Suicidal Thoughts and Behaviours Among Autistic Adults Presenting to the Psychiatric Emergency Department: An Exploratory Chart Review

Suicidal Thoughts and Behaviors in People on the Autism Spectrum

PURPOSE OF REVIEW

This review synthesizes recent research on suicidal thoughts and behaviors among autistic individuals. We present literature on risk and protective factors, risk assessment, intervention, and crisis services, and recommendations for future research.

RECENT FINDINGS

Literature on this topic has grown substantially in recent years. Areas of advancement include improved understanding of risk factors (e.g., Interpersonal Theory of Suicide constructs, autistic burnout, mental health conditions, cognitive factors, diagnosis timing, emotion dysregulation), screening, assessment, acute-care services, and suicide-specific psychosocial treatments (e.g., safety planning, dialectical behavior therapy). Gaps include protective factors, impact of intersectional identities, and tailored approaches to screening, assessment, and intervention. Heightened awareness of suicide risk in autistic individuals has led to increased understanding of why autistic individuals think about and attempt suicide and the strategies used to identify and reduce suicide risk. We recommend community-partnered, multi-faceted, and strength-based approaches to inform tailored prevention and intervention efforts.

Exploring the landscape of adult autism research in psychology: a bibliometric and network analysis

The global prevalence of autism spectrum disorder (ASD) is increasing. ASD manifests with persistent social communication and interaction challenges, limited interests, and repetitive behaviors. As the scientific literature on ASD in adults varies greatly, mapping the recent global research becomes valuable for enhancing comprehension of this subject. This study aims to map recent global scientific publications on ASD in adults. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, bibliometrics, and network analyses, we assessed 850 articles indexed in the Web of Science Core Collection between 2013 and 2022 assigned to the research area of psychology. Findings indicate an annual average growth of 11.69%. Key keywords include Emotion, Anxiety, and Depression, with Anxiety, Depression, and Mental Health as central nodes in the network. Rehabilitation, Behavioral Sciences, and Psychiatry frequently co-occur, and Psychology, Psychiatry, and 'Neurosciences and Neurology' are central nodes in the network of research areas. The United States of America and the United Kingdom lead in publications, with the United Kingdom being the most central country in the network. King's College London and the University of California are the main research organizations, with King's College London as the central node in the network. The American Psychiatric Association's DSM-5-TR was the most cited reference in the period. This comprehensive analysis contributes to understanding the landscape of ASD research in adults, providing insights for future research and fostering collaborations.

Diagnosis of common health conditions among autistic adults in the UK: evidence from a matched cohort study

Background

Autistic people are disproportionately likely to experience premature mortality and most mental and physical health conditions. We measured the incidence of diagnosed conditions accounting for the most disability-adjusted life years in the UK population according to the Global Burden of Disease study (anxiety, depression, self-harm, harmful alcohol use, substance use, migraine, neck or back pain, and gynaecological conditions).

Methods

Participants were aged 18 years or above and had an autism diagnosis recorded in the IQVIA Medical Research Database between 01/01/2000 and 16/01/2019. We included 15,675 autistic adults without intellectual disability, 6437 autistic adults with intellectual disability, and a comparison group matched (1:10) by age, sex, and primary care practice. We estimated crude incidences and incidence rate ratios (IRRs) adjusted for age and sex.

Findings

Autistic adults without intellectual disability experienced a higher incidence (IRR, 95% CI) of self-harm (2.07, 1.79-2.40), anxiety (1.91, 1.76-2.06), depressive disorders (1.79, 1.67-1.92), and substance use (1.24, 1.02-1.51) relative to comparison participants. Incidences of harmful alcohol use (1.01, 0.85-1.18), migraine (0.99, 0.84-1.17), and gynaecological conditions (1.19, 0.95-1.49) did not differ. Neck or back pain incidence was lower (0.88, 0.82-0.95). Autistic adults with intellectual disability experienced a higher incidence of self-harm (2.08, 1.69-2.56). Incidences of anxiety (1.14, 1.00-1.30), gynaecological conditions (1.22, 0.93-1.62), and substance use (1.08, 0.80-1.47) did not differ, and lower incidences were found for depressive disorders (0.73, 0.64-0.83), harmful alcohol use (0.65, 0.50-0.84), migraine (0.55, 0.42-0.74), and neck or back pain (0.49, 0.44-0.55).

Interpretation

Although our findings cannot be directly compared to previous prevalence studies, they contrast with the higher frequency of mental and physical health conditions in autistic adults reported in studies that directly assessed and/or surveyed autistic people about co-occurring conditions. The present findings may suggest under-diagnosis of common conditions in autistic people, particularly those with intellectual disability. Improved detection should be a clinical and policy priority to reduce health inequalities.

Funding

Dunhill Medical Trust, Economic and Social Research Council, National Institute of Health and Care Research.

Are autistic females at greater risk of suicide? A call for clarity to advance suicide prevention for the whole community

Understanding suicide risk is critical for supporting prevention. A growing body of evidence shows autistic people are at greater risk for multiple suicide-related outcomes than non-autistic people. This commentary is in response to an observed pattern of miscommunication in scientific and community spaces about autistic females having higher risk of suicide. However, it is not always clear who they are being compared with in these statements. To address this confusion, we summarize the current population-based evidence on autistic suicide risk, highlighting findings related to sex similarities and differences, which actually indicates comparable rates of suicide death among autistic males and females, and mixed findings related to sex differences in risk of other suicidal behaviors. We call for greater clarity in suicide risk communication moving forward focused on outcomes, measurement, sampling methods, and comparison groups to reflect accurate conclusions about existing evidence. Further research is needed about the full range of suicide-related outcomes for autistic people, including a greater understanding of sex differences as well as potential gender differences to include transgender and nonbinary autistic people. However, studies of sex and gender differences should not overshadow the compelling need for efforts to understand and address the elevated risk of suicidal thoughts, behaviors, and death among autistic people across sex and gender boundaries.

Network Structure of Autism Spectrum Disorder Behaviors and Its Evolution in Preschool Children: Insights from a New Longitudinal Network Analysis Method

Network modeling of the social, communication and restrictive/repetitive behaviors (RRBs) included in the definition of Autism Spectrum Disorder was performed. The Autism Diagnostic Interview-Revised (ADI-R) assessed behaviors in 139 pre-school cases at two cross-sections that averaged 34.8 months apart. Cross-sectional networks were based on the correlation matrix of the ADI-R behavioral items and the "bootCross" method was developed and enabled the estimation of a longitudinal network. At both stages, RRB items/nodes formed a consistent peripheral cluster, while social and communication nodes formed a core cluster that diverged with time. These differences in the nature and evolution of the RRB and socio-communicative dimensions indicate that their inter-behavior dynamics are very different. The most central behaviors across stages are proposed as prime targets for efficient therapeutic intervention.

Linehan's biosocial model applied to emotion dysregulation in autism: a narrative review of the literature and an illustrative case conceptualization

Emotion dysregulation (ED) is a transdiagnostic difficulty prevalent in autism spectrum condition (ASC). Importantly, recent research has suggested that ED is involved in self-harm and suicidality. Pre-existing models on the etiology of ED in ASC focus mainly on biological factors to ASC features, such as sensory sensitivities, poor flexibility, and sensitivity to change. However, although psychosocial factors seem to play a role in the emergence of ED in ASC as well (e.g., childhood maltreatment and camouflaging), there is a lack of a comprehensive model conceptualizing biosocial factors involved in ED in autistic people. Linehan's biosocial model (1993) is one of the leading etiological models of ED in borderline personality disorder (BPD). It conceptualizes ED as emerging from transactions between a pre-existing emotional vulnerability in the child and an invalidating developmental environment. Beyond its clinical relevance, Linehan's model has gathered empirical evidence supporting its pertinence in BPD and in other psychiatric disorders. Although ASC and BPD are two distinct diagnoses, because they may share ED, Linehan's biosocial model might be useful for understanding the development of ED in ASC. Hence, this article aims to provide an application and extension of Linehan's model to conceptualize ED in ASC. To do so, we conducted a narrative review of the literature on ED and its underlying factors in ASC from a developmental perspective. To investigate the pertinence of the biosocial model applied to ED in autistic people, we were interested on data on (i) ED and its behavioral correlates in ASC, in relation to the biosocial model, (ii) the potential biological and psychosocial correlates of ED in ASC and (iii) the overlapping difficulties in ASC and BPD. Finally, to assess the pertinence of the model, we applied it to the case of an autistic woman presenting with ED and suicidal behaviors. Our review and application to the case of an autistic woman suggest that ED in ASC encompasses factors related to both biological and psychosocial risk factors as conceptualized in the BPD framework, although in both domains ASC-specific factors might be involved.

Autism in adult psychiatric out-patients: self-reported suicidal ideation, suicide attempts and non-suicidal self-injury

BACKGROUND

The prevalence of self-reported suicidal ideation, suicide attempts and non-suicidal self-injury (NSSI) remains unclear among adults with autism unrecognised in childhood who attend psychiatric services.

AIMS

We aimed to estimate the prevalence of suicidal ideation, suicide attempts and NSSI; identify factors associated with suicide attempts and NSSI; and describe NSSI in this group.

METHOD

Sixty-three new patients at an adult psychiatric out-patient clinic (57% women, mean age 32 years) who met full (n = 52) or subthreshold (two A criteria and minimum of two B criteria; n = 11) DSM-5 criteria for autism spectrum disorder were included in the study. Clinical assessments included overall diagnostic review, Paykel's questions on passive and active suicidality, evaluation of NSSI with the Functional Assessment of Self-Mutilation, and results of cognitive tests. One follow-up of medical records was made.

RESULTS

In this sample of psychiatric out-patients identified as first having autism in adulthood, almost a third (31%) of patients reported suicidal ideation during the past month, 86% had lifetime suicidal ideation and 25% reported at least one suicide attempt. Factors associated with suicide attempts included hazardous or harmful alcohol use and/or drug-related problems, and severity of depression. A total of 44% reported NSSI. Factors associated with NSSI were female sex, history of suicidal plans and antisocial personality disorder. Substance or alcohol use were often overlooked, especially in women.

CONCLUSIONS

Suicidal ideation, suicide attempts and NSSI were very common in adults with autism who were recently referred to an out-patient psychiatric service. Suicidal ideation and NSSI were more common than suicide attempts. Clinicians should always consider suicidal ideation and NSSI in adult psychiatric patients with autism.

Suicidal ideation and intentional self-inflicted injury in autism spectrum disorder and intellectual disability: An examination of trends in youth emergency department visits in the United States from 2006 to 2014

LAY ABSTRACT

Youth suicide is a major problem in the United States and globally, but little is known about suicide risk in autistic youth and youth with intellectual disability specifically. Using data from the National Emergency Department Sample, which is the largest database of emergency department visits in the United States, we found that emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis were more common in autistic youth and youth with intellectual disability than in youth without these diagnoses (i.e. the comparison group). This was true when examining both suicidal ideation diagnoses and intentional self-inflicted injury diagnoses at emergency department visits. In addition, the number of emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis increased more from 2006 to 2014 in autistic youth and youth with intellectual disability compared with the comparison group. We also found both similarities and differences when examining factors, such as age, sex, and co-occurring mental health conditions, related to emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis across groups that may be helpful for understanding suicide risk. It is urgent that we improve our understanding, assessment, and treatment of suicidality and self-harm in these groups through more research and clinical efforts.