureyriAkureyriIceland

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