Global burden and trend of substance use disorders, self-harm, and interpersonal violence from 1990 to 2021, with projection to 2040

doi:10.21203/rs.3.rs-5001193/v1

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Global burden and trend of substance use disorders, self-harm, and interpersonal violence from 1990 to 2021, with projection to 2040

https://doi.org/10.21203/rs.3.rs-5001193/v1

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Background: Alcohol use disorders (AUD), drug use disorders (DUD), interpersonal violence, and self-harm are a major public health concern globally, with high rates of disability, morbidity, and mortality associated with this. To estimate the burden, trends, forecasts, and disparities of AUD, DUD, interpersonal violence, and self-harm among all ages and sexes from 1990 to 2021.

Methods: This was a cross-sectional study that used data from the Global Burden of Disease (GBD) 2021 in 204 countries and territories. The incidence, deaths, and disability-adjusted life years (DALYs), projection, and the inequality were estimated for AUD, DUD, interpersonal violence, and self-harm among all age and sex.

Finding: In 2021, there were 55.78 million new cases of AUD, 13.61 million new cases of DUD, 29.40 million new cases of interpersonal violence, 5.49 million new cases of self-harm globally, while in 2040 will be 51.98 million of AUD, 13.81 million of DUD, 36.01 million of interpersonal violence, and 10.55 million of self-harm. The burden of age standardized rates of incidence, mortality, and DALYs for AUD, DUD, interpersonal violence, and self-harm were higher in male than in female across all ages. Meanwhile, ages 15-49 have the highest burden of DUD, interpersonal violence, and self-harm, and ages 50-74 have the highest burden of AUD. We also found that 68.45% of attributable deaths due to self-harm and interpersonal violence were related to AUD, and 11.11% related to DUD based on GBD 2021 results. Between 1990 and 2021, both the slope index of inequality and relative concentration index decreased for AUD and interpersonal violence, and increased for DUD and self-harm.

Interpretation: Multilevel interventions should be initiated to prevent disease burden related to DUD, interpersonal violence, and self-harm among individuals ages 15-49, and the burden of disease related to AUD among individuals ages 50-75, especially among male. Policy for the management of alcohol and drug use can also simultaneously reduce the social burden of interpersonal violence and self-harm.

The harm arising from alcohol use disorders (AUD), drug use disorders (DUD), interpersonal violence, and self-harm are internationally-accepted public health challenge. The high incidence and serious consequences of these behaviors impose an enormous burden on individuals, families and communities. AUD, DUD, interpersonal violence, and self-harm are interrelated and associated with social chaos. The global burden of alcohol and drug is not only attributed to their inherent characteristics as risk factors, but a significant part can be attributed to the health consequences they produce, such as self-harm and interpersonal violence.^[1] Similarly, the burden caused by interpersonal violence and self-harm can be partly attributed to the influence of alcohol and drug. The complex causal relationship increases the difficulty of burden statistic and the formulation of public health policy. Compared to alcohol and drug abuse, the statistic of interpersonal violence and self-harm incidence cases may be seriously underestimated, which may related to many factors, like personal privacy and social factors.^[2] Currently, certain regions are engaged in the collection of data on interpersonal violence and self-harm, while some regions are still lacking, thus the global statistic remain ambiguous, which make it more difficult to formulate and disseminate globalized health public policy.

Previous studies on these social events have tended to focus on specific population (i.e., 10–24, years adolescence and young adult) and regions^[3–5], and lacks research on the burden of social events in all populations worldwide. This study aims to delve into the global burden caused by alcohol, drugs, interpersonal violence, and self-harm. Since each iteration of the Global Burden of Disease (GBD) recalculates the prevalence of risk factors and disease burden reports, we have re-estimated the incidence and disease burden of alcohol, drugs, interpersonal violence, and self-harm using the GBD 2021 dataset. In addition, by calculating the temporal trends from 1990 to 2021, we can capture the trends of these four risk factors across sex, age, and region. Finally, the burden of disease in 2040 is projected based on a Bayesian age-period-cohort (BAPC) mode. In short, we hope to contribute to public health policy and health promotion initiatives by providing more reliable and detailed data to support global health issues.

Study design and data sources

The GBD 2021 project estimated the disease burden associated with 371 diseases and injuries for 204 countries and territories from 1990 to 2021.^{[6, 7]}

In this study, we reported the quantitative burden of AUD, DUD, interpersonal violence, and self-harm for the period 1990–2021 by four age groups (0–14 years, 15–49 years, 50–74 years, 75་years), sex, 21 GBD regions and 5 SDI levels.

Case definition of AUD, DUD, interpersonal violence, and self-harm

Substance use disorders were defined based on ICD-10^[8] and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorder, version 4 (DSM-IV).^[9] Substance use disorders include AUD and DUD.^[6] The DUD in the GBD framework include opioid use disorders, cocaine use disorders, amphetamine use disorders, cannabis use disorders, and other use disorders.

Self-harm is a broad concept, ranging from non-suicidal self-harm to attempted suicide to suicides.^[10] The ICD-10 codes for self-harm are X60-X64.9, X66-X84.9, Y87.0. Interpersonal violence includes family and intimate violence and community violence. The ICD-10 codes for interpersonal violence are T74.2-T76.22, X85-Y08.9, Y87.1-Y87.2.

Estimating association between burden and sociodemographic index

Sociodemographic index (SDI) was used in the GBD study as a composite measure of development status, it derived by calculating the geometric mean of per capita income, mean years of schooling among individuals aged 15 years and older, and the total fertility rate (TFR) among females under 25 years of age.^[11] SDI scores ranges from 0 to 1, with 0 representing lowest income, lowest education, and highest TFR, and 1 representing highest income, highest education, and lowest TFR. The SDI score for each GBD location was updated annually.

In this study, we investigate the relationship between SDI and incidence, mortality, and DALYs rates attributable to AUD, DUD, interpersonal violence, and self-harm separately.

Decomposition analysis

To qualified the drivers of changes in the counts of individuals with AUD, DUD, interpersonal violence, and self-harm, we estimated the relative contribution of population growth, population aging, and epidemiology changes. We employed the Das Gupta method for decomposition analysis, using algebraic methods to isolate the standardized impact of each factor, and summarizing the influence of various factors on the observed changes.

Inequality analysis

The slope inequality index (SII) and the concentration index are used to measure health inequalities among different regions. The SII is calculated following: first, ranking countries or regions according to their socioeconomic status, calculating the cumulative proportion of health outcomes for each country or region; then, based on the Lorenz curve to illustrate the distribution of health outcomes; the end, the SII value is calculated based on the ratio of the area between the Lorenz curve and the line of perfect equality (the 45-degree line). A positive value of SII indicates that health outcomes are disproportionately concentrated in groups with higher socioeconomic status, while a negative value indicates concentration in groups with lower status. The concentration index is calculated by numerical integration of the area under the Lorenz curve. The concentration index is derived from the sum of the differences between the health status of each socioeconomic group and its distribution proportion in the total population, sorted by socioeconomic status. The value of the concentration index reflects the concentration of health outcomes among groups with different socioeconomic statuses, with a positive value indicating concentration in higher-status groups and a negative value indicating concentration in lower-status groups, and when there’s no inequality, the concentration index is at zero.

In this study, we analyzed the distribution and trends of disability-adjusted life years (DALYs) caused by AUD, DUD, interpersonal violence, and self-harm among different regions from 1990 to 2021.

Statistical analysis

The actual number was estimated with DisMod-MR 2.1^[12], a Bayesian meta-regression tool that estimates non-fatal health outcomes by location, age, sex, and year. The incidence, prevalence, mortality, years lived with disability (YLDs), years of life lost (YLLs), and DALYs of AUD, DUD, interpersonal violence, and self-harm were original downloaded from the GBD 2021 result tool (http://ghdx.healthdata.org/gbd-results-tool). YLDs are years lived with disability estimated by multiplying estimates of different severity with appropriate disability weights. YLLs are years of life lost due to premature death, calculated from the number of observed deaths and the reference standard life expectancy at age of actual death, which is obtained from the GBD standardized life tables. All accessible data, including those for covariates, were used to develop a set of plausible models and eventually, the best ensemble predictive model to produce estimates of deaths and YLLs by location, age, sex, and year. DALYs are disability-adjusted life years, as the sum of total health loss for each disorder, location, age group, sex, and year. DALYs calculated by the equation of DALYs = YLLs ་ YLDs. Age-standardized incidence, prevalence, deaths, YLLs, YLDs, and DALYs were estimated using the GBD world population age standard. The temporal trends in incidence, mortality, and DALYs rates from 1990 to 2021 calculated with estimated the annual percent change (EAPC). The EAPC value over 0 indicate an upward trend, and less than 0 signify a downward trend. Annual percentage change (APC) of age and regions trend calculated by Joinpoint regression model. The projection analysis is performed by Bayesian age-period-cohort model (BAPC) to forecast the disease burden until 2040. BAPC employ integrated nested Laplace approximations (INLA) to facilitate comprehensive Bayesian inference, and the Poisson noise will be involved when focus on the predictive distribution. All statistical analysis and visualization of results were performed by using the R software (version 4.3.0) and Joinpoint (version 4.9.0).

Role of the funding source

The funder of the study had no role in the study design, data collection, data analysis, data interpretation, or the writing of the report. All authors had full access to the data in the study and final responsibility for the decision to submit for publication.

Global trend in incidence

Globally in 2021, an estimated 69.39 million people with AUD and DUD, 34.89 million people have experienced interpersonal violence and self-harm. From 1990 to 2021, there was a declining trend in the annual change of age-standardized incidence rates (ASIRs) worldwide for AUD with an EAPC at -0.79%, DUD at -0.36%, interpersonal violence at -1.44%, and self-harm at -1.42% (Table 1 and Figure S1).

Global trend in mortality

Approximately 0.17 million deaths were associated with AUD and DUD, 1.07 million deaths were associated with interpersonal violence and self-harm in 2021 worldwide. Similarly, from 1990 to 2021, there was a declining trend in the annual change of age-standardized mortality rate (ASMRs) for AUD with an EAPC of -1.75%, interpersonal violence at -1.40%, and self-harm at -1.97%, while DUD showed an upload ASMR with an EAPC of 0.28% (Table 1 and Figure S1).

Global trends in DALYs

Globally in 2021, an estimated 32.54 million DALYs cases were associated with AUD and DUD, 60.36 million DALYs cases were correlation to interpersonal violence and self-harm. From 1990 to 2021, attributable age-standardized DALYs rate (ASDRs) showed a downward trend in AUD, interpersonal violence, and self-harm, with EAPC of -1.30%, -1.35%, and -1.96%, respectively, while DUD remained relatively stable, with an EAPC of 0.04% (Table 1 and Figure S1).

Global trends by sex

From 1990 to 2021, males experienced higher incidence and death rates for AUD, DUD, and interpersonal violence, and with pronounced fluctuating trends. Conversely, the self-harm incidence was more common in females, and showing an increasing trend for both sexes. The burden of attributable DALYs was higher for males for all four causes. Over the past three decades, the change in the number of DALYs due to AUD and interpersonal violence have remained stable for females and fluctuated for males. Meanwhile, the number of DALYs due to DUD has increased for all sexes. Despite larger incidence number of self-harm among females, the decline in DALYs is more pronounced for females than males (Figure 1 and Table S1-3).

Global trends by age group

The trends in ASIRs vary across the four causes, with all ASIRs peaked in the 15-49 age group and show a declining trend from 1990 to 2021 (average annual percent change of ASIR for AUD was -0.24, DUD was -0.23, interpersonal violence was -1.39, and self-harm was -0.74). Whereas ASDR varies across the four causes, such as for AUD, the peak age group has shifted to 50-74 age group, showed a significant downward trend between 1994 to 1998 with an APC of -4.26 (Figure 2).

Global projection

Globally in 2040, the projection of incidence and DALYs attributable to AUD will decrease by -2.45% and -13.52% compared to 2021, and the AUD incidence for males will be 3.83 times higher than females. The incidence, DALYs, and ASDRs of DUD are expected to increase 3.48%, 24.60% and 7.18%, respectively, while ASIRs will decrease by -11.01%, and the burden of DUD still higher for males. The incidence and ASIRs for interpersonal violence are expected to increase by 20.53% and 3.76%, while the DALYs and ASDRs will decrease by -22.03% and -32.87%, with the burden of interpersonal violence still being heavier in males. The incidence and ASIRs of self-harm are expected to increase significantly by 96.98% and 69.28%, while the DALYs and ASDRs will decrease by -7.52% and -20.41%, respectively. Self-harm remains prevalent among females, with 2.15 times more than male cases, whereas the DALYs is higher among males, with 1.8 times more than females (Figure 3).

Regional trends

By SDI category, for AUD, DUD, and self-harm, we found the highest ASIR, ASMR, and ASDR in countries with a high and high-middle SDI, and countries with a low SDI had the highest ASMR and ASDR for interpersonal violence. Burden of AUD, DUD, and self-harm were higher in high SDI regions, with an extra 8.52 million incidence cases and 12.42 million DALYs compared to low SDI regions. Conversely, the burden of interpersonal violence was higher in low SDI, with an additional 2.26 million incidence cases and 2.47 million DALYs cases compared to high SDI (Figure 4 and Table S4-15).

From 1990 to 2021, among the GBD regions, five Sub-Saharan Africa regions have significantly increased in the incidence of AUD and DUD, and South Asia and East Asia have distinct decreased ASIRs for AUD and DUD. The largest increase of interpersonal violence incidence was in Oceania region with 2.20%, followed by Western Sub-Saharan Africa with 1.15%, where was also increased for self-harm incidence with 1.88%. The downward trend for ASIRs of interpersonal violence has observed in Central Asia (-2.47%), East Asia (-2.55%), and Eastern Europe (-2.29%) regions. East Asia had the highest downward trend for ASIR in self-harm, with an EAPC of -2.87% (Table S4-15).

ASMRs for AUD, DUD, interpersonal and self-harm in high-middle SDI shown a download trend over the period 1990-2021. High-income North America had the significant higher growth trend in ASMRs of AUD and DUU, while East Asia had distinct downward trend in ASMRs of AUD (-6.19%), interpersonal violence (-5.41%) and self-harm (-4.11%) (Table S4-15).

In terms of DALYs caused by AUD, the highest burden was in South Asia with 3.23 million incidence cases and ASDR of 175.81 per 100 000 in 2021. As for DALYs caused by DUD, the highest burden was in high-income North America with 6.81 million cases, and the lowest incidence was in Oceania with 9679.65 cases. Central Latin America had the highest burden attribute to interpersonal violence with DALYs of 4.56 million cases and ASDR of 1705.92 per 100 000 in 2021. South Asia had the highest burden attribute to self-harm with DALYs of 11.32 million cases and ASDR at 576.13 per 100 000 in 2021, and with an EAPC of -1.63% from 1990 to 2021 (Table S4-15).

The relation of ASIR, ASMR, ASDR and SDI

Figure 5 shown the observed regional and ASIR, ASMR, and ASDR in relation to SDI, and the expected level for each location on the basis of SDI. From 1990 to 2021, we observed the Caribbean, South Sub−Saharan Africa, and Central Sub−Saharan Africa closely followed expected trends in ASDRs from 1990 to 2021. North Africa and Middle East, High-income Asia Pacific, East Asia staying well below expected levels throughout the study period with little change in ASDRs. Eastern Europe well above expected levels with fluctuating ASDRs. For DUD, most regions were closely followed expected trends, expected for Eastern Europe and High-income North America with a higher trend than expected. Conversely, in interpersonal violence, most regions were far from the expected trend, and Southern Sub-Saharan Africa, Central Asia, Central Latin America, and Eastern Europe significantly higher than expected trend over the study trend. Similar to interpersonal violence, ASDRs attributable to self-harm showed an unpredictable trend with a fluctuating line in most regions, and Eastern Europe distinctly higher than expected trend.

Cross-nation health inequality

In 2021, the SII for ASDRs of AUD, DUD and self-harm were 207.32 per 100 000, 121.13 per 100 000 and 134.11 per 100 000, respectively, indicating a positive correlation between ASDRs and SDI index, whereas SII for ASDR of interpersonal violence was -314.38 per 100 000, indicating a negative relation between ASDR and SDI index. From 1990 to 2021, the relative gradient inequality, as measured by the relative concentration index, was -0.15 and -0.11 for AUD, -0.11 and -0.42 for DUD, 0.06 and 0.16 for interpersonal violence, and 0.04 and 0.01 for self-harm, which suggests that relative inequality in the burden of AUD and self-harm have decreased, while DUD and interpersonal violence have increased regionally between the poor and the rich populations. From 1990 to 2021, both the SII and relative concentration index decreased for AUD and interpersonal violence, increased for DUD and self-harm (Figure 6).

Decomposition analysis of the changed DALYs

Decomposition analysis revealed that epidemiological alteration demonstrated a considerable positive contribution of 105.62%, 677.97%, 1395.58% to the decreased DALYs burden of AUD, interpersonal violence, and self-harm from 1990 to 2021, respectively. Conversely, epidemiological alteration shown a negative contribution of -23.87% to the decreased DALYs burden of DUD. Population growth and aging negatively impact on reducing burden of DALYs for AUD, DUD and self-harm, while the increased burden of interpersonal violence has been attributed to population growth (Figure 7).

In terms of the SDI regions, high SDI had a negative DALYs decreasing effect for AUD, DUD, and self-harm, especially in high-income North American region, which had the most significant increase in the burden of DUD, and mainly attributable to epidemiological alteration with 88.68%. The burden of DALYs associated with all four events increased in low- and low-middle SDI regions, largely attributable to population growth, especially in South Asia, where the burden of the four events was most pronounced (Figure 7).

This study estimated incidence, mortality, and DALYs attributed to AUD, DUD, interpersonal violence, and self-harm worldwide from 1990 to 2021. Globally in 2021, AUD carried the heaviest disease burden among these four behaviors, with an estimated 55.78 million new cases, followed by interpersonal violence, with 29.40 million new cases, 13.61 million new DUD cases, and 5.49 million new self-harm cases. The proportion of males among new AUD, DUD, and interpersonal violence, self-harm cases was 78%, 54.67%, 75.82%, 40.33%, while the proportion of males among DALYs were 80.91%, 62.05%, 77.48%, 68.65% and the proportion for new death cases were 85.32%, 71.26%, 82.31%, 69.54%, respectively. It is indicated that the severity of self-harm among males is more severe compared to females, which is consistent with previous findings^[13]. The 15–49 age group have the highest burden of DUD, interpersonal violence, and self-harm and tend to decreased with increasing age. While 50–74 age group has the highest burden of AUD, followed by the 15–49 age group, and similar trends in the APC of DALYs rate for these two age groups from 1990 to 2021.

These findings provide key insights for the formulation of public health policies and interventions, emphasizing the importance of prevention and early intervention due to high incidence and mortality rates. Focusing on the risk factors and interventions for specific gender and age groups is crucial. The high incidence and lower DALYs of self-harm among females suggest that they are more likely to seek help and treatment when experiencing mental health problems, which calls for a more comprehensive mental health counseling and support system. For the 15–49 age group, particularly adolescents and young adults, the implementation of early identification systems, such as educational programs on drug abuse, violence prevention, and mental health may improve the current situation of this demographic. For the 50–74 age group, provide specific interventions for AUD, such as screening and brief intervention programs, which may facilitate access to treatment and rehabilitation services. Whereas policies aimed at reducing occupational stress and promoting healthy lifestyles for middle-aged adults may benefit them more. Based on this data, it guides policy-making, monitors trends in health issues, and ensures the resource allocation is practical and effective.

Alcohol-specific policy development

In 2021, the disease burden caused by alcohol has shifted from sub-Saharan Africa to South Asia compared to the 2016 GBD study, and it is still mainly concentrated in low and lower-middle SDI regions, that may be related to stricter alcohol control and public health measures in high income countries. Compared to wealthier drinkers, poorer populations are more likely to engage in heavy episodic drinking, which can significantly increase the risk of death, that may be the mainly reason for the difference in life expectancy between Eastern and Western Europe^[14]. From 1990 to 2021, the DALYs burden caused by alcohol increased by 3.99 million worldwide. Except for declines in Central Europe, Eastern Europe, and the high-income Asia Pacific, all other regions have seen an increase, indicating that it is necessary for global health organizations to establish a framework convention for alcohol control.

Policies targeting alcohol can focus on aspects such as price (affordability), availability, social norms, and education. Reducing the supply of alcohol, especially by restricting late-night sales, will significantly reduce the public health burden of AUD. We always hope to raise awareness of the adverse consequences of alcohol use through education and information provision, even though there is currently no high-quality evidence to suggest that providing cognition and education can substantially reduce the harm of AUD. Alcohol policies are defined as a series of measures aimed at minimizing the health and social harm caused by drinking.^[15] Although most research on the effectiveness of alcohol policies has been conducted in high-income countries, these policies have good generalizability and are also applicable to other societies. For example, increasing taxes, setting maximum consumption limits, raising the minimum purchase age, and regulating supply and marketing can reduce the adverse consequences related to AUD.^[16] Drunk driving is a common consequence of drinking, which can be reduced through a series of interventions, such as strengthening random breath testing to lower alcohol-related casualties. Implementing effective drunk driving policies can also commit the public and politicians to such measures and provide a reference for the gradual implementation of other policy measures, with media channels being utilized when necessary. Furthermore, early identification and brief advice for individuals engaging in harmful drinking but not yet dependent have been proven effective in both high and low-income countries, and for those with severe alcohol dependence, pharmacological therapies such as glutamate inhibitors and opiate antagonists can reduce the adverse consequences of alcohol.^{[17, 18]} It should be noted that among all mental health disorders, AUD has the lowest treatment rate. Currently, the first-line medications for alcohol intervention are naltrexone and acamprosate, with oral naltrexone being more effective in reducing the rate of relapse to heavy drinking compared to acamprosate.^[19] However, medication compliance among the AUD population is relatively low, with only 0–5% of AUD patients in Australia adhering to a 3-month course of naltrexone or acamprosate treatment.^[20] In the United States, the number of deaths attributable to unhealthy drinking can reach 145,000 per year, and a 2020 statistical report indicated that over 29.5 million people in the U.S. meet the diagnostic criteria for AUD, yet only 0.9% are receiving treatment.^[21] It indicated that medicine is far from sufficient for the treatment of AUD, and combined with other interventions may be more effective.

Drug-specific policy development

Currently, DUD burden remained higher in high SDI regions, especially in high-income North America. This may be related to economic availability and drug communities established in high-income countries. It also indicates that even in high-income countries, the development and implementation of public health policies is not perfect; for example, racial discrimination persists in North America's drug poisoning emergencies.^[22] In 2020, 37.3 million people over the age of 12 in the United States have used illegal drugs, with 24.7% of them having opioid use disorders.^[23] In Canada, 1,720 people died from opioid poisoning between April and June 2021, a 66% increase compared to the same period in 2019, which is largely attributed to clandestinely produced synthetic opioids, isolation, and limited access to medical and social services.^[24] Similar to alcohol, drug abuse is influenced by price and availability. South America is the top global supplier of cocaine^[25], and the high prevalence of cocaine use there may be related to low price, while low prevalence of heroin use in South America may be related to high price.

DUD individuals have intersecting structural vulnerabilities and may be accompanied by mental illnesses, personality or mood disorders^[26], experiencing inequalities in various resources (such as education, income, etc.), leading to social exclusion and relative poverty.^[26] Public health policies and social interventions that address the causes and consequences of this vulnerability can fundamentally reduce the burden of DUD. At the same time, harm reduction policies should be implemented, such as the distribution of sterile syringes and pharmacological interventions like methadone and naltrexone. The drug use issue among young people is currently a social focus, especially the 10–24 age group, who are at an important juncture of cognitive and emotional transformation and are very susceptible to drug dependence after external interventions. Regular health checks should be carried out for these high-risk groups. In addition, community treatment can reduce the burden of DUD, but the coverage of resources in this area is still relatively low, especially in low- and middle-income countries. Current drug policies usually only focus on one-dimensional social positions, emphasizing individual behavioral interventions. Incorporating cross-departmental approaches into drug policy may better adapted to multiple injustices, especially for institutions responsible for health and social policy, which remains challenging.^[27]

Interpersonal violence and self-harm specific policy development

One of the serious consequences of interpersonal violence and self-harm is mental health issues. Strengthening social support to alleviate the psychological pressure on those who have suffered from violence and self-harm is essential. Fortunately, from 1990 to 2021, the incidence, DALYs, and mortality rates of global violence and self-harm have shown a downward trend. This reflects an increased awareness of mental health issues worldwide and has also increased the opportunities for this group to access mental health services and social support. Previous GBD studies have found that alcohol and drug use disorders, as major risk factors for violence and self-harm, affect the social burden of disease. So that intervention policies targeting alcohol and drug use disorders may also improve the occurrence of violence and self-harm.

Females have higher self-harm rates, possibly related to the fact that the risk of depression in females is almost twice higher than males.^[28]. According to the psychiatric epidemiological survey report, it indicates that females tend to focus on their emotion more than males^[29], which may explain the high risk of depression in women. In addition, we found that males have a higher DALYs and mortality attributable to self-harm than females, indicating that they are more likely to choose fatal self-harm methods when encountering mental health problems. It is estimated that 60% of women experience violence at least once in their lives^[30], and the interpersonal violence suffered by the female population is more likely from intimate partner violence (IPV).^[31] This may be related to the vulnerable status of women in the family and society, as well as the remnants of gender discrimination culture. Although the social status of women has been significantly improved, further progress is still needed. Therefore, interventions targeting this group should address their specific needs and vulnerabilities, including raising the minimum marriage age, improving mandatory reporting systems for violence against minors, and integrating early education on preventing violence against girls into school curricula. In 2018, the U.S. Preventive Services Task Force (USPSTF) recommended IPV screening for women of childbearing age in all medical institutions, and the screening environment should consider differences between regions. The application of intervention measures, resource allocation, and other potential obstacles still need to be discussed. Future research can promote the implementation of public health policies in this field in the following ways: observing these harmful events, studying more new risks and protective factors in different regions and populations, evaluating the actual public health and emergency management measures after the occurrence of violence and self-harm events, incorporating the perspectives of survivors^[32], and understanding which services can help this group after the occurrence of violent events or even during mental health changes.

Many of the causes of the burden of alcohol and drugs are preventable or treatable. A plethora of policies aim to mitigate the health, social, and economic harm caused by alcohol and drugs. However, differences in geography, sex, etiology, age, and other factors lead to varying effectiveness and cost-effectiveness of these policies, posing challenges in identifying the most effective and economical methods for prevention and health improvement. It is important to note that AUD, DUD, interpersonal violence, and self-harm influence each other, complicating the etiology of these social events themselves. In this study, we found that alcohol as a risk factor accounted for 68.45% and 68.87% of attributable deaths and DALYs due to self-harm and interpersonal violence, and drug use contributed 11.11% and 9.92%, respectively, which is in line with previous studies. Hoaken et.al concluded that alcohol is more strongly associated with violence than any other psychoactive substance.^[33] Cherpitel C.J. and colleagues found an inverse U-shaped relationship between blood alcohol concentrations and the risk of violence^[34], and 14.9% of violence is alcohol-related.^[35] Acute intoxication increases the tendency to attempt suicide, while long-term alcohol use increases suicidal ideation.^[36] From 1990 to 2021, the proportion of DALYs caused by self-harm and interpersonal violence related to alcohol and drug use has changed, increased from 7.6–8.4% globally. Geographically, High-income North America saw a 6.5% increase in the proportion related to drug use, with alcohol remaining relatively stable. While in Andean Latin America, there was a more pronounced increase in the proportion related to alcohol of 5% (Figure S2). Overall, policies designed to control alcohol and drugs also apply to violence and suicide. According to our predictions, by 2040, the burden of AUD, DUD, interpersonal violence, and suicide will remain high worldwide. If left controlled, this will pose a heavy burden on global public health and social well-being.

Furthermore, the attributable burden across different SDI levels reveals the varying degrees of AUD, DUD, interpersonal violence, and self-harm, as well as the relationship between the burden and SDI. Our study results indicate that as SDI increases, the health impact of drug use may become more severe, while lower SDI regions face more complex and heavier health issues. Compared to high SDI areas, populations in lower SDI regions are exposed to more socioeconomic disadvantages, such as poverty, lack of education, and violence, and are more susceptible to mental health problems related to self-harm. However, they also have limited access to opportunities for prevention and treatment, creating a vicious cycle. Establishing comprehensive policies targeting social chaos factors globally is crucial for creating a favorable social environment, especially for those "diagnosed individuals" who wish to restore a healthy lifestyle and social environment. However, the coverage of these interventions remains low, particularly in low- and lower-middle income regions. Promoting collaboration between public health, education, law enforcement, and community organizations to jointly develop and implement effective intervention strategies is essential.

Limitation

In GBD studies, the concept of disability is confined to the health losses of individuals, excluding the social and other impacts on others, the absence of certain DUD, such as cannabis, leads to an underestimation of the estimated number of deaths. Furthermore, the data gap in medical facilities in less developed areas results in insufficient support for statistics on drug use and violence, significantly underestimating the detrimental effects of AUD and DUD, as well as interpersonal violence and self-harm on society. Additionally, GBD calculates the total disease burden of AUD without stratifying by severity, which may lead to varying impacts of public health intervention policies across different regions, impeding policy universality. The definitions of DUD severity differ from country to country, and the diagnostic coding for deaths caused by DUD also varies in some regions, leading to an under- or overestimation of the disease burden associated with DUD. To achieve more accurate data, it is essential to take into account the cultural, economic, and social contexts of different areas when compiling statistics on DUD.

Our findings provide insight into the contemporary and future global burden of AUD, DUD, interpersonal violence, and self-harm. Multilevel interventions should be initiated to prevent disease burden related to DUD, interpersonal violence, and self-harm among individuals ages 15–49, and the burden of disease related to AUD among individuals ages 50–75, especially among male. Policy for the management of alcohol and drug use can also simultaneously reduce the social burden of interpersonal violence and self-harm.

Human Ethics and Consent to Participate declarations: not applicable

Declaration of interests: All authors declare no competing interests.

Acknowledgement: The GBD 2021 study was supported by the Bill & Melinda Gates Foundation. The work in this paper was supported by the National Natural Science Foundation of China (81970265, 82270310, 82370306). The lead authors affirm that the manuscript is an honest, accurate, and transparent account of the study being reported.

Author contributions: Jia An, Qiang Wang, and Zihao Bai drafted the manuscript; Xueying Du first analysis the data; Di Yu and Xuming Mo revised the manuscript. All authors feedback the data statistical analysis, had full access to all the data in the study, and had final responsibility for the decision to submit for publication.

Funding: This work was supported by the National Natural Science Foundation of China (81970265, 82270310, 82370306), and Science and Technology Development Project of Nanjing (YKK21146).

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Table 1 is available in the Supplementary Files section.

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Global burden and trend of substance use disorders, self-harm, and interpersonal violence from 1990 to 2021, with projection to 2040

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