Association between alcohol abuse, childhood adverse events and suicide 365
IzvIrnI znAnstvenI člAnek
1 Department of 
Psychology, Faculty 
of Arts, University of 
Ljubljana, Ljubljana
2 Department of 
Psychiatry, Faculty of 
Medicine, University of 
Ljubljana, Ljubljana
3 University Psychiatric 
Hospital Ljubljana, 
Ljubljana
4 Institute of 
Biochemistry, Faculty of 
Medicine, University of 
Ljubljana, Ljubljana
5 Institute of Forensic 
Medicine, Faculty of 
Medicine, University of 
Ljubljana, Ljubljana
Korespondenca/
Correspondence:
tomaž zupanc
t: +386 1 5437235
e: tomaz.zupanc@mf.uni-
lj.si
Ključne besede:
samomorilno vedenje; 
preprečevanje 
samomora; študija 
kontrol in primerov; 
psihološka avtopsija; 
zloraba alkohola; stresni 
dogodki v otroštvu
id 1510PsihiatrijaIzvirni znanstveni članek zdrav vestn | september – oktober 2017 | letnik 86
Association between alcohol abuse, 
childhood adverse events and suicide
Povezava med zlorabo alkohola, stresnimi 
dogodki v otroštvu in samomorom
vida Ana Politakis,1 Peter Pregelj,2,3 Alja videtič Paska,4 tomaž zupanc5
Abstract
Background: Negative life events present a risk for suicidal behaviour. The occurrence of suicidal 
behaviour also depends on type of negative life events, time of their appearance and the support 
person has in their environment, and can be part of a process triggered by a stressful event. The aim 
of the study was to investigate adverse childhood events, parental alcoholism and alcohol abuse in 
association with suicidal behaviour of suicide victims.
Methods: A case-control study was conducted involving 90 individuals from Slovenian population 
who committed suicide and 90 age-sex matched controls drawn from the living population. Data 
were collected by means of semi-structured interviews with key informants by the principles of 
psychological autopsy.
Results: Alcohol abuse was reported more often for suicide victims than for controls. The same was 
true for severe deprivation in childhood and alcoholism of one or both parents. Differences between 
groups in separation from one or both parents, death of one or both parents, reported parental di-
vorce in childhood or sexual abuse in childhood were not observed.
Conclusions: We should conclude that negative events in childhood and alcohol abuse in adulthood 
of suicide victims could be related to suicidal behaviour in population with higher suicide rate. When 
planning measures for the prevention of suicidal behaviour, adverse events in childhood and alco-
hol abuse should not be neglected to plan measures to prevent such events accordingly and to raise 
awareness about the dangers of alcohol abuse for suicidal behavior.
Izvleček
Izhodišča: Negativni življenjski dogodki predstavljajo tveganje za samomorilno vedenje. Pojav sa-
momorilnega vedenja je odvisen od vrste negativnega življenjskega dogodka, časa njegovega pojava 
in podpore, ki jo ima oseba v svojem okolju in je lahko del procesa, ki ga je sprožil stresni dogodek. 
Namen študije je bil raziskati pojav neželenih dogodkov in alkoholizma staršev v otroštvu pri žrtvah 
samomora, zlorabo alkohola med žrtvami ter morebitno povezanost teh dogodkov s pojavom samo-
morilnega vedenja.
Metode: V raziskavo je bilo vključenih 90 žrtev samomora in 90 intervjuvancev iz splošne popula-
cije, ki so bili vključeni kot kontrolna skupina. Med osebami, ki so bile vključene v raziskavo, ni bilo 
razlik v spolu in starosti. Podatki so bili zbrani s pomočjo polstrukturiranih intervjujev po metodi 
psihološke avtopsije.
Rezultati: O zlorabi alkohola so pogosteje poročali pri žrtvah samomora kot v kontrolni skupini. 
Tudi poročanje o hudem pomanjkanju in alkoholizmu enega ali obeh staršev v otroštvu je bilo po-
gostejše v skupini žrtev samomora kot v kontrolni skupini intervjuvancev. Razlik med skupinama v 
366 zdrav vestn | september – oktober 2017 | letnik 86
PsIhIAtrIjA
Key words:
suicidal behaviour; 
suicide prevention; 
case-control study; 
psychological autopsy; 
alcohol abuse; childhood 
adverse events
Citirajte kot/Cite as:
zdrav vestn. 2017;  
86:365–72.
Prispelo: 17. 3. 2016 
sprejeto: 23. 7. 2017
pogostosti ločitve preiskovancev od enega ali od obeh staršev, smrti enega ali obeh staršev, razvezi 
staršev v otroštvu ali razlik v poročanju o spolni zlorabi v otroštvu nismo ugotovili.
Zaključki: Negativni dogodki v otroštvu in zloraba alkohola bi lahko bili povezani s tveganjem za 
samomorilno vedenje v populaciji z enim višjih količnikov samomorilnosti. Pri načrtovanju ukre-
pov za preprečevanja samomorilnega vedenja ne bi smeli spregledati neželenih dogodkov v otroštvu 
pri žrtvah samomora in zlorabe alkohola ter temu primerno načrtovati ukrepe za preprečevanje 
tovrstnih dogodkov in ozaveščanje o nevarnostih zlorabe alkohola za pojav samomorilnega vedenja.
1. Introduction
Negative life events present a risk for 
suicidal behaviour (1). The occurrence of 
suicidal behaviour also depends on type 
of negative life event, time of its appea-
rance and support a person has in his en-
vironment, and can be part of a process 
triggered by a stressful event. Especial-
ly threatening are negative events that 
occur in childhood  (2). An expanding 
body of research suggests that child-
hood trauma and adverse experiences 
can lead to a variety of negative health 
outcomes, including substance abuse, 
depressive disorders, and attempted sui-
cide among adolescents and adults (2-4). 
It was shown that childhood sexual and 
physical abuse are strongly associated 
with suicidal behaviour in adulthood (5).
Studies also reported that children 
living in families with alcohol-abusing 
parents are more likely than other chil-
dren to have an unpredictable dome-
stic situation and to carry a burden of 
secrecy as a result of their attempts to 
hide the alcohol abuse from others. The-
se children also have an increased risk 
of a variety of other adverse childhood 
experiences, including being abused or 
neglected, witnessing domestic violen-
ce, and being exposed to drug-abusing, 
mentally ill, suicidal, or criminal house-
hold members (6-11). A greater risk of al-
cohol abuse, other psychopathology, and 
other medical and social problems have 
also been reported among adult children 
of parents with alcohol dependence than 
among other adults (12-14).
Alcohol dependence and misuse 
have also been reported to be a signi-
ficant risk factors for all types of suici-
dal behaviour  (15,16). In Slovenia, the 
use of alcohol and annual mortality 
due to chronic liver disease are among 
the highest in Europe (17). Slovenia is a 
country with one of the highest suicide 
rates in European Union (21.5/100,000 
per year)  (18). Particularly high rates 
have been reported among older adults 
in Slovenia (18). At least 28 % of people 
that commit suicide in Slovenia have a 
diagnosed mental disorder associated 
with alcohol. Mental disorders associ-
ated with alcoholism are also the best 
predictors for suicide rates in different 
parts of Slovenia  (9). The aim of this 
study was to investigate adverse child-
hood events, parental alcohol abuse and 
alcohol abuse in adulthood of suicide 
victims in association with suicide in a 
population with one of the highest sui-
cide rates. It was hypothesized that the 
majority of included factors would be 
associated with suicidal behaviour and 
would therefore give a clearer picture of 
factors related to suicide risk.
2. Methods
2.1. Participants
A case-control design was used, in-
volving 90 cases (suicide victims) and 90 
age-sex matched living controls selected 
from population (27 female, 63 male, 
Association between alcohol abuse, childhood adverse events and suicide 367
IzvIrnI znAnstvenI člAnek
average age 48.5 years, standard deviati-
on 17.36 years).
Cases were recorded by medical exa-
miners at the Institute of Forensic Me-
dicine, Faculty of Medicine, University 
of Ljubljana, Slovenia, in the years 2001 
to 2004. The next-of-kin of the suicide 
victim was contacted by letter explain-
ing the research, and invited to partici-
pate in the study. In some cases, a more 
appropriate informant was chosen. Of 
212 relatives of suicide victims 90 agreed 
to participate, an overall response rate of 
approximately 42 %. They were all from 
the central part of Slovenia. Participa-
tion was voluntary and informants si-
gned written consent. With them a semi-
-structured interview by the principels 
of psychological autopsy was performed.
Living controls were used since the 
aim was to identify those characteristics 
that differentiate individuals at greater 
risk of suicide from the general popula-
tion. They were matched for age (within 
5 years) and sex and were found among 
relatives of psychology students.
The research was approved by the 
Slovenian Medical Ethics Committee.
2.2. Data collection
Data were collected by means of se-
mi-structured interviews, using a que-
stionnaire designed for psychological 
autopsy that was also used in previous 
studies (20,21) where the data of the first 
group (cases) were gathered. In the con-
trol group, questionnaires were comple-
ted at the University during class time 
under supervision of the researcher, who 
explained each question and guided the 
controls through the questionnaire.
The questions covered sociodemo-
graphic characteristics, family and social 
relationships and conditions (reports of 
adverse events in childhood–separation 
from one or both parents, death of one 
or both parents, parental divorce, paren-
tal alcohol abuse, sexual abuse and seve-
re deprivation) and data about alcohol 
consumption. The data about alcohol 
consumption comprised frequency of 
alcohol consumption per week, the daily 
pattern of alcohol consumption, data 
about unsuccessful efforts to control al-
cohol use and data about problems rela-
ted to alcohol use. The questionnaire was 
not validated. Alcohol use was defined as 
“yes” answer to the question about alco-
Table 1: Demographic variables in the group of suicide victims and the control 
group.
group (%) victims (%)
Nationality
slovenian 94.4 90
other 5.6 10
Marital status
single 24.4 49.4
in combination 75.6 50.6
Number of marriages
none 28.9 35.6
one 62.2 57.8
more than one 8.9 6.6
Place of residence
alone 10.3 16.7
in couple 87.4 78.9
other 2.3 4.4
Eucation
completed Ps* 6.9 32.2
more than completed Ps* 93.1 67.8
Employment
unemployed 3.3 22.2
employed 60 24.4
school child, student or 
solider
13.3 12.2
retired 23.4 41.2
PS: primary school
368 zdrav vestn | september – oktober 2017 | letnik 86
PsIhIAtrIjA
hol use. Alcohol abuse was defined with 
available data on alcohol use in physical-
ly hazardous situations and data on ne-
gative consequences of repeated alcohol 
use. Data about childhood adversities 
were established when “yes” answer was 
given by the reporter about each adverse 
event.
2.3. Data analysis
Analysis was performed with Excel 
2010 (Microsoft), using descriptive stati-
stics and χ2 tests, since the results were 
two unrelated samples with the variables 
on the nominal level.
3. Results
3.1. Nationality, marital status, 
num ber of marriages, place of resi­
dence, education and employment
Table 1 presented some demographic 
variables of the investigated groups. Par-
ticipants’ nationality in both groups was 
mostly Slovenian. There were more sin-
gles and also more unemployed and less 
educated among the victims of suicide 
than in the control group. No significant 
differences were noted in the number of 
marriages and in place of residence at 
the time of suicide or interview.
Statistically significant differences 
between the samples appearing in ma-
rital status (single or in combination) 
(p < 0.001), education (primary edu-
cation, or more than primary school) 
(p < 0.001) and employment (unemplo-
yed, employed, school child, student, or 
soldier and retired) (p < 0.001) (Table 2).
3.2. Use and abuse of alcohol
Statistical analysis using χ2 test 
showed important differences in alcohol 
use (χ2 = 22.603; df = 1; p < 0.001) and 
abuse (χ2 = 24.096; df = 1; p < 0.001) bet-
ween groups of suicide victims and con-
trols, with reported alcohol misuse being 
more frequent in the group of suicide 
victims and reported alcohol use in the 
control group (Figure 1).
3.3. Adverse childhood 
events and sexual abuse
The statistical analysis showed severe 
deprivation in childhood and alcoholism 
of one or both parents as important risk 
factors for suicidal behaviour (p < 0.001). 
The differences between both groups in 
other variables (separation from one or 
both parents, death of one or both pa-
rents, parental divorce, and sexual abuse) 
were not significant (Table 3).
4. Discussion
Our results show that alcohol abuse 
is more frequent in suicide victims than 
in control group in the population with 
high alcohol consumption and suicide 
rates. The results of the present study ge-
Table 2: the results of χ2 test to verify the differences between the group of 
suicide victims and the control group with respect to nationality, marital status, 
number of marriages, living conditions, education and employment variables. 
*p < 0.001.
χ2 df p
nationality 1.239 1 0.266
Marital status 12.01 1 0.001*
0
number of marriages 1.055 2 0.590
Place of residence 2.287 2 0.319
education 17.85 1 0.000*
5
employment 30.49 3 0.000*
6
Note: * p < 0,001
Association between alcohol abuse, childhood adverse events and suicide 369
IzvIrnI znAnstvenI člAnek
Figure 1: Use and abuse 
of alcohol in suicide 
victims and controls. 
**p < 0.001.
nerally support the findings of previous 
research that alcohol abuse is an impor-
tant risk factor for suicidal behaviour, 
as suicide victims abused alcohol more 
often than controls (17). It is also known 
that alcohol-dependent suicide victims 
express more aggressive and impulsive 
behaviour than victims without sub-
stance abuse (22). This observation is in 
accordance with previous reports. It was 
estimated that in Slovenia 11 % of general 
population have evolved alcohol addic-
tion, additionally 13 % of general popu-
lation misuse alcohol and only 14.5 % of 
general population do not consume al-
cohol (23).
The relationship between alcohol 
misuse and suicidal behaviour can be 
conceptualized in a number of different 
ways. It can be examined from a perspec-
tive of biological, psychological or social 
effects, or it can be analysed by the tem-
poral relationship between the use of al-
cohol and the suicidal behaviour. Howe-
Table 3: reported stressful events in childhood of suicide victims and controls.
Suicide victims, 
n = 90; number (%)
Control, n = 90; 
number (%)
χ2 df p
separation from one or 
both parents
28 (31) 22 (24.4) 0.740 1 0.390
Death of one or both 
parents
17 (18.8) 14 (15.6) 0.312 1 0.577
Parental divorce 15 (16.7) 11 (12.2) 0.719 1 0.396
severe deprivation 30 (33.3) 9 (10.0) 12.508 1 0.000**
Alcoholosim of one or 
both parents
41 (45.6) 15 (16.7) 15.273 1 0.000**
sexual abuse 2 (2.2) 0 (0.0) 1.955 1 0.162
Note: ** p < 0,001
0
10
20
30
40
50
60
70
80
90
N
um
be
r 
of
 p
er
so
ns
controls
alcohol use
**
**
alcohol abuse
suicide victims controls suicide victims
370 zdrav vestn | september – oktober 2017 | letnik 86
PsIhIAtrIjA
ver, data about gene polymorphisms 
involved in serotonergic system regula-
tion and suicidal behaviour of persons 
with alcohol abuse are not well under-
stood (19). It seems that genes involved 
in serotonin synthesis regulation could 
be involved in alcohol-related suicide. 
However, for other genetic polymorphi-
sms involved in serotoninergic regulati-
on no association was observed in Slove-
nian population (22).
On the other hand, an indirect rela-
tionship between alcohol misuse and 
suicidal behaviour that is seen mainly 
on interpersonal and social levels can be 
established. Kendall proposed that alco-
hol abuse leads to lowered self-esteem, 
and ultimately increased risk of suicide, 
through a process of negative life events 
(such as marital separation and work 
problems), loss of social networks and 
social isolation (24).
Maltreatment, neglect and other re-
lationship problems may lead to a later 
psychiatric disorder, such as alcohol 
abuse or dependence, through multiple 
pathways, including exposure to further 
trauma, poor educational attainment, 
unemployment, poverty, alcohol and 
drug misuse, and unsatisfactory adult 
relationships  (25). The present study 
showed difference between groups of 
suicide victims and controls in the pre-
sence of severe deprivation and alcoho-
lism of one or both parents, with events 
being higher in the group of suicide 
victims. Previous research indicates that 
the effects of childhood adversity are 
contingent on other risk factors, espe-
cially lack of parental care  (26). It was 
reported that effects of the parent–child 
relationship varied with parental mental 
health  (27). Genetic predisposition to 
mental disorder may outweigh effects of 
exposures such as affectionless control, 
or may be mediated by the latter  (28). 
Conversely, parental alcohol dependen-
ce may be completely confounded by 
poor parenting given the difficulty of 
providing secure, affectionate care when 
suffering from a mental illness  (29). In 
alcohol dependence the genetic compo-
nent also plays an important role and 
on the other hand the child is growing 
up in an environment where alcohol 
and its misuse are constantly present. 
Nevertheless, present study provides 
additional support that parental alcohol 
dependence in childhood and alcohol 
abuse could be important risk factors 
for suicidal behaviour. These observa-
tions are in accordance with previous 
research indicating that suicide victims 
were more often reported to have had 
inadequate family environment and 
abuses (physical and sexual) in their 
childhood (24,30). In the present study, 
differences in the reported sexual abu-
se (in childhood or adulthood) were 
not observed. Also, differences between 
groups regarding separation from one 
or both parents, death of one or both 
parents or reported parental divorce in 
childhood were not observed. However, 
methodological limitations could influ-
ence these results.
5. Limitations
One of the limitations of this study 
was sample size. The total number of 
subjects in the control group was too 
small for a detailed examination of the 
association between suicide and certain 
categories of childhood adverse events. 
For instance, only two case subjects and 
none in the control group were reported 
to be a victim of sexual abuse.
Second, some of the variables used 
in the questionnaire could be more de-
tailed. For instance, the criteria for se-
vere deprivation in childhood were not 
further defined. Also, in determining 
alcohol abuse we encountered limitati-
Association between alcohol abuse, childhood adverse events and suicide 371
IzvIrnI znAnstvenI člAnek
ons. In the questionnaire the data on the 
frequency of alcohol use were obtained, 
but not also on the quantity of alcohol 
consumed. In statistical analysis the li-
mit between still acceptable use of al-
cohol and its abuse was made (three or 
more times per week), but the data for a 
reliable limit were missing.
Third, there are several methodologi-
cal concerns in a case-control psycholo-
gical autopsy study. As in similar studies, 
the use of proxy informants, the retro-
spective data collection, the lack of blin-
ding regarding case and control subjects, 
and the potential impact of bereavement 
and stigma against suicide, mental illness 
and alcohol abuse may have an impact 
on the reliability of the reported data. 
Also, our strategy of scheduling inter-
views with proxy informants for suicide 
victims 3 to 6 months after suicide clear-
ly differed from our strategy with infor-
mants for living control subjects and co-
uld increase the risk of recall bias. This is 
also a major challenge in other psycho-
logical autopsy studies of suicide (31,32).
Lastly, the chosen methodology, a way 
of choice of the control group, may af-
fect the results of the study. The obser-
ved differences between groups could be 
associated with different demographic 
characteristics of the groups. Namely, 
the subjects are the relatives of psycho-
logy students, which may in terms of the 
sociodemographic parameters depart 
from the general population.
Because different groups of intervi-
ewers were working on data collection 
separately at various research sites for 
a period of time, the reliability of data 
across investigators, time, and location 
was a challenge. However, the data col-
lected in this study are very likely relia-
ble because of the efforts we put into the 
training of all interviewers. Nevertheless, 
the interrater reliability, validation of the 
questionnaire and correction for multi-
ple comparisons were not performed. Be-
cause of many limitations, the reported 
data should be interpreted with caution.
6. Conclusions
Our study found a significant diffe-
rence in alcohol abuse between suicide 
victims and controls, and pointed out 
alcohol misuse as an important factor 
associated with suicidal behaviour. Also, 
severe deprivation in childhood and al-
coholism of one or both parents seem 
to be important predictors for suicidal 
behaviour in a population with high su-
icide rate. Further studies are needed to 
investigate the influence of negative life 
events on alcohol abuse and suicidal be-
haviour. However, in prevention of sui-
cidal behaviour adverse events in child-
hood and alcohol abuse should not be 
overlooked.
References
1. Nrugham L, Holen A, Sund AM. Associations bet-
ween attempted suicide, violent life events, depres-
sive symptoms, and resilience in adolescents and 
young adults. J Nerv Ment Dis. 2010;198(2):131–6.
2. Blaauw E, Arensman E, Kraaij V, Winkel FW, Bout 
R. Traumatic life events and suicide risk among 
jail inmates: the influence of types of events, time 
period and significant others. J Trauma Stress. 
2002;15(1):9–16.
3. Dube SR, Anda RF, Felitti VJ, Chapman DP, Wil-
liamson DF, Giles WH. Childhood abuse, house-
hold dysfunction, and the risk of attempted sui-
cide throughout the life span: findings from the 
Adverse Childhood Experiences Study. JAMA. 
2001;286(24):3089–96.
4. Anda RF, Whitfield CL, Felitti VJ, Chapman D, 
Edwards VJ, Dube SR, et al. Adverse Childhood 
Experiences, Alcoholic Parents, and Later Risk 
of Alcoholism and Depression. Psychiatr Serv. 
2002;53(8):1001–9.
5. Martin G, Bergen H, Richardson A, Roeger L in 
Allison S. Sexual abuse and suicidality: gender 
differences in a large community sample of adole-
scents. Child Abuse Negl. 2004;28(5):491–503.
6. Felitti VJ, Anda RF, Nordenberg D, Williamson 
DF, Spitz AM, Edwards V, et al. The relationship of 
372 zdrav vestn | september – oktober 2017 | letnik 86
PsIhIAtrIjA
adult health status to childhood abuse and house-
hold dysfunction. Am J Prev Med. 1998;14(4):245–
58.
7. Anda RF, Croft JB, Felitti VJ, Nordenberg D, Gi-
les WH, Williamson DF, et al. Adverse childhood 
experiences and smoking during adolescence and 
adulthood. JAMA. 1999;282(17):1652–8.
8. Fox KM, Gilbert B. The interpersonal and psycho-
logical functioning of women who experienced 
childhood physical abuse, incest, and parental al-
coholism. Child Abuse Negl. 1994;18(10):849–58.
9. McCloskey LA, Figueredo AJ, Koss MP. The effects 
of systemic family violence on children’s mental 
health. Child Dev. 1995;66(5):1239–61.
10. Wolock I, Magura S. Parental substance abuse as 
a predictor of child maltreatment. Child Abuse 
Negl. 1996;20(12):1183–93.
11. Brent DA, Moritz G, Liotus L, Schweers J, Balach 
L, Roth C, et al. Familial risk factors for adolescent 
suicide: a case-control study. Acta Psychiatr Scand. 
1994;89(1):52–8.
12. West MO, Prinz RJ. Parental alcoholism and 
childhood psychopathology. Psychol Bull. 
1987;102(2):204–18.
13. Henderson MC, Albright JS, Kalichman SC, 
Dugoni B. Personality characteristics of young 
adult offspring of substance abusers: a study hi-
ghlighting methodologic issues. J Pers Assess. 
1994;63(1):117–34.
14. Steinhausen HC. Children of alcoholic pa-
rents: a review. Eur Child Adolesc Psychiatry. 
1995;4(3):143–52.
15. Brown GK, Beck AT, Steer RA, Grisham JR. Risk 
factors for suicide in psychiatric outpatients: a 
20-year prospective study. J Consult Clin Psychol. 
2000;68(3):371–7.
16. Landheim AS, Bakken K, Vaglum P. What cha-
racterizes substance abusers who commit suicide 
attempts? Factors related to Axis I disorders and 
patterns of substance use disorders. A study of tre-
atment-seeking substance abusers in Norway. Eur 
Addict Res. 2006;12(2):102–8.
17. Marusic A. Suicide mortality in Slovenia. regional 
variation. Crisis. 1998;19(14):159–66.
18. Statistical Office of Republic of Slovenia (2011)
[cited 2015.09.22]. Available from: http://www.stat.
si/. 
19. Zupanc T, Pregelj P, Tomori M, Komel R, Paska AV. 
TPH2 polymorphisms and alcohol-related suici-
de. Neurosci Lett. 2010;490 (1):78–81.
20. Pregelj P, Nedic G, Paska AV, Zupanc T, Nikolac 
M, Balažic J, et al. The association between bra-
in-derived neurotrophic factor polymorphism 
(BDNF Val66Met) and suicide. J Affect Disord. 
2011;128(3):287–90.
21. Suicide: Psychological autopsy, a research tool for 
prevention. In: INSERM Collective Expert Re-
ports. Paris: Institut national de la santé et de la 
recherche médicale; 2005. 
22. Zupanc T, Pregelj P, Tomori M, Komel R, Paska AV. 
No association between polymorphisms in four 
serotonin receptor genes, serotonin transporter 
gene and alcohol-related suicide. Psychiatr Danub. 
2009;22(4):522–7.
23. Cnossen S. Alcohol taxation and regulation in 
the European Union. Int Tax Public Finance. 
2007;14(6):699–732.
24. Kendall RE. Alcohol and suicide. Subst Alcohol 
Actions Misuse. 2009;22(4):522–7.
25. Gladstone GL, Parker GB, Mitchell PB, Malhi GS, 
Wilhelm K, Austin MP. Implications of childhood 
trauma for depressed women: an analysis of path-
ways from childhood sexual abuse to deliberate 
self-harm and revictimisation. Am J Psychiatry. 
2004;161(8):1417–25.
26. Hill J, Pickles A, Burnside E, Byatt M, Rollinson L, 
Davis R, et al. Child sexual abuse, poor parental 
care and adult depression: evidence for different 
mechanisms. Br J Psychiatry. 2001;179:104–9.
27. Nomura Y, Wickramaratne PJ, Warner V, Mufson 
L, Weissman MM. Family discord, parental de-
pression, and psychopathology in offspring: ten-
-year follow-up. J Am Acad Child Adolesc Psychi-
atry. 2002;418(4):402–9.
28. Kendler KS, Gardner CO, Prescott CA. Toward 
a comprehensive developmental model for 
major depression in women. Am J Psychiatry. 
2002;159(7):1133–45.
29. Weich S, Patterson J, Shaw R, Stewart-Brown 
S. Family relationships in childhood and com-
mon psychiatric disorders in later life: systema-
tic review of prospective studies. Br J Psychiatry. 
2009;194(5):392–8.
30. Lizardi D, Thompson RG, Keyes K, Hasin D. The 
role of depression in the differential effect of 
childhood parental divorce on male and female 
adult offspring suicide attempt risk. J Nerv Ment 
Dis. 1983;4(2–3):121–7.
31. Martin G, Bergen H, Richardson A, Roeger L, 
Allison S. Sexual abuse and suicidality: gender 
differences in a large community sample of adole-
scents. Child Abuse Negl. 2004;28(5):491–503.
32. Zhang J, Xiao S, Zhou L. Mental disorders and 
suicide among young rural Chinese: a case-con-
trol psychological autopsy study. Am J Psychiatry. 
2010;167(7):773–81.
33. Mann JJ, Apter A, Bertolote J, Beautrais A, Curri-
er D, Haas A, et al. Suicide prevention strategies: 
a systematic review. JAMA. 2005;294(16):2064–74.