Monday, 21 October 2013

Suicidal behaviour in autism

The paper by Hannon and Taylor* was the starting point for today's post looking at suicidal behaviour among people diagnosed as being on the autism spectrum. Granted such a topic is hardly great dinner table conversation, but as per their suggestion on the prevalence of "suicidal behaviour among young people with ASD ranges from 7-42%", this is nevertheless a potentially important subject to cover. Even more so if one considers the age range included in the Hannon/Taylor review (< 25 years) allied to the numbers of children on the autism spectrum who are turning into young adults and the various challenges they face.

As I've indicated on previous posts, suicide either completed or ideation, is a very complicated process. It is neither uniform in the reasons which bring a person to such a state nor is it necessarily biomarker-able (despite some good research attempts - see here). I should also add that whilst there is some quite lively research interest looking into the role of certain agents or organisms being somehow correlated with suicide risk - think T.gondii and 'cat ladies' - issues remain in teasing out such variables as being the most important 'causative' ones in that relationship.

The Hannon/Taylor paper does provide one or two suggestions about how suicide might be a risk issue for some on the autism spectrum. To quote again: "Depression and abuse are risk factors for suicidal behaviour in this population". Indeed this issue of depression being a potentially important aspect was something that has been picked up by other authors, in particular the paper by everyone's favourite 'historical character has autism' author, Prof. Michael Fitzgerald in his paper on suicide and Asperger syndrome**. Depression as autism research sort of already knows, is no stranger to autism as comorbidity (see here) although there is still discussion about the hows and whys of depression onset in cases of autism. I'd hazard a guess that it's probably going to be a complicated, and yet again, non-uniform relationship.

The suggestion that abuse might be a risk factor for suicide ideation/completion in relation to cases of autism is also a very relevant topic these days. More than one campaigner (see here and here) here in the UK is bringing the issue of bullying in relation to autism for example, into the public consciousness. If one assumes that bullying (whether person-to-person or online) is a form of abuse, you can see how it might affect anyone; but perhaps more so someone who might already be quite anxious, sometimes quite socially-isolated and perhaps prone to a heightened degree of mental 'regurgitation' (i.e. going over the same thoughts again and again and again). The term also includes other forms of more readily recognised abuse such as physical or sexual abuse, which have also, unfortunately, been reported to be part and parcel of the history of some on the spectrum***.

Outside of depression and abuse being linked to suicide in autism, I was also drawn to the paper by Raja and colleagues**** (open-access here) and their suggestion that "Most patients with suicidal behavior or ideation presented psychotic symptoms". Again, this is a most interesting area of research when it comes to autism, albeit still quite an emerging area. I've talked before about the paper by Davidson and colleagues (see here) for example, reporting on the prevalence of Asperger syndrome in cases of first episode psychosis (3.6%). This combined with the growing interest in the overlap between the autism spectrum and the schizophrenia spectrum (see here) adds a further degree of complexity to the question of how suicide might be linked to cases of autism. And then there is the gender issue to consider when it comes to suicide...

Outside of the issue of awareness that as Kato and colleagues***** put it: "ASDs should always be a consideration when dealing with suicide attempts in adults at the emergency room", the combined research in this area offers some potentially important ways that professionals and families might be able to intervene if suicide ideation starts to become an issue for some on the spectrum. I've listed a few points below but please, don't see this as some sort of definitive list by any means. Also keep in mind my caveat on this blog about not giving medical or clinical advice being particularly important when it comes to something like suicide.

(i). Social circles and support. In the same way that having a social network might be one of the tools in the arsenal to relive parenting stress (see here) so I'm minded to point out that it might also serve some positive function when it comes to affecting risk of suicide in cases of autism. Extrapolating from research on the periphery of autism such as the paper by Szanto and colleagues****** some degree of social support or having a social network might be seen as a protective factor against suicide risk. How this translates practically is another issue, particularly in these austere times, but one could argue that social support could mean face-to-face contact or even something like an online group outside of just family contact. The issue of religious belief and affiliations impacting on suicide risk is perhaps a related issue and not necessarily something that should be discounted despite the sweeping generalisations made about autism and a belief in God.

(ii). Medication. I'm by no means qualified to talk about medication and who should be prescribed what, so please don't take this as any kind of advice. Drawing on research again outside or on the periphery of autism however, there does appear to be a case for certain medicines being used where suicide ideation comes about. Reutfors and colleagues******* for example, looking at suicide risk in schizophrenia and the use of preventative medication suggested that: "Lower suicide risk was found in patients who had been prescribed a second generation antipsychotic (clozapine, olanzapine, risperidone, or ziprasidone)". As I've mentioned, the Fitzgerald paper on suicide and Asperger syndrome also talked about depression as being potentially linked, so perhaps there may be merit in looking at medication to combat this aspect as also potentially affecting suicide risk. That being said, one has to mindful of the results by Björkenstam and colleagues******** (open-access) "linking initiation of SSRI to increased short-term suicide risk". The take-home message is to speak to someone in medical authority about this option.

(iii) The talking therapies. I'm not going to get too hung up on the use of things like cognitive behavioural therapy (CBT) as another option when it comes to suicide ideation and autism but it is something that could perhaps be considered for some. Based on the published literature on CBT for suicide ideation, the picture is still a little bit tentative for (a) effects and (b) why it may have some positive effect for some people. To quote from the paper by Handley and colleagues********* "CBT appears to be associated with reductions in hopelessness.... Less consistent results were observed for suicidal ideation". In short, it's again complicated.

There are various other strategies which have been suggested more generally with regards to suicide prevention (see here) but as of yet, there's little in the way of published evidence as to whether suicide ideation in cases of autism is more or less likely to be affected by such options.

From a cold, hard research point of view, I do think there is quite a bit more to do on this topic and not necessarily just with purely social or psychological factors in mind. I'm for example intrigued by the idea that gut and brain might be involved in depression, one of the risk factors for suicide ideation and autism (see here).  I'm also taken back to the collected work on suicide and vitamin D and suicide and lithium (see here) as other potentially important factors, especially given the emerging results on some of these areas with autism in mind (see here). Of course, harking back to my opening statement, the path towards suicide and suicide ideation is a complex one and likely to be a very individual one too.

To close, just in case you need someone to talk to, the Samaritans here in the UK (see here) and in the US (see here) are only a phone call or email away...


* Hannon G. & Taylor EP. Suicidal behaviour in adolescents and young adults with ASD: Findings from a systematic review. Clinical Psychology Review. 2013: October 15 [in press].

** Fitzgerald M. Suicide and Asperger's syndrome. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 2007; 28: 1-3.

*** Mandell DS. et al. The prevalence and correlates of abuse among children with autism served in comprehensive community-based mental health settings. Child Abuse Negl. 2005 Dec;29(12):1359-72.

**** Raja M. et al. Autism Spectrum Disorders and Suicidality. Clin Pract Epidemiol Ment Health. 2011 Mar 30;7:97-105.

***** Kato K. et al. Clinical features of suicide attempts in adults with autism spectrum disorders. Gen Hosp Psychiatry. 2013 Jan-Feb;35(1):50-3.

****** Szanto K. et al. Social emotion recognition, social functioning, and attempted suicide in late-life depression. Am J Geriatr Psychiatry. 2012 Mar;20(3):257-65.

******* Reutfors J. et al. Medication and suicide risk in schizophrenia: A nested case-control study. Schizophr Res. 2013 Oct 1. pii: S0920-9964(13)00500-8.

******** Björkenstam C. et al. An Association between Initiation of Selective Serotonin Reuptake Inhibitors and Suicide - A Nationwide Register-Based Case-Crossover Study. PLoS One. 2013 Sep 9;8(9):e73973.

********* Handley TE. et al. Incidental treatment effects of CBT on suicidal ideation and hopelessness. J Affect Disord. 2013 Oct;151(1):275-83.

--------- Geraldine Hannon, Emily P. Taylor (2013). Suicidal behaviour in adolescents and young adults with ASD: Findings from a systematic review Clinical Psychology Review DOI: 10.1016/j.cpr.2013.10.003