HEAVY COFFEE DRINKING AND THE RISK OF SUICIDE

Name : Angeline Tancherla Tutor : dr. Janet

NIM : 01071170034

1. Description of Place Person Time

Place Person Time
 Finnish coffee drinkers
Finland 1972, 1977, 1982, 1987, 1992
 Finnish aged 25-62 years old

2. Hypothesis : Heavy coffee drinking and the risk of suicide

3. Find the best possible Association :

a) Chance (Yes/No)
Explanation :

There is a possibility that heavy coffee drinking association with the risk of
suicide is a coincidence. It is stated in the introduction that, according to
trade statistics, Finland's average annual consumption of coffee per capita
was 12.4 kg (which is about 4 cups/day) in 1994. This was the highest
amount in the world. The suicide rate of the Finns itself is also high
internationally, and is increasing during the recent decades. With these high
numbers of statistics, we may deduce that it is simply a coincidence that the
Finnish coffee drinkers committed suicide. Aside from that, from the results
of the study, the age-adjusted risks of suicide varied and had a wide interval.
The association is also J-shaped, which makes the association of amount of
coffee drinking and the risk of suicide uncertain. Although there was 58%
higher relative risk of suicide among heavy coffee drinkers (more than 8
cups/day), but there was also higher relative risk of suicide among coffee
drinkers that drink 0-1 cups/day (RR=1.00) compared to coffee drinkers that
2-7 cups/day (RR=0.67-0.82). The result of association differs among the
coffee drinkers and it may become insignificant.
b) Bias (Yes/No)
Explanation :
The association between coffee drinking and risk of suicide may be because
of bias. The first type of bias that may occur is recall bias. The subjects of the
study may not remember clearly the amount of coffee they drank, and so the
data they provided on the questionnaire weren't accurate. And there was a
flaw in determining the measurement of amount of coffee. In this study, the
amount of coffee was measured in cups, but the researchers didn't state how
many milliliters a cup of coffee exactly is. The size of cups may vary
differently. And this may cause measurement bias. There was also no
classification of different types of coffee and their amount of caffeine in each
cup. Another type of bias in the study is the selection bias. The populations
chosen were the people in Finland. According to the trade statistics, the Finns
drink many cups of coffee per day, and they also have high rates of suicide
cases. So, the sample chosen cannot truly represent the general public,
because the Finns already have high rate of suicide previously. So, the result
of the study would more likely show that there's association between coffee
drinking and suicide risk. In addition, there may be changes of circumstances
in lives of the subjects that may also change the coffee-suicide association.
This makes the sample unfit to represent true population. And there may be
loss of follow up that leads to information bias. This is because there were
many subjects and the time of study is long-term. So it is difficult to keep on
following up with the subjects, especially when they would be unwilling to
continue to be observed in the study. Aside from that, the information on
suicide deaths, obtained from the National Death Register, may be
incomplete and inaccurate. These problems can also cause the study to be
information-biased.

c) Confounding (Yes/No)
Explanation :
Confounding is also a possible association between coffee drinking and the
risk of suicide. There may be a third factor that was the real cause of suicide,
and that was not observed. These confounding factors are mental health
 problems, such as depression, anxiety, fear, phobia and etc. Although the
subjects with mental health problems at baseline were excluded, there is also
a potential that the subjects may develop mental health problems afterwards.
This is because coffee is an addictive psychoactive substance that may
increase nervousness, fear, tension, palpitations, restlessness, tremors and
may induce the subject-related anxiety and panic attacks in sensitive normal
subjects. The subjects may also encounter problems or certain circumstances
in their lives, such as unemployment or relationship problems that would
lead to stress and depression. This can cause them to be emotionally unstable
and have thoughts about ending their lives.

d) Reverse Time Order (Yes/No)

Explanation :
There is no possibility that the association is actually a reversed time order.
People who had high risk of suicide would experience many mental and
psychological problems. They wouldn't have the time or interest to even
drink coffee. It is also impossible that people who wanted to end their lives,
would drink many cups of coffee on a daily basis. While, a possible situation
is that people who had high risk of suicide would overdose on drugs or
alcohol. But, they are not likely to develop heavy coffee drinking habit.

e) Causal (Yes/No)
Explanation :
Suicide is the act of killing oneself, and it is often caused by mental disorder
or psychological problems, such as depression, stress and anxiety. While
during the beginning of the study, people with feelings of depression,
anxiety, phobia or psychosocial stress, and with current psychotropic
medication at baseline were excluded. Drinking coffee itself does not directly
cause the increase of risk of suicide, instead, there may be a third factor
(confounding) that wasn't observed. Even if heavy coffee drinking and
suicide are significantly associated, there is also no explanation about how
and why, biologically, heavy coffee drinking could give rise to the risk of
suicide. Therefore, it's not biologically plausible. The result of the study is
also different from the previous studies, and that makes it inconsistent.
4. The most possible Association : Bias
The most possible association is bias, because we can find many evidences, as
written above, that prove the study to have many cases of bias.

5. Write 2 action of prevention/policy (practical) to prevent the risk of suicide.

 The first suicide prevention is that we can provide crisis intervention for the
people who have the risk of suicide. The people with the risk of suicide can
have a structured counseling and psychotherapy with a professionally trained
therapist. They can also call the suicide hotline to get rid of the thoughts of
suicide, because the suicide hotline provides free and confidential emotional
support for people in suicidal crisis or emotional distress. We can also
promote suicide prevention campaigns in the community, such as schools, and
give educations about suicide, its risk factors and prevention.
 The second prevention is to form a support group that can help prevent
suicide. The support group can be in a form of voluntary group or even
religious group. The people with risk of suicide are invited to join the
voluntary group so that they can meet other people and learn to care for others,
and especially for themselves. They can learn to share their problems with
others so that the others can provide emotional support. They can also have
recreational activities to relieve stress. While in religious groups, the people
with risk of suicide can join rituals and prayers. Through those activities, they
can learn more about their religion and they'd be taught about value of life and
that they should avoid having any suicidal thoughts.

6. Write the weaknesses in the study and give suggestions that can make this study
better.
There were many limitations that made the study flawed. The first one is there
are many biases, such as measurement, information and selection bias, as what I have
explained above. The researchers were also not able to do a complete follow up and to
control the subjects until the end of the study. There may be some life circumstances
of the subjects that may alter the coffee-suicide relationship. So, I suggest the study
should minimize the bias and avoid the loss of follow up.