Autism Tied to Suicidal Behavior in Teens, Young Adults

Batya Swift Yasgur, MA, LSW

January 29, 2018

Adolescents and young adults with autistic spectrum disorder (ASD) have a higher risk for suicide attempts, compared to the nonautistic population, new research shows.

Taiwanese investigators headed by Ya-Mei Bai, MD, PhD, of the Department of Psychiatry, Taipei Veterans General Hospital, Taipei, used data from a national insurance database to compare more than 5600 adolescents and young adults to 22,500 age- and sex-matched control persons.

They found that the incidence of suicide attempts was higher among adolescents and young adults with ASD than among those without ASD, especially during later life. The prevalence of suicide-related psychiatric comorbidities was also higher among those with ASD.

"Our study results supported the hypothesis that adolescents and young adults with ASD are more likely to attempt suicide in later life, compared with those without ASD, after adjustment for demographic data and psychiatric comorbidities," the authors write.

"In clinical practice, suicide-related symptoms and psychopathology should be more closely monitored among patients with ASD," they note.

The study was published online in the Journal of Clinical Psychiatry.

Emotional Dysregulation

"Several recent studies have suggested a potential relationship between ASD and suicide," the authors write.

However, these studies have several limitations, including small sample sizes, the use of self-report questionnaire rather than medical documents that provide evidence of suicidality, and the application of a retrospective rather than a longitudinal follow-up study design, they note.

To fill these gaps in existing studies, the researchers turned to the Taiwan National Health Insurance Research Database, which consists of healthcare data from >97% of the population of Taiwan, to investigate the risk for suicide attempts among adolescents and young adults with ASD. Their study had a longitudinal follow-up design.

Children and adolescents aged 12 and 17 years and young adults aged 18 to 29 years who were diagnosed with ASD between January 1, 2001, and December 31, 2009 (n = 5618) were included as the ASD cohort. They were compared to a randomly identified cohort of 22,472 predominantly male (78.2%) age- and sex-matched control persons.

Any suicide attempt coded by emergency department and internal medicine physicians, psychiatrists, and surgeons was identified during the follow-up period, which was from the time of enrollment to December 31, 2011, or death.

Comorbid psychiatric diagnoses included attention-deficit/hyperactivity disorder [ADHD], disruptive behavior disorders, intelligence disability, unipolar depression, bipolar disorder, alcohol use disorder, and substance use disorder. Thse comorbidities were assessed as confounding factors.

Individuals who had attempted suicide prior to enrollment (n = 113) were included.

The incidence of suicide attempts in the ASD cohort was higher than in the control group (3.9% vs 0.7%, P < .001). Also, for the ASD cohort, the duration between enrollment and the first suicide attempt was shorter (3.57 ± 2.63 years vs 6.00 ± 2.58 years, P < .001).

The prevalence of psychiatric comorbidities was higher among the ASD cohort than among than those in the control group. Comorbidity prevalence rates among those with ASD and the control group were as follows: ADHD, 25.3% vs 1.3%; disruptive behavior disorders, 6.6% vs 0.2%; intelligence disability, 42.8% vs 0.7%; anxiety disorders, 11.2% vs 0.4%; bipolar depression, 16.0% vs 1.7%; and bipolar disorder, 8.4% vs 0.3%. (For all comorbidty rates, P < .001.)

Patients with ASD tended to reside in less urbanized regions, and the amount for which they were insured, as related to income, was less (P < .001).

When the researchers applied Kaplan-Meier survival analysis with a log-rank test, it emerged that adolescents and young adults with ASD had a higher likelihood of suicide attempts (P < .001) than did the control persons.

These findings remained after adjusting for demographic data and psychiatric comorbidities (hazard ratio = 6.07; 95% confidence interval, 4.64 - 7.93).

Independent Risk Factor

The findings applied equally to adolescent and young adult male and female persons.

The researchers conducted sensitivity analyses that excluded the first year and first 3 years of observation. They consistently found that ASD was associated with an elevated risk for subsequent suicide attempts in later life.

Unipolar depression, alcohol use disorders, and substance use disorders were related to an increased risk for suicide attempts.

The researchers note that ASD was "an independent risk factor for attempted suicide, regardless of the presence of psychiatric comorbidities, including depression, bipolar disorder, and alcohol and substance use disorder."

Moreover, ASD patients attempted suicide at a significantly younger age than did patients without ASD.

The authors offered several possible explanations for the significant relationship between ASD and suicidality.

"ASD in adolescence and adulthood may be associated with mood disorders (depression and bipolar disorder), further increasing the risk of suicidality, including suicidal ideation, suicide plans, and suicide attempts," they suggest.

The core symptoms of ASD, such as deficits in social cognition and communication, restricted thoughts, and cognitive rigidity, may also be related to an elevated likelihood of suicidality.

In addition, "ASD-related irritability and emotional dysregulation may contribute to the risk of suicidality."

They hypothesize that the "aforementioned findings collectively indicate that ASD-related emotional dysregulation and maladaptive emotional regulation strategies may increase the risk of suicidality when ASD patients experience depression or maltreatment."

Continuous Assessment Necessary

Commenting on the study for Medscape Medical News, Michael J. Murray, MD, associate professor of psychiatry and director, Division of Autism Services, Penn State Hershey Autism Center, who was not involved with the study, called it "well designed, using a national insurance database with longitudinal follow-up."

Moreover, the inclusion and matching criteria were "well considered."

However, although the study "highlights the clear increase in suicidal thoughts and behavior by individuals with ASD, its design does not allow for understanding of risk-protective factors," he pointed out.

"For instance, is employment protective against suicide for individuals with ASD? Does social isolation lead to greater suicidality?"

Despite these limitations, the study is "very significant" and "highlights the importance of using big datasets to further our understanding of the clinical trajectories of individuals living with ASD."

He noted that although the study was conducted in Taiwan, the findings are relevant in the United States as well and that the study has important take-home messages for clinicians, including "the need to continuously assess adolescents and young adults with ASD for suicidal thoughts and behaviors."

He noted that "adolescents and young adults may be at high risk during transition periods, such as transitioning from middle school to high school, as there is a need to tolerate uncertainty as new routines and expectations are learned."

He added, "this can be particularly heightened when the transition is from a highly structured routine and setting to less structure, such as the terminal transition form school to adult life."

The authors conclude that additional studies "are warranted to elucidate the pathophysiology underlying the association between ASD and suicide, and to clarify whether prompt intervention for ASD may reduce this risk."

The study was supported by a grant from Taipei Veterans General Hospital. The authors and Dr Murray have disclosed no relevant financial relationships.

J Clin Psychiatry. 2017;78:e1174-e1179. Abstract

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