Increased rates of suicidal ideation in adults with Asperger syndrome

"Our 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".

Sunrise @ Wikipedia 

That was the very stark conclusion reached by the study by Sarah Cassidy and colleagues [1] (open-access) looking at self-reported rates of suicide ideation and suicide plans/attempts in a sample of adults newly diagnosed with Asperger syndrome attending a "specialist diagnostic clinic" between 2004 and 2013. That depression seemed to play an important role in the engagement of such extreme thoughts or behaviour was also important. The press release accompanying the research can be read here.

As per some previous discussion on this topic (see here), suicide, whether attempted or completed, is a difficult topic to talk about. Not only because of the emotions which it invariably stirs up but also because the various paths towards someone reaching such an extreme point are complex, often very individual and still not well understood. Among the various risk factors suggested to be linked to [completed] suicide [2] some key points quite consistently come out including (a) a previous history of suicide ideation or suicide attempts, (b) the presence of psychiatric comorbidity such as depression or psychotic illness, and (c) some degree of social exclusion or alienation. I should mention that this is not an extensive list of risk factors, merely those which seem to appear with greatest frequency in the various research literature in this area.

The Cassidy paper is open-access but a few points are pertinent:

• As part of their attendance at clinic, nearly 400 adults ranging in ages from 17 - 67 years old at time of diagnosis, completed a self-report "patient screening questionnaire" containing items of about suicide and mood. The paper states the relevant questions: "have you ever been diagnosed with depression?", "have you ever felt suicidal?" and "if yes, have you ever planned or attempted suicide?".
• Participant were also asked to complete the Empathy Quotient (EQ) and the Autism Spectrum Quotient (AQ) questionnaires, both self-report measures which provide information about empathy and some of the "cognitive-behavioural traits associated with autism". Data derived from the suicide questioning items were compared with "published rates of suicidal ideation in the general population and other clinical groups".
• Results: "a 66% lifetime experience of suicidal ideation and a 35% lifetime experience of planned or attempted suicide supports the assertion that these occurrences are common in people with Asperger's syndrome". Compared with the population control data on these issues, the authors report that their sample were "more likely to report lifetime experience of suicidal ideation than were individuals from a general UK population sample". This included those with medical illnesses or psychotic illness. But... those with drug dependency and ADHD were still marginally more likely to report suicide ideation.
• Depression also seemed to play it's part in the reports. "Individuals with a history of depression ... were more likely to report suicide ideation ... and more likely to report suicide plans or attempts" compared with those without depression. And as for the EQ and AQ data, well higher scores on the AQ seemed to link with those reporting suicide plans or attempts but that was about it.

There are limitations to this study based on issues like the use of self-report questionnaire items asking about things like planned or attempted suicide or depression diagnosis without other evidence sources. Also as the authors note, their focus on "the population of people who reach adulthood without a diagnosis of Asperger's syndrome" is relevant. But the results are pretty stark particularly in respect to the numbers who have actually planned or attempted suicide. 

Going back to those more generalised population risk factors linked to suicide ideation or completion, it's not difficult to see how many of those might especially apply to some diagnosed with Asperger syndrome. Comorbidity such as depression is quite a well-known issue in relation to the autism spectrum [3]. Indeed, not so long ago I was interested to read the paper by Gotham and colleagues [4] on how rumination - "compulsively focused attention on the symptoms of one's distress" - might play a role in depression in some cases of autism and where this could lead from a therapeutic standpoint. I'll also direct you to the paper by Ljung and colleagues [5] concluding that: "Attention-deficit/hyperactivity disorder [ADHD] is associated with an increased risk of both attempted and completed suicide" which might tie into the links being made between autism and ADHD (see here).

Insofar as other conditions more generally linked to suicide such as psychosis [6] there is also perhaps something to do with the Cassidy results in mind, as a consequence of Asperger syndrome not being protective against the development of psychosis (see here). Social exclusion or alienation is also something reported with regards to the autism spectrum. I'm due to publish a mega-post quite soon on some of the research literature looking at quality of life (QoL) with autism in mind. Certainly in amongst that collected work, there are multiple examples of how loneliness and social isolation can be very detrimental factors to QoL.

At this point I'm also minded to bring in the possibility that suicide ideation or planning might not be just solely due to psychological or societal factors but rather may be influenced by something like biology too. Regular readers of this blog probably already know about my fascination with all-things vitamin D. It's timely that I talked about some of the collected literature looking at vitamin D deficiency in relation to something like depression recently (see here). Even perhaps more timely that said deficiency of the sunshine vitamin/hormone might also be something to look at with [adult] autism in mind (see here). I'm not necessarily suggesting a cause-and-effect scenario linking these elements, merely that this could be something to look at in future. Perhaps also in the same light as looking at another interest of mine: gluten and "feelings of depression"? How about other trace minerals and suicide too?

Whatever the reasons for thoughts of suicide to be linked to the autism spectrum, there is an important message to come from the Cassidy results and other papers on this topic: "inform appropriate service planning and support to reduce risk in this clinical group". Or I could just say make greater efforts to ensure that everyone knows how valuable their lives are, how valued they are as individuals and that there are people to talk to...

Everybody Hurts... so hold on.

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[1] Cassidy S. et al. 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. June 25.

[2] Pelkonen M. & Marttunen M. Child and adolescent suicide: epidemiology, risk factors, and approaches to prevention. Paediatr Drugs. 2003;5(4):243-65.

[3] Matson JL. & Williams LW. Depression and mood disorders among persons with Autism Spectrum Disorders. Res Dev Disabil. 2014 Sep;35(9):2003-2007.

[4] Gotham K. et al. Rumination and Perceived Impairment Associated With Depressive Symptoms in a Verbal Adolescent-Adult ASD Sample. Autism Res. 2014 Jun;7(3):381-91.

[5] Ljung T. et al. Common Etiological Factors of Attention-Deficit/Hyperactivity Disorder and Suicidal Behavior. JAMA Psychiatry. 2014. June 25.

[6] Björkenstam C. et al. Suicide in first episode psychosis: A nationwide cohort study. Schizophr Res. 2014 May 31. pii: S0920-9964(14)00240-0.

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Sarah Cassidy, Paul Bradley, Janine Robinson, Carrie Allison, Meghan McHugh, & Simon Baron-Cohen (2014). Suicidal ideation and suicide plans or attempts in adults with Asperger's syndrome attending a specialist diagnostic clinic: a clinical cohort study Lancet Psychiatry : doi:10.1016/S0140-6736(08)61345-8