Sex-specific association of acute alcohol use with suicide risk: a meta-analysis of observational studies

This meta-analysis aims to investigate sex-specific associations between acute alcohol use (AAU) and suicide risk, with a focus on gender-stratified relationships between AAU and specific suicide methods. A systematic search was conducted in PubMed, Embase, and the Cochrane Library from their inception to May 2025. Observational studies on suicidal behaviors following AAU were included, providing odds ratios (ORs) and 95% confidence intervals (CIs) for suicide risk and suicide methods. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was employed to evaluate the overall quality of the evidence. Pooled sex-specific ORs were calculated using fixed-effects models when P ≥ 0.1 and I² ≤ 50%, and random-effects models were used when P < 0.1 or I² > 50%. Sensitivity analyses, funnel plots, and Egger’s test were used to assess the robustness of the results and publication bias. Subgroup analyses examined geographic regions and suicide methods. Eleven observational studies involving 352,634 individuals were included. The pooled OR estimate was numerically higher for females (OR = 2.04, 95% CI: 1.24–3.36, I² = 97.8%, P < 0.001, very low quality) than for males (OR = 1.62, 95% CI: 1.24–2.11, I² = 98.7%, P < 0.001, very low quality). Subgroup analyses revealed that both males (OR = 6.82, 95% CI: 1.71–27.1, I² = 86.5%, P = 0.007, very low) and females (OR = 3.62, 95% CI: 1.67–7.86, I² = 75.2%, P = 0.018, very low) had a higher incidence of suicide attempts compared to suicide deaths, the strongest associations in North America for both males (OR = 2.44, 95% CI: 1.49–4.00, I² = 97.9%, P < 0.001, very low quality) and females (OR = 2.62, 95% CI: 1.54–4.46, I² = 96.8%, P < 0.001, very low quality). Concerning suicide methods, AAU was significantly associated with an increased risk of drowning (OR = 1.28, 95% CI: 1.04–1.58, I² = 46.2%, P = 0.021, low quality), but not with jumping, hanging, or firearm use. The results were robust in sensitivity analyses, and no significant publication bias was detected. The findings suggest that AAU is associated with increased suicide risk, and the association appears to be stronger in females than in males. The relationship appears particularly pronounced in North America. AAU may also specifically elevate the risk of suicide by drowning. These findings underscore the importance of sex-specific interventions targeting AAU in suicide prevention efforts. The protocol for this meta-analysis was pre-registered on PROSPERO (Preregistration ID: CRD420251054210). Not applicable.