Suicide risk in adults with Asperger's syndrome

Abstract

In The Lancet Psychiatry, Sarah Cassidy and colleagues1Cassidy S Bradley P Robinson J Allison C McHugh M Baron-Cohen S Suicidal ideation and suicide plans or attempts in adults with Asperger's syndrome attending a specialist diagnostic clinic: a clinical cohort study.Lancet Psychiatry. 2014; (published online June 25.)http://dx.doi.org/10.1016/S2215-0366(14)70248-2Google Scholar report a surprisingly high prevalence of lifetime experience of suicidal ideation and suicide plans or attempts among adults with Asperger's syndrome compared with patients with psychotic disorders in another study.2Radomsky ED Haas GL Mann JJ Sweeney JA Suicidal behavior in patients with schizophrenia and other psychotic disorders.Am J Psychiatry. 1999; 156: 1590-1595PubMed Google Scholar This finding should encourage clinicians to be vigilant in assessment of the risk of suicide in these patients. Until now, the issue of suicide has been neglected in the scientific literature about autism, possibly because of the low rate of suicidal behaviour in children and preadolescents3Dervic K Brent DA Oquendo MA Completed suicide in childhood.Psychiatr Clin North Am. 2008; 31: 271-291Summary Full Text Full Text PDF PubMed Scopus (104) Google Scholar and the underdiagnosis of autism spectrum disorders in the adult psychiatric setting.4Engström I Ekström L Emilsson B Psychosocial functioning in a group of Swedish adults with Asperger syndrome or high-functioning autism.Autism. 2003; 7: 99-110PubMed Google Scholar Specialists in autism spectrum disorders deal mainly with children or preadolescents, and rarely examine suicidal behaviour and suicide. However, adults with autism spectrum disorders are seldom seen by mental health professionals unless they present with mood changes, obsessive or psychotic symptoms, or behavioural disorders in addition to autism spectrum disorder. These adults are usually treated by psychiatrists unfamiliar with childhood-onset disorders and are often given an incorrect diagnosis (eg, schizophrenia, schizoid or schizotypal personality disorder, obsessive-compulsive disorder, mood disorder, or social phobia), meaning that suicidal behaviour in adult patients with autism spectrum disorders is often not linked with the unrecognised psychopathological autistic dimension. One caveat of Cassidy and colleagues' study is that it included data only from patients who were not diagnosed with Asperger syndrome until adulthood, because they grew up before the disorder was formally recognised. A question for future research is whether patients correctly diagnosed and treated as children show the same risk of suicidal ideation, plans, and attempts in adulthood. Prospective studies are needed to evaluate rates of suicidal ideation, plans, and attempts in adults with autism spectrum disorders in different settings, such as general or psychiatric hospitals, mental health services, rehabilitation services, and specialist autism centres. An interesting finding reported by Cassidy and colleagues is that the depression dimension is distinct from the suicidality dimension. Although patients with a history of depression reported more frequent suicidal ideation and suicide plans or attempts than did those with no history of depression, far more patients reported suicidal ideation than reported a previous diagnosis of depression. Suicidality is also distinct from depression in patients with mood or psychotic disorders, and is more closely related to variables such as impulsivity5Swann AC Dougherty DM Pazzaglia PJ Pham M Steinberg JL Moeller FG Increased impulsivity associated with severity of suicide attempt history in patients with bipolar disorder.Am J Psychiatry. 2005; 162: 1680-1687Crossref PubMed Scopus (329) Google Scholar or physical aggressiveness.6Brent DA Bridge J Johnson BA Connolly J Suicidal behavior runs in families. A controlled family study of adolescent suicide victims.Arch Gen Psychiatry. 1996; 53: 1145-1152Crossref PubMed Scopus (420) Google Scholar Intensity of depressive symptoms and risk of suicide are not closely related. Some patients with mild or no depressive symptoms present serious suicidal behaviour, whereas others with extremely severe depression show no suicidal behaviour.7Koukopoulos A Koukopoulos A Agitated depression as a mixed state and the problem of melancholia.Psychiatr Clin North Am. 1999; 22: 547-564Summary Full Text Full Text PDF PubMed Scopus (267) Google Scholar Interestingly, in Cassidy and colleagues' study, patients reporting suicide plans or attempts had higher Autism Spectrum Quotient scores (ie, presented more cognitive-behavioural traits associated with autism) than did the rest of the cohort, suggesting a specific role of autistic psychopathology in fostering of suicidal behaviour. This study highlights the need to develop appropriate psychological and psychopharmacological therapies. The rigid thinking style and lack of imagination (ie, not being able to see any other way out) that is typical of Asperger's syndrome might respond well to psychological interventions. No systematic data about psychopharmacological treatment of suicidality in autism spectrum disorders have been reported. The high risk of suicidal behaviour in these patients suggests an urgent need to test drugs that have shown efficacy in the prevention of suicide in other disorders (eg, lithium8Carney SM Goodwin GM Lithium—a continuing story in the treatment of bipolar disorder.Acta Psychiatr Scand. 2005; 426: 7-12Crossref Scopus (49) Google Scholar or clozapine9Meltzer HY Alphs L Green AI et al.Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT).Arch Gen Psychiatry. 2003; 60: 82-91Crossref PubMed Scopus (1052) Google Scholar) in these patients. Medical specialists therefore need to be involved in services for adults with autism spectrum disorders. Suicidal behaviour in patients with autism spectrum disorders might be related to different clinical features than are those typically noted in patients with mood or schizophrenia spectrum disorders, which probably contributes to the difficulty of recognising suicidal risk in these patients. The identification of specific risk factors for suicide in patients with autism spectrum disorders would be clinically useful in view of the fact that many of the features of these disorders—eg, impaired social interaction and communication, lack of emotional reciprocity, and inappropriate or bizarre behaviour—make psychiatric assessment difficult. Anecdotal evidence suggests that delusions and hallucinations in adults with autism spectrum disorders are associated with a high risk of dying by suicide;10Raja M Azzoni A Frustaci A Autism spectrum disorders and suicidality.Clin Pract Epidemiol Ment Health. 2011; 7: 97-105Crossref PubMed Scopus (47) Google Scholar hopelessness, impulsivity, pervasive obsessive traits, and physical aggressiveness should also be investigated. A major question is the role of familial suicidality, because risk of suicidal behaviour (including attempts and completion) seems to be transmitted within families as a trait independent of categorical psychiatric diagnoses.6Brent DA Bridge J Johnson BA Connolly J Suicidal behavior runs in families. A controlled family study of adolescent suicide victims.Arch Gen Psychiatry. 1996; 53: 1145-1152Crossref PubMed Scopus (420) Google Scholar Cassidy and colleagues' study makes an important contribution to clinical practice by highlighting the risk of suicide in adults diagnosed with Asperger syndrome. Future studies should assess which psychopathological aspects of autism, comorbid mental symptoms, and behavioural abnormalities are related to suicidality, and investigate both psychological and pharmacological interventions to reduce the risk of suicide in this population. I declare no competing interests. Suicidal ideation and suicide plans or attempts in adults with Asperger's syndrome attending a specialist diagnostic clinic: a clinical cohort studyOur findings lend support to anecdotal reports of increased rates of suicidal ideation in adults with Asperger's syndrome, and depression as an important potential risk factor for suicidality in adults with this condition. Because adults with Asperger's syndrome often have many risk factors for secondary depression (eg, social isolation or exclusion, and unemployment), our findings emphasise the need for appropriate service planning and support to reduce risk in this clinical group. Full-Text PDF Open Access