Autism and Suicide Risk: What Do We Know?

I was reading SpectrumNews yesterday, and came across an important article about increased suicide risk among women with ASD. I went to the original article to learn more about the research, and wanted to share what I found. This research provides critical information about suicide risk in males and females with ASD (with and without intellectual disability and attention deficit/hyperactivity disorder).

The study

The study was published in June, 2019 in Psychological Medicine and included more than 54,000 individuals with ASD and matched controls. The research was conducted in Sweden using data collected between 1987-2013 from Swedish national registers. The overall goal of the study was to better understand whether individuals with ASD are at an increased risk of suicide attempts or death by suicide compared to neurotypical controls. Another goal was to explore whether suicidal actions were further increased in individuals with ASD + attention deficit/hyperactivity disorder (ADHD) and/or intellectual disability (ID). Finally, the authors wanted to better understand gender differences in suicide attempts/death by suicide.

Methods

Researchers separated records from individuals with ASD into four separate groups:

1. Those with ASD without ID or ADHD (24,535 people)

2. Those with ASD without ID with ADHD (19,035 people)

3. Those with ASD with ID and ADHD (2,894 people)

4. Those with ASD with ID without ADHD (7,704 people)

Within these four groups, researchers further parsed the effect of gender (i.e. the difference in suicide risk for males in a given group versus females in a given group). Finally, the researchers controlled for other psychiatric conditions that are known to increase the risk of suicide (i.e. depression, anxiety, substance abuse).

Results

I am going to discuss the findings for suicide attempts/death by suicide for each group one at a time, starting with group 1 (ASD without ID or ADHD).

ASD without ID or ADHD

Individuals with ASD who did not have ID or ADHD were over 4x more likely to attempt suicide compared to controls (women were over 6x more likely to attempt).

When taking other psychiatric conditions into account (depression, anxiety, substance use), the group overall was 1.7x more likely to attempt suicide than controls (women were 2x more likely to attempt).

In terms of death by suicide, even when controlling for the psychiatric conditions mentioned above, the group overall was over 4x more likely to die by suicide (women were 3.85 more likely to die by suicide).

ASD without ID with ADHD

Individuals with ASD who did not have ID, but who did have ADHD were over 7x more likely to attempt suicide than neurotypical controls (women were over 10x more likely to attempt). The authors noted that among females in this group, approximately 1:5 had attempted suicide at least once (20.39%).

When controlling for other psychiatric conditions, the group overall was 2.3x more likely to attempt suicide (women were 2.8x more likely to attempt).

In terms of death by suicide, after controlling for the psychiatric conditions above (depression, anxiety, substance use), the group overall was 3.6x more likely to die by suicide compared to controls (women were 3.15 more likely to die by suicide).

ASD with ID and ADHD

Individuals with ASD and ID + ADHD were over 5x more likely to attempt suicide than neurotypical controls (women were over 6x more likely to attempt).

When controlling for other psychiatric conditions, the group overall was 2.9x more likely to attempt suicide (women were 2.4x more likely to attempt).

There were insufficient numbers of death by suicide in this group to conduct analyses.

ASD with ID without ADHD

Individuals with ASD and ID, but who did not have ADHD were over 2x more likely to attempt suicide than neurotypical controls (women were over 2.5x more likely to attempt).

When controlling for other psychiatric conditions, the group overall was 2x more likely to attempt suicide (women were 1.9x more likely to attempt).

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In terms of death by suicide, after controlling for the psychiatric conditions above (depression, anxiety, substance use), the group overall was 1.4x more likely to die by suicide compared to controls. There were insufficient numbers to analyze how likely women alone were to die by suicide in this group.

Conclusions

Overall, this study is extremely informative in terms of how to help individuals with ASD. It is troubling to see such a significant increase in risk of suicide attempts and death by suicide in individuals with ASD, particularly the marked increase in suicide attempts for women with ASD and ADHD.

This article underscores the importance of paying more attention to suicidal ideation/risk in those with ASD, and to never ignore warning signs of suicide (here is a list of warning signs, although keep in mind that not all suicide attempts/completed suicides have these signs beforehand).

From a clinical perspective, it is important for us to remember this increased risk. For many of us, we were taught that ADHD, depression, anxiety, bipolar disorders, substance use disorders, and other diagnoses come with increased suicide risk. However, ASD is not a condition that is typically taught as one in which suicide risk is increased. Unfortunately, that means clinicians are often on "high alert" for any signs of suicidal ideations/behaviors in the aforementioned diagnoses, but not necessarily watching as carefully for warning signs in those with ASD. This article is a clear signal for all of us to be more vigilant/careful about watching for these signs in ASD, and to teach clinicians-in-training that ASD comes with increased suicide risk.