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Background: Suicide is a serious public health problem that affects our entire country, including the Galician provinces. The aim of this research was to study the variation in completed suicide rates, between and , in the different Galician provinces and their relationship with the consumption of addictive substances. Methods: Completed suicide data from the Spanish Office for National Statistics and the Institute of Legal Medicine of Galicia were analyzed with a Joinpoint regression model to determine time trends. The relationship between the variation in completed suicide rates with sociodemographic variables obtained from the Spanish Office for National Statistics and variables related to the consumption of substances obtained from the survey on alcohol and other drugs in Spain EDADES of the Government Delegation for the National Plan on Drugs was also analyzed. Results: The Joinpoint regression model did not reveal any point of significant change in the period studied for any Galician province. The following variables correlated positively with the variation in completed suicide rates in the Galician provinces: masculinity ratio, average age, daily alcohol consumption and daily illegal substance consumption. Conclusion: Applying preventive strategies on the daily consumption of alcohol and illegal substances would help reduce the rates of completed suicide in the Galician provinces. Suicide and substance abuse represent two serious problems in the health system and in society. Both problems extend globally. According to the World Health Organization WHO , the number of deaths by suicide stands at approximately , people per year, although it is estimated to be higher due to the underreporting that occurs in the different registries 1. The global rate is estimated at 9. In Spain, according to data from the 3 , suicide has been the leading external cause of mortality since and exceeds deaths because of traffic accidents 4. In Spanish autonomous communities, the high suicide rates in Asturias and Galicia stand out with a percentage of Suicide is the leading cause of death in people with substance use disorder 5. It is estimated that the risk of death by suicide compared to the general population increases fold and fold for alcohol use disorder and addiction to other substances, respectively 6. Compared to , the figure has decreased from Alcohol plays a relevant role, not only as a risk factor, but also as a precipitating factor, due to the disinhibition and executive dysfunction produced by alcohol intoxication 7. In terms of suicide prevention strategies, it is especially relevant to note that to date, of all the strategies that have been used, very few enjoy any degree of sufficient evidence to be able to ensure that they are able to reduce the incidence of suicide 10 , Work continues to identify a cornerstone intervention 12 , The main aim of this study is to determine the relationship between the variation in completed suicide rates in the Galician provinces between and and active substance use variables in these provinces. A secondary objective would be to perform the same evaluation, but for other variables indirectly related to substance use. The working hypothesis is that active substance use has a significant influence on the variation in completed suicide rates in the Galician provinces between and If this hypothesis is verified, the importance of globally reducing the consumption of psychoactive substances as a preventive measure against suicide would be confirmed in the study population. The incidence rates of suicide deaths for the four Galician provinces between and were obtained from two databases Tables 1 , 2. Table 1. Table 2. Prevalence of suicide deaths in the 4 Galician provinces from to according to INE. The following data were also obtained by means of the INE database for the four Galician provinces: unemployment rates, masculinity ratio number of men for every women , average life expectancy and mean age Table 3. Table 3. The data on substance use for the same period for the four Galician provinces come from the survey on alcohol and other drugs in Spain EDADES 4 , which the Government Delegation for the National Plan on Drugs has performed biannually since Table 4. Finally, another variable to consider is the Intensive Intervention Programme for suicidal behavior. An outpatient programme launched in the province of Ourense since , with the aim of reducing mortality from suicide and suicide attempts in the province During the study period, there was no similar programme in the other Galician provinces. They complied with the requirements established in Spanish legislation in the field of medical research, the protection of personal data and bioethics and all other requirements set out by Spanish legislation on this topic. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. The current research contains no human or animal studies. The temporal trend of completed suicide incidence rates in each Galician province was evaluated using a Joinpoint regression model. This statistical modeling technique is ideal to analyze the appearance of temporal changes and trends over lengthy periods of time and has previously been used successfully in the field of addictions 15 , Changes in the time trend are called Joinpoints or inflection points. Statistical criteria determine the final number of Joinpoints. A Poisson distribution model was used in the estimation. This regression model also enables calculation of the percentage annual change PAC. Joinpoint analysis also facilitates two-by-two comparisons. It performs the test on the slopes by testing whether the two functions are parallel parallelism test. These data are used as covariates to model the incidence rates of completed suicide. This technique makes it possible to see the oscillations of the suicide incidence rates as a function of the covariates. The completed suicide rates and the rest of the variables were also compared between provinces applying ANOVA comparisons non-parametric test for sample size with post-hoc analysis of two-by-two comparison. Table 1 shows the prevalence of completed suicide in the four Galician provinces according to IMELGA data and the significant differences between them. Table 2 shows the prevalence of completed suicide in the four Galician provinces according to the INE data and the significant differences between them. As can be observed in Figures 1 , 2 , the Joinpoint regression model did not lead to identification of any significant change points for the completed suicide rates in any Galician province in both databases. Figures 3 , 4 show the variation in completed suicide rates in each Galician province throughout the study period for each database. In the two-to-two Joinpoint comparison, performing the contrast on the best estimated model, results are obtained that indicate that the option of parallelism cannot be ruled out. And for the INE data, average age: 4. Figure 1. Figure 2. Joinpoint regression models in each Galician province for completed suicide rates according to the INE. Figure 3. Figure 4. Evolution of completed suicide rates in the four Galician provinces according to INE during the study period. First, it is necessary to point out, as has been highlighted previously 17 , concerns in relation to the evident discrepancy in the data provided by both sources IMELGA and INE , without either of them being considered more reliable. This indicates a problem in the registration system that must be resolved if we seek to have reliable and accurate data that allows us to know the actual magnitude of the situation and thus be able to intervene effectively. Fortunately, the statistical study reveals that these differences are not relevant and the variation in rates behaves similarly for both databases, as reflected in both the univariate and multivariate studies. This stability in variation is also observed when performing the two-by-two joinpoint regression and observing that parallelism cannot be rejected. However, accounting for why these differences are maintained over the years is difficult. Both are variables positively related to suicide deaths. In addition, completed suicide is more common in men from rural areas, the most prevalent environment being Lugo and Orense, since these men tend to be stoic and do not seek help from health professionals in the face of mental disorders and stress As these variables are also significant in the LOESS locally weighted least squares regression regressions that model the variation in suicide death rates, their relevance is clearly highlighted. Seen together, these two variables provide a robust explanation why Lugo is the province with the most prevalent rates of suicide. However, by themselves they do not enable accounting for the rest of the provinces. Substance use is another first-order risk factor for suicide death, and the SMR data is a way to measure high risk substance use. To account for these unclear results, two causes can be suggested. First, it is possible that there are statistically significant differences between provinces in terms of the prevalence of mental illnesses related to completed suicide, such as depression 19 — Second, these differences could be related to different styles and interpretation of the procedures in each province when determining cases of suicide deaths, especially in more complex cases. It must be remembered that the prevalence of suicide, although a first-order health problem, is a statistically rare phenomenon; minor variations in the way cases are counted could lead to statistically significant differences between provinces. Joinpoint regression, in its two analyses used in this study, indicates that there is no time of significant change, for both databases, in the variation in suicide rates in each Galician province. It may be difficult to explain the reason for the differences between provinces, but it is clear that these differences remain stable over time. First, the masculinity ratio and mean age, variables that cannot be modified by means of preventive interventions. Second, the daily consumption of alcohol and illegal substances. These variables indicate patterns of daily consumption that guide toward dependency and addiction, and therefore to the more serious substance use disorder SUD. In addition, these variables can be modified by means of prevention and treatment strategies Universal prevention can be useful by means of measures that reduce the overall consumption of alcohol and illegal substances in the general population, thus reducing the incidence of SUDs. In addition, these measures also reduce the risk that alcohol and drugs intoxication becomes a precipitating factor for suicidal behavior in a person who presents suicidal ideation but does not meet the criteria for SUD. Indicated prevention interventions can be suggested to reduce active consumption and its negative consequences in patients presenting SUD and thus minimize suicidal risk. Finally, selective prevention models can be used to undertake suicide prevention plans in patients with SUD at higher risk, due to presenting other associated risk factors such as previous attempts, social maladjustment and psychiatric comorbidity 5 , 22 , Currently, the main purpose for the most selective prevention and intervention programmes has been to reduce the risk of retry and completed suicide in patients after an attempted suicide. It is striking that the Intensive Intervention Programme for treating suicidal behavior, which has these same characteristics and has been performed in Orense since , has not proven to be effective In the analysis of the two databases, in no case was there evidence of a positive result when it came to reducing suicide deaths, as reflected in the Joinpoint regression. Obviously, Adjustment Disorder presents less severity and less risk. It should be noted that currently there is an important debate about the effectiveness of these programmes, especially about their usefulness as a solo intervention measure. Although they have proven their efficacy, many authors recommend combining them with other interventions It is necessary to remember, despite the statistical results, that these programmes help many patients in an unstable psychopathological situation by means of structured and intensive intervention models. This probably reflects what some authors have already indicated: these are significant variables but with a minor effect 21 , 24 , However, it would be desirable to collect more variables related to suicide risk to improve the analysis, especially variables related to severe mental disorder with a particular emphasis on depression. Reducing the consumption of alcohol and illegal substances in those people who consume on a daily basis would help reduce the rates of suicide deaths in the Galician provinces. This is because consumption has significantly influenced the variation in the prevalence of suicide in the Galician provinces during the period studied. NL and TS-P as biostatisticians assisted in formal statistical analysis. GF wrote the first draft of the manuscript. AE and PS reviewed and edited the manuscript. NL and AE provided input on the analysis and interpretation of the results, and assisted with revising drafts of the manuscript. PS supervised the progress of the study. All authors revised the manuscript critically for important intellectual content and approved the final manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. World Health Organization. Estimated suicide worldwide. Google Scholar. Suicide and self-harm. Spanish Office for National Statistics Deaths by cause of death. Year Definitive data press releases. Rev Psiquiatr Salud Ment. Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug Alcohol Depend. Addiction and suicide: a review. Am J Addict. The world report on violence and health. Suicide prevention: a review of evidence of risk and protective factors, and points of effective intervention. Wellington: Ministry of Health Suicide risk and addiction: the impact of alcohol and opioid use disorders. Curr Addict Rep. Implementation and outcomes of suicide-prevention strategies by restricting access to lethal suicide methods in Korea. J Public Health Policy. Evidence-based national suicide prevention taskforce in Europe: a consensus position paper. Eur Neuropsychopharmacol. Improving suicide prevention through evidence-based strategies: a systematic review. Am J Psychiatry. Suicide prevention strategies: a systematic review. Evaluation of an intensive intervention program in suicidal behaviour. Actas Espanolas Psiquiatr. PubMed Abstract Google Scholar. Changes in alcohol consumption in Spain between and Giner, L, and Guija, JA. Can J Psychiatr. Psychiatric disorders in cases of completed suicide in a hospital area in Spain between and Risk of suicide ideation in comorbid substance use disorder and major depression. PLoS One. Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies. Environ Health Prev Med. Cannabis and suicide: longitudinal study. Br J Psychiatry. Suicide attempts among substance use disorder patients: an initial step toward a decision tree for suicide management. Alcohol Clin Exp Res. Suicide, unemployment, and economic recession in Spain. The economy and suicide: an interaction of societal and intrapersonal risk factors. Keywords: alcohol, completed suicide, illegal substances, Joinpoint regression, preventive strategies. The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Top bar navigation. About us About us. Sections Sections. About journal About journal. Article types Author guidelines Editor guidelines Publishing fees Submission checklist Contact editorial office. Psychiatry , 14 August Suicide deaths and substance use in the Galician provinces between and Introduction Suicide and substance abuse represent two serious problems in the health system and in society. Materials and methods Data The incidence rates of suicide deaths for the four Galician provinces between and were obtained from two databases Tables 1 , 2. Table 4. Rates of variables associated with substance use obtained from the PNSD.

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