The risk of suicide is assessed by identifying the relationship between alcohol-use patterns and suicidal ideation in Korean employees.
The study involved 13,858 employees who underwent workplace mental health screening at the Workplace Mental Health Institute of Kangbuk Samsung Hospital over a 6-year period between 2014 and 2019. Analysis was performed separately for Alcohol Use Disorders Identification Test-Korea (AUDIT-K) items related to the frequency/volume of alcohol consumption (items 1 to 3, AUDIT-C) and those regarding alcohol dependence/related problems (items 4 to 10, AUDIT-D/P). Subjects were then classified into three groups on the basis of the presence or absence of clinical depression and suicidal ideation. The groups’ sociodemographic factors and clinical features of depression, anxiety, and alcohol-use patterns were analyzed with a chi-square test as well as one-way analysis of variance, followed by a post hoc test using the Bonferroni correction.
AUDIT-K and AUDIT-D/P scores were significantly associated with the presence or absence of clinical depression as well as the presence or absence of suicidal ideation (p<0.05). However, no significant differences were found among the three groups with regard to the AUDIT-C score (p=0.054).
Identifying or treating alcohol dependence/related problems can help lower the occurrence of mental health problems, and suicidal ideation in particular, in employees and reduce social costs.
The average employment rate in member countries of the Organization for Economic Cooperation and Development in 2019 was 68.7% [
Alcohol use is associated with a lot of harmful health problems and even contributes to death and disability [
In Korea, the suicide death rate is high, as shown in a 2019 report by Statistics Korea; in 2018, the number of suicides per 100,000 people was 26.6 which is much higher than the OECD average of 11.0 [
The study evaluated 15,360 male and female workers ranging in age from 20 to 65 years who underwent workplace mental health screening at the Workplace Mental Health Institute of Kangbuk Samsung Hospital over a 6-year period between 2014 and 2019. The subjects were office or manufacturing-facility workers at one of the country’s 52 public institutions or large companies. Of those, 1,502 workers who did not manifest clinical depression symptoms (a Center for Epidemiological Studies-Depression Scale score lower than 16 points) but had suicidal ideation were excluded. Data for a total of 13,858 workers were analyzed (
The study was approved by the Kangbuk Samsung Hospital Institutional Review Board (IRB No. KBSMC 2019-01-042). Written consent forms were not obtained because the study was conducted using anonymized data only.
Information on age, sex, marital status, education level, job title, and body mass index (BMI) of the study subjects was collected. Marital status included single, married, and others such as divorced, separated, or widowed. Education level either an associate degree or below or bachelor’s degree or above. Job title included staff, senior staff, assistant manager, manager, deputy general manager, general manager, executive, and others.
Alcohol consumption was assessed using a version of the Alcohol Use Disorders Identification Test standardized for Koreans (AUDIT-K). The AUDIT-K consists of 10 items, including three regarding the frequency and volume of alcohol consumption in the past year, three regarding alcohol dependence, and four regarding problematic drinking behavior. Each item is given a score between 0 and 4 points [
Suicidal ideation was assessed using one of the items regarding suicidal ideation and suicide attempts included in the Korea National Health and Nutrition Examination Survey: “Have you had a suicidal thought in the past year?.” [
Depression was assessed using the Korean version of the Center for Epidemiological Studies-Depression Scale (CES-D) [
Of the 15,360 subjects, the 10,532 who were not determined to be clinically depressed (due to a CES-D score below 16) and responded that they did not have suicidal thoughts were assigned to Group 1; the 1,807 who were determined to be clinically depressed (due to a CES-D score of 16 or higher) and responded that they did not have suicidal thoughts were assigned to Group 2; and the 1,519 who were determined to be clinically depressed (a CES-D score of 16 or higher) and responded that they had suicidal thoughts were assigned to Group 3. There is a temporal discordance between suicidal thoughts and clinical depression assessments [
The Korean version of the Beck Anxiety Inventory (BAI) [
All measurements were written through a questionnaire, then we coded and anonymized. The data were analyzed using PASW Statistics for Windows, Version 18.0 (SPSS Inc., Chicago, IL, USA) A p value<0.05 was considered significant. First, to examine the sociodemographic factors and characteristics on major variables, descriptive statistics were computed for each variable. Subjects were the assigned to groups on the basis of the presence or absence of clinical depression and suicidal ideation. Those without clinical depression and suicidal ideation (Group 1), those with clinical depression but without suicidal ideation (Group 2), and those with both clinical depression and suicidal ideation (Group 3). The groups’ sociodemographic factors and clinical features of depression, anxiety, and alcohol consumption were analyzed with chi-square tests as well as one-way analysis of variance, followed by post hoc tests using the Bonferroni correction. We also performed multiple logistic regression models to evaluate the association between groups and clinical features; CES-D, BAI, WHO-QOL, PSS, DLSS, KOSS, K-CD-RISC, AUDIT-K.
Of the 13,858 subjects, 8,216 (59.3%) were male and 5,642 (40.7%) were female. In total, 3,326 subjects scored 16 or higher on the CES-D, and were determined to have significant depression symptoms; of these, 1,519 reported having suicidal thoughts. Accordingly, 10,532 subjects were assigned to Group 1 (a CES-D score below 16 and no suicidal ideations), 1,807 to Group 2 (a CES-D score of 16 or higher and no suicidal ideations), and 1,519 to Group 3 (a CES-D score of 16 or higher and suicidal ideations) (
CES-D scores were 5.57±4.17 points for Group 1, 23.26±7.43 for Group 2, and 27.32±9.36 for Group 3. Likewise, BAI scores (which are indicative of the level of anxiety) and of the various scales measuring job stress (KOSS), perceived stress (PSS), and stress in a variety of everyday events (DLSS) were elevated in Group 2 compared with Group 1, and in Group 3 compared with Group 2 (p<0.001). Between-group differences were found to be significant (p<0.001) in the post hoc test, as well. The higher the K-CD-RISC and WHO-QOL scores, the higher the levels of resilience and quality of life, respectively. In both measures, the scores were highest in Group 1 and lowest in Group 3. The differences were statistically significant (p<0.001) (
Both AUDIT-K and AUDIT-D/P scores were significantly associated with the presence or absence of clinical depression as well as the presence or absence of suicidal ideation (
When analysis was performed on individual AUDIT-K items, only item 1 of those included in AUDIT-C (“How frequently do you drink?”) was associated with suicidal ideation (p=0.001), and none of the remaining AUDIT-C items were associated with either suicidal ideation or clinical depression. In contrast, most AUDIT-D/P items were associated with suicidal ideation and clinical depression, with two exceptions: item 6 was not associated with suicidal ideation (p=0.134) and item 9 was not associated with clinical depression (p=0.231) (
With regard to alcohol use, both the rate of drinking and drinking behavior as well as physiological sensitivity to alcohol varied by sex and age. Consequently, additional analysis was performed after the data were grouped by the participants’ sex and age (ages 20–29, 30–39, and 40 years old and older) (
The present study examined various factors associated with suicidal ideation in employees, including depression, anxiety, stress and alcohol. The findings demonstrated that alcohol dependence/related problems after drinking in particular, were linked to both depression and suicidal ideation. Regarding the effect of drinking on suicidal ideation, Gallyer et al. [
In analyses of all subjects, AUDIT-D/P but not AUDIT-C was associated with clinical depression and suicidal ideation (
The AUDIT-K scores differed significantly between the group with both depression and suicidal ideation (Group 3) and the group with neither (Group 1). This is in line with the findings of a previous study in which a logistic regression analysis was performed on data taken from employees, and which reported that the AUDIT-K score was associated with both depressive mood and suicidal ideation (
Because previous studies have found that drinking behavior differs between men and women [
The study has a few limitations. First, it was based on data collected via a self-reporting questionnaire, and not on structured interviews conducted by clinicians. However, the questionnaire items used in the study are commonly utilized; the CES-D and the AUDIT-K are widely used to screen for depression and alcohol dependence, respectively. Second, the subjects of the study were among those who underwent workplace mental health screening at Kangbuk Samsung Hospital, limiting the generalizability of the findings to other workers. Third, the study was cross-sectional in design, no causal relationship between suicidal ideation and alcohol use pattern could be identified. Accordingly, future studies should take confounding factors fully into consideration. Finally, the questionnaires included past-year suicidal ideations and past-week depression. Therefore, it has been possible to have suicidal ideation over the past year, even without the current coexisting depression. So we excluded 1,502 people to eliminate temporal inconsistencies.
The strengths of the present study are as follows. First, it is the first to investigate the link between clinical depression and suicidal ideation in employees separately by the frequency/volume of alcohol consumption and dependence/related problems. Second, far more subjects (>15,000) were involved compared with previous studies, which typically involved only a few thousand. Third, this study targeted multiple occupational groups of office and manufacturing workers at large companies. Previous studies focused on a single occupation, and no study included several subjects working at a number of different institutions as was done in the present study. Our results may provide helpful insights into the understanding of depression and alcohol use pattern in employees, compared with other studies.
In conclusion, this study included a large number of subjects and a wide range of occupations to investigate the relationship between alcohol use and suicidal ideation. The results are can be generalized to all workers, unlike those of previous studies. This was a cross-sectional study and the causal relationship between suicidal ideation and alcohol consumption cannot be derived based on the study findings alone. However, identifying or treating alcohol dependence/related problems is likely to help lower the occurrence of mental health problems, and suicidal ideation in particular, in employees while reducing social costs. From the perspective of the suicidal process, we studied the suicidal thoughts of workers, but we expect it to be deeply related to their deaths by suicide [
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
The authors have no potential conflicts of interest to disclose.
Conceptualization: Sung Joon Cho, Sang-Won Jeon. Data curation: Mikyung Sim. Formal analysis: Mikyung Sim, Jinmi Seol. Investigation: Miji Lee, Sung Joon Cho. Methodology: Sung Joon Cho, Sang-Won Jeon. Project administration: Young-Chul Shin. Validation: Sang-Won Jeon, Sung Joon Cho, Jae-Hyun Park. Writing—original draft: Miji Lee, Ung Lee, Mikyung Sim, Jinmi Seol. Writing—review & editing: Jae-Hyun Park, Young-Chul Shin, Kang-Seob Oh, Dong-Won Shin, Sang-Won Jeon, Sung Joon Cho.
None
Classification of subjects into groups. Group 1: participants who had no clinical depression and no suicidal ideation; Group 2: participants who had clinical depression and no suicidal ideation; Group 3: participants who had clinical depression and suicidal ideation; O: with clinical depression or with suicidal ideation; X: without clinical depression or without suicidal ideation. SI, suicidal ideation.
Comparison between groups. Group 1: participants who had no clinical depression and no suicidal ideation; Group 2: participants who had clinical depression and no suicidal ideation; Group 3: participants who had clinical depression and suicidal ideation. SI, suicidal ideation; AUDIT-K, Alcohol Use Disorders Identification Test-Korea; AUDIT-C, Alcohol Use Disorders Identification-Alcohol Consumption Score; AUDIT-D/P, Alcohol Use Disorders Identification-Alcohol Dependent-related Problem Score.
Sociodemographic characteristics of employees
Group 1 (N=10,532) |
Group 2 (N=1,807) |
Group 3 (N=1,519) |
|
---|---|---|---|
N (%) or mean±SD | N (%) or mean±SD | N (%) or mean±SD | |
Age | 39.87±9.448 | 36.56±9.123 | 37.11±8.802 |
Sex | |||
Male | 6,661 (63.3) | 882 (48.8) | 673 (44.2) |
Female | 3,870 (36.7) | 924 (51.1) | 848 (55.8) |
BMI | 23.43±3.74 | 23.08±4.40 | 23.21±4.94 |
Marital status | |||
Single | 3,086 (29.3) | 775 (42.9) | 642 (42.2) |
Married | 6,813 (64.7) | 898 (49.7) | 735 (48.3) |
Others | 184 (1.7) | 48 (2.6) | 62 (4.1) |
Education | |||
High school/associate degree | 3,061 (29.0) | 564 (31.2) | 490 (32.3) |
Bachelor’s degree or greater | 7,022 (66.7) | 1,157 (64.0) | 949 (62.5) |
Position | |||
Staff | 2,290 (21.7) | 503 (27.8) | 400 (26.3) |
Senior staff | 2,471 (23.5) | 460 (25.5) | 419 (27.5) |
Assistant manager | 1,734 (16.5) | 291 (16.1) | 255 (16.8) |
Manager | 1,461 (13.9) | 213 (11.8) | 181 (11.9) |
Deputy general manager | 1,017 (9.7) | 112 (6.2) | 117 (7.7) |
General manager | 668 (6.3) | 64 (3.5) | 30 (2.0) |
Executive | 383 (3.6) | 37 (2.0) | 19 (1.2) |
Others | 506 (4.8) | 126 (7.0) | 98 (6.4) |
Group 1: participants who had no clinical depression and no suicidal ideation; Group 2: participants who had clinical depression and no suicidal ideation; Group 3: participants who had clinical depression and suicidal ideation. SD, standard deviation; BMI, body mass index
Psychiatric clinical features between groups
Group 1 (N=10,532) |
Group 2 (N=1,807) |
Group 3 (N=1,519) |
p value | Group 1 & 2 p value | Group 2 & 3 p value | Group 1 & 3 p value | |
---|---|---|---|---|---|---|---|
Mean±SD | Mean±SD | Mean±SD | |||||
CES-D | 5.57±4.17 | 23.26±7.43 | 27.32±9.36 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
BAI | 3.96±4.61 | 14.39±8.92 | 19.34±10.51 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
WHO-QOL | 57.13±7.89 | 48.61±6.88 | 44.09±7.02 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
PSS | 14.67±4.72 | 21.42±4.57 | 23.49±4.72 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
DLSS | 3.34±2.70 | 6.89±3.26 | 8.91±3.77 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
KOSS | 59.05±8.79 | 67.02±8.67 | 69.72±9.00 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
K-CD-RISC | 67.27±14.64 | 55.48±14.51 | 49.70±1 5.48 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
Values are presented as mean±standard deviation (95% confidence interval).
p<0.05; Bonferroni correction is used.
Group 1: participants who had no clinical depression and no suicidal ideation; Group 2: participants who had clinical depression and no suicidal ideation; Group 3: participants who had clinical depression and suicidal ideation. SD, standard deviation; CES-D, The Center for Epidemiologic Studies-Depression Scale; BAI, Beck Anxiety Inventory; WHO-QOL, World Health Organization Quality of Life; PSS, Perceived Stress Scale; DLSS, Daily Life Stressors Scale; KOSS, Korean Occupational Stress Scale; K-CD-RISC, The Korean version of the Connor-Davidson Resilience Scale
Individual AUDIT-K factor analysis of groups
Group 1 (N=10,532) |
Group 2 (N=1,807) |
Group 3 (N=1,519) |
p value | Group 1 & 2 p value | Group 2 & 3 p value | Group 1 & 3 p value | |||
---|---|---|---|---|---|---|---|---|---|
Mean±SD | Mean±SD | Mean±SD | |||||||
AUDIT-K | 7.66±6.13 | 8.51±7.08 | 9.74±7.93 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
||
AUDIT-C | 5.22±3.32 | 5.20±3.45 | 5.44±3.55 | 0.054 | 1.000 | 0.120 | 0.058 | ||
AUDIT 1 | 1.92±1.024 | 1.93±1.106 | 2.02±1.119 | 0.001 |
1.000 | 0.026 |
0.001 |
||
AUDIT 2 | 1.95±1.365 | 1.97±1.403 | 1.98±1.449 | 0.706 | 1.000 | 1.000 | 1.000 | ||
AUDIT 3 | 1.79±1.186 | 1.81±1.208 | 1.86±1.277 | 0.107 | 1.000 | 0.926 | 0.121 | ||
AUDIT-D/P | 2.44±3.56 | 3.30±4.35 | 4.30±5.10 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
||
AUDIT 4 | 0.54±0.897 | 0.76±1.079 | 0.92±1.168 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
||
AUDIT 5 | 0.30±0.600 | 0.46±0.775 | 0.57±0.851 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
||
AUDIT 6 | 0.15±0.471 | 0.23±0.615 | 0.27±0.678 | <0.001 |
<0.001 |
0.134 | <0.001 |
||
AUDIT 7 | 0.52±0.746 | 0.72±0.919 | 0.90±1.034 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
||
AUDIT 8 | 0.49±0.745 | 0.62±0.887 | 0.73±0.939 | <0.001 |
<0.001 |
0.001 |
<0.001 |
||
AUDIT 9 | 0.19±0.693 | 0.23±0.775 | 0.40±1.007 | <0.001 |
0.231 | <0.001 |
<0.001 |
||
AUDIT 10 | 0.57±1.277 | 0.79±1.492 | 1.06±1.639 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
Values are presented as mean±standard deviation (95% confidence interval).
p<0.05; Bonferroni correction is used.
Group 1: participants who had no clinical depression and no suicidal ideation; Group 2: participants who had clinical depression and no suicidal ideation; Group 3: participants who had clinical depression and suicidal ideation. SD, standard deviation; AUDIT-K, Alcohol Use Disorders Identification Test-Korea; AUDIT-C, Alcohol Use Disorders Identification-Alcohol Consumption Score; AUDIT-D/P, Alcohol Use Disorders Identification-Alcohol Dependent-related Problem Score
AUDIT-K–specific factor analysis by age groups
Group 1 |
Group 2 |
Group 3 |
p value | Group 1 & 2 p value | Group 2 & 3 p value | Group 1 & 3 p value | |||
---|---|---|---|---|---|---|---|---|---|
Mean±SD | Mean±SD | Mean±SD | |||||||
Male (N) | 6,659 | 881 | 673 | ||||||
20s | |||||||||
AUDIT-K | 8.87±5.619 | 9.86±6.958 | 11.94±7.441 | <0.001 |
0.220 | 0.052 | <0.001 |
||
AUDIT-C | 6.24±2.852 | 6.36±3.410 | 6.72±3.122 | 0.432 | 1.000 | 1.000 | 0.586 | ||
AUDIT-D/P | 2.63±3.577 | 3.50±4.359 | 5.23±5.153 | <0.001 |
0.043 |
0.006 |
<0.001 |
||
30s | |||||||||
AUDIT-K | 9.18±6.291 | 10.83±7.482 | 11.61±7.364 | <0.001 |
<0.001 |
0.458 | <0.001 |
||
AUDIT-C | 6.15±3.132 | 6.49±3.543 | 6.67±3.227 | 0.017 |
0.214 | 1.000 | 0.045 |
||
AUDIT-D/P | 3.04±3.963 | 4.31±4.851 | 4.94±5.058 | <0.001 |
<0.001 |
0.213 | <0.001 |
||
Over 40s | |||||||||
AUDIT-K | 8.91±6.204 | 10.57±7.172 | 12.74±8.439 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
||
AUDIT-C | 6.07±3.323 | 6.27±3.332 | 6.79±3.719 | <0.001 |
0.784 | 0.100 | <0.001 |
||
AUDIT-D/P | 2.83±3.688 | 4.30±4.585 | 5.95±5.576 | <0.001 |
<0.001 |
<0.001 |
<0.001 |
||
Female (N) | 3,870 | 925 | 848 | ||||||
20s | |||||||||
AUDIT-K | 7.08±5.849 | 8.07±6.613 | 9.02±8.068 | <0.001 |
0.044 |
0.212 | <0.001 |
||
AUDIT-C | 4.65±2.927 | 4.93±3.054 | 5.03±3.364 | 0.114 | 0.413 | 1.000 | 0.221 | ||
AUDIT-D/P | 2.43±3.620 | 3.14±4.216 | 3.99±5.395 | <0.001 |
0.018 |
0.031 |
<0.001 |
||
30s | |||||||||
AUDIT-K | 5.55±5.482 | 6.17±6.121 | 7.84±7.192 | <0.001 |
0.212 | <0.001 |
<0.001 |
||
AUDIT-C | 3.73±2.884 | 3.87±2.982 | 4.41±3.206 | <0.001 |
1.000 | 0.037 |
<0.001 |
||
AUDIT-D/P | 1.82±3.168 | 2.30±3.766 | 3.43±4.559 | <0.001 |
0.055 | <0.001 |
<0.001 |
||
Over 40s | |||||||||
AUDIT-K | 4.02±4.415 | 4.74±5.544 | 5.86±6.033 | <0.001 |
0.117 | 0.050 | <0.001 |
||
AUDIT-C | 2.98±2.708 | 3.07±2.969 | 3.56±2.978 | 0.025 |
1.000 | 0.226 | 0.020 |
||
AUDIT-D/P | 1.04±2.215 | 1.67±3.101 | 2.31±3.567 | <0.001 |
0.002 |
0.030 |
<0.001 |
Values are presented as mean±standard deviation (95% confidence interval).
p<0.05; Bonferroni correction is used.
Group 1: participants who had no clinical depression and no suicidal ideation; Group 2: participants who had clinical depression and no suicidal ideation; Group 3: participants who had clinical depression and suicidal ideation. SD, standard deviation; AUDIT-K, Alcohol Use Disorders Identification Test-Korea; AUDIT-C, Alcohol Use Disorders Identification-Alcohol Consumption Score; AUDIT-D/P, Alcohol Use Disorders Identification-Alcohol Dependent-related Problem Score