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Clinical features of suicide attempts in adults with autism spectrum disorders
General Hospital Psychiatry 35 (2013) 50–53
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General Hospital Psychiatry j o u r n a l h o m e p a g e : h t t p : / / w w w. g h p j o u r n a l . c o m
Clinical features of suicide attempts in adults with autism spectrum disorders Koji Kato, M.D., Katsunaka Mikami, M.D., Ph.D. ⁎, Fumiaki Akama, M.D., Keigo Yamada, M.D., Mizuki Maehara, M.D., Keitaro Kimoto, M.D., Kousuke Kimoto, M.D., Reiko Sato, M.D., Yuki Takahashi, M.D., Ryoko Fukushima, M.D., Atsushi Ichimura, M.D., Ph.D., Hideo Matsumoto, M.D., Ph.D. Department of Psychiatry, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan
a r t i c l e
i n f o
Article history: Received 11 June 2012 Revised 2 September 2012 Accepted 18 September 2012 Keywords: Autism spectrum disorders Suicide attempts Adults Emergency room
a b s t r a c t Objective: The objective of this study was to investigate the frequency and clinical features of suicide attempts in adults with autism spectrum disorders (ASDs). Methods: We enrolled 587 consecutive patients aged 18 or over who attempted suicide and were hospitalized for inpatient treatment. Psychiatric diagnoses, suicide attempt frequency and clinical features were compared between ASD and non-ASD patients. Results: Forty-three (7.3%) of the 587 subjects who attempted suicide had ASDs. The incidence of patients with mood disorders was significantly lower (Fisher's Exact Test, P= .043) and that of those with an adjustment disorder was significantly higher (Fisher's Exact Test, Pb .001) in the ASD group than in the non-ASD group. The average length of stay at both the hospital and intensive care unit in the ASD group was longer than that in the non-ASD group (z=−2.031, P= .042; z=−2.322, P= .020, respectively). Conclusions: ASDs should always be a consideration when dealing with suicide attempts in adults at the emergency room. © 2013 Elsevier Inc. All rights reserved.
1. Introduction The annual suicide rate in 2009 was 24.4 per 100,000, which has remained high in Japan since it initially exceeded 30,000 (31,755) in 1998 [1]. It ranks seventh as a cause of death in Japan [1]. Suicide attempts in individuals with Asperger syndrome (AS) have been described by Wing [2] and Gillberg [3]. According to their descriptions, individuals with AS had a tendency to develop suicidality in adolescence or early adult life. Mikami and colleagues retrospectively reported that 12 of 94 (12.8%) adolescent patients who were hospitalized because of suicide attempts had pervasive developmental disorders [4]. Using questionnaires, Balfe and colleagues investigated social and health profiles in a community sample of adults and adolescents with AS or high-functioning autism. Among 42 responders (mean age, 26.21 years), 15% attempted suicide [5]. Fitzgerald pointed out that AS is one of the most commonly missed diagnoses in adult psychiatry and that the suicide risk is much higher in individuals with AS than previously recognized [6]. A recent study by Raja and colleges examined suicidal behaviors in adult patients affected by autism spectrum disorders (ASDs) and found that 2 of the
⁎ Corresponding author. Department of Psychiatry, Tokai University School of Medicine, 143 Shimokasuya, Isehara-shi, Kanagawa 259-1143, Japan. Tel.: + 81 463 94 1121; fax: + 81 463 94 5532. E-mail address: [email protected] (K. Mikami). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2012.09.006
26 subjects (7.7%) committed suicide, 1 (3.8%) attempted suicide twice and 1 (3.8%) self-harmed by cutting his face and one finger [7]. These studies have gradually accumulated evidence of characteristics concerning suicide risk in individuals with ASDs. However, few reports are available on the characteristics of suicide attempts in individuals with adult ASDs at the emergency room. A few case reports were found on a suicide attempt in an adult with AS [8,9]. The aim of the present study was to investigate the frequency and clinical features of suicide attempts in patients with adult ASDs at the emergency room. 2. Methods 2.1. Subjects This retrospective study was conducted at the Advanced Critical Care Center of Tokai University Hospital, which serves four cities with a total population of approximately 600,000 and offers a full range of primary, secondary and tertiary care services. All individuals brought to the hospital after attempting suicide were referred to the psychiatric department, where three or four psychiatrists were always on duty. In total, we enrolled 587 consecutive patients at the age of 18 years or over who attempted suicide and had been hospitalized at the Advanced Critical Care Center of Tokai University Hospital between April 2010 and December 2011. Interviews with individuals who had made serious but nonfatal suicide attempts could provide valuable information regarding those who had succeeded in the attempt. We
K. Kato et al. / General Hospital Psychiatry 35 (2013) 50–53
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chose patients who had been admitted to the hospital after suicide attempts for physical treatment (i.e., patients involved in serious suicide attempts) because it excluded cases of minor self-injury.
3. Results
2.2. Assessment
Subjects were divided into two groups: an ASD group and a non-ASD group. Forty-three of the 587 subjects (7.3%) were diagnosed with ASDs. The baseline characteristics of the subjects are summarized in Table 1. The ratio of men to women, the incidence of unmarried individuals and the incidence of living alone in the ASD group were significantly higher than those in the non-ASD group. However, the incidence of presenting with a psychiatric history in the ASD group was significantly lower than that in the non-ASD group. Drug overdose, as a method of attempted suicide in the ASD group, was significantly lower than that in the non-ASD group. Fatal cutting/ stabbing and carbon monoxide intoxication were attempted significantly more often by the ASD group than the non-ASD group. Five of nine cases (55.6%) were due to hara-kiri in cutting/stabbing.
One or two trained psychiatrists routinely examined the patients and obtained their histories by interviewing the patient's relatives. Patients were diagnosed with psychiatric disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) [10]. Psychiatric morbidity was assessed with the Mini International Neuropsychiatric Interview (MINI) [11], which includes Axis I (psychiatric) for DSM-IV and International Classification of Diseases, 10th Revision, diagnoses [12]. The Autism-Spectrum Quotient-Japanese version (AQ-J) targets adults with normal intelligence [13,14]. At a cutoff of 26, the sensitivity and specificity of the AQ-J were 0.76 and 0.71, respectively [14]. We included not only patients diagnosed with ASD by DSM-IV but also those who had a cutoff score of 26 or more on the AQ-J. In addition, we did not consider the information before the age of 3 when ASDs in adults were diagnosed with the DSM-IV because the information was difficult to collect. Physical severity after attempted suicides was divided into serious and nonserious conditions. Patients who required a respirator were categorized as being in a serious condition [15]. 2.3. Statistical analysis Continuous variables are presented as mean (S.D.) or median (interquartile range), and categorical variables were compared using Fisher's Exact Test. Because the number of subjects was not normally distributed, continuous variables were examined using the Mann– Whitney U test. In these analyses, a two-tailed probability b .05 was considered to denote a statistically significant difference. PASW Statistics 18 for Windows (SPSS Inc., Chicago, IL, USA) was used for data analysis. 2.4. Ethics This study was retrospectively conducted by reviewing medical records of the selected patients. The Institutional Review Board for Clinical Research of the Tokai University School of Medicine approved the protocol for this medical record review.
3.1. Background characteristics
3.2. Psychiatric characteristics of suicide attempts in patients with ASDs The proportion of patients with mood disorders was significantly lower in the ASD group than in the non-ASD group (Table 2), whereas no significant difference in the proportion of patients with anxiety disorders was observed between the two groups. On the other hand, the proportion of patients with an adjustment disorder was significantly higher in the ASD group (Table 2). 3.3. Length of stay (LOS) at the hospital or the intensive care unit (ICU) The average LOS at the hospital and ICU was longer in the ASD group than in the non-ASD group. 4. Discussion This is the first study to compare suicide attempts in ASD and non-ASD patients in adults at the emergency room. Forty-three of the 587 subjects (7.3%) who attempted suicide and had been hospitalized due to these attempts were diagnosed with an ASD. The proportion of patients with mood disorders was significantly lower and that of those with an adjustment disorder was significantly higher in the ASD group than in the non-ASD group. The average LOS
Table 1 Background characteristics ASDs group (n= 43)
Non-ASDs group (n= 544)
Test results
Age, mean (S.D.)
33.7 (12.6)
42.5 (17.0)
Gender (male), n (%) Unmarried, n (%) Duration of education, mean (S.D.)
35 (81.4) 33 (76.7) 12.3 (2.2)
165 (30.3) 204 (37.5) 11.7 (2.1)
Jobless, n (%) Living alone, n (%) Psychiatric history, n (%) Family psychiatric history, n (%) Family suicide attempt history, n (%) Suicide attempt history, n (%) Consultation before suicide attempt, n (%) Precipitating eventa, n (%) Alcohol intake at suicide attempt, n (%) Methods of attempted suicide, n (%) Drug overdoses Jumping from a great height Cutting/stabbing Carbon monoxide intoxication
15 (34.9) 18 (41.9) 22 (51.2) 6 (14.0) 2 (4.7) 10 (23.3) 5 (11.6) 16 (37.2) 5 (11.6)
211 103 393 157 55 257 109 292 105
(38.8) (18.9) (72.2) (28.9) (10.1) (47.2) (20.0) (53.7) (19.3)
MWU (z=−3.279) Fisher Fisher MWU (z=−1.596) Fisher Fisher Fisher Fisher Fisher Fisher Fisher Fisher Fisher
15 (34.9) 6 (14.0) 9 (20.9) 9 (20.9)
349 36 37 18
(64.2) (6.6) (6.8) (3.3)
Fisher Fisher Fisher Fisher
Abbreviations: Fisher, Fisher's Exact Test; MWU, Mann–Whitney U test. a The event occurred within 24 h of a patient's admission to a hospital.
P .001 b .001 b .001 .111 .745 .001 .005 .035 .418 .002 .230 .040 .309 b .001 .113 .004 b .001
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K. Kato et al. / General Hospital Psychiatry 35 (2013) 50–53
Table 2 Psychiatric characteristics of patients with ASD who attempted suicide
Major psychiatric disorders Mood disorders, n (%) Anxiety disorders, n (%) Adjustment disorders, n (%) Substance-related disorders, n (%) Dissociative disorders, n (%) Eating disorders, n (%) Somatoform disorders, n (%) Physical severity Serious conditiona, n (%) LOS In the hospital, days, median (interquartile range), In the intensive care unit, days, median (interquartile range), Hospital transfer, n (%) a
ASD group
Non-ASD group
(n= 43)
(n= 544)
Test results
P
8 (18.6) 7 (16.3) 30 (70.0) 1 (2.3) 0 0 0
186 (34.2) 107 (19.7) 226 (41.5) 42 (7.7) 14 (2.6) 14 (2.6) 8 (1.5)
Fisher Fisher Fisher Fisher Fisher Fisher Fisher
.043 .692 b .001 .355 .614 .614 1.000
20 (46.5)
187 (34.4)
Fisher
.135
6.0 (3.0–13.0) 6.0 (3.0–12.0) 13 (30.2)
4.0 (2.0–8.0) 4.0 (2.0–7.0) 131(24.1)
MWU (z=−2.031) MWU (z=−2.322) Fisher
.042 .020 .361
Patients requiring a respirator were categorized as being in serious condition.
in either the hospital or the ICU was longer in the ASD group than in the non-ASD group. An epidemiological survey of childhood autism conducted by Honda et al. showed that cumulative incidence and prevalence were 16.2 and 21.1 per 10.000, respectively [16]. Compared with this epidemiological survey, the frequency of suicide attempters with ASDs (7.3%) may be higher. Furthermore, Mikami and colleagues reported that 12.8% of patients among adolescent suicide attempters had ASDs [4]. Although it is difficult to determine whether or not the rate of ASDs observed in this study is universal, we believe that ASDs should always be considered when dealing with suicide attempts in adults. The background characteristics had several distinguishing features. First, the mean age of the patients with ASDs was younger. Poor interpersonal problem-solving skills or impulsive behavior, which is characteristic of individuals with ASDs, had been linked with an increased risk of suicidal behavior among youth [17,18]. Gillberg [3] suggests that suicidal acts are more frequent in adolescents with AS, perhaps due to bullying and feelings of inadequacy in coping with the social demands that occur during puberty. Second, a higher incidence of single individuals and individuals living alone in the ASD group could be explained by ASD characteristics such as lack of social reciprocity and/or repeated failure to develop peer relationships since childhood or adolescence. Third, the lower incidence of family psychiatric history in the ASD group may have been reflected by the lower rate of patient's own psychiatric problems, such as mood disorders. Both depression and anxiety have been reported to be common psychiatric problems in adolescents or young adults with ASDs [19,20]. In this study, 70% of ASD patients met the criteria of the diagnosis for adjustment disorders, although an adjustment disorder was not included in the MINI. The individuals with ASDs in this study were compared to control subjects who had also attempted suicide; in other words, the control subjects were not in the general population. There may have been more individuals with mood disorders among these study subjects than among the general population, and, therefore, it may have been possible that the ASD group had higher levels of mood disorders than the general population. In addition, individuals with ASDs were more frequently diagnosed with an adjustment disorder than those with non-ASDs, which suggested that the individuals with ASDs also had symptoms of depression or/and anxiety during suicide attempts. Therefore, there is no certainty that an adjustment disorder with ASDs is a suicidal risk; however, not only mood disorders but also an adjustment disorder may contribute to suicidal behavior in individuals with ASDs. The reason that individuals with ASDs are more likely to choose lethal methods of suicide needs to be examined. One possibility is the higher rate of males in the ASD group. Males in Japan and worldwide
are more likely to succeed at suicide than females [1], even though more females attempt suicide. In addition, impulsive behavior and poor interpersonal problem-solving skills have been linked with an increased risk of suicidal behavior in youth [17,18]. Dumais and colleagues indicated that higher levels of impulsivity and aggression were associated with suicide [21]. Impulsive behavior, which is characteristic of individuals with ASDs, may be related to the higher percentage of choosing lethal methods among individuals with ASDs. Furthermore, a lack of active imagination, frequently observed among individuals with ASDs [22], may be a contributing factor. The choice of lethal methods for suicide among individuals in the ASD group and the resulting more serious bodily harm led to lengthier hospitalizations. In addition to their choosing more serious attempt methods, ASD individuals were less likely to attempt suicide based on events occurring in the last 24 h, which suggests that the stressors are not spontaneous. Moreover, individuals with ASDs had lower incidence of presenting with a history of psychiatric treatment. These results indicate that individuals with ASDs are more likely to succeed in their first attempt at suicide. Therefore, it is important to consider suicidal possibility when dealing with diagnosed ASD individuals with mood disorders or adjustment disorder. The present study had the following limitations that must be acknowledged. First, the number of cases was rather small because only one institution was involved, and, therefore, the accumulation of more data from multiple institutions is necessary. Second, comparisons with control groups are essential in future studies to clarify the features of suicide attempts among patients with ASDs. Third, although trained psychiatrists examined the patients, the examinations for ASDs were not in the form of structured interviews. In addition, information regarding each adult patient at or before the age of 3 was not examined in detail. Without this information, it was not possible to diagnose specific developmental disorders, such as classical autism or AS. Fourth, although AQ-J needs normal intelligences, it was difficult to examine the intelligence of suicide attempters in an emergency room using a test battery such as the Wechsler Adult Intelligence Scale. Therefore, we could not accurately assess the intelligence of the patients, but individuals whose suicidality could not be checked by a verbal interview were excluded from the group of subjects. In addition, individuals with self-injury, such as a part of a pattern of repetitive stereotypes, were excluded from the group of subjects. Furthermore, the mean duration of education in the two groups was about 12 years, which was not significantly different. Taken together, the intelligence level may be concluded to be similar among the study subjects. Fifth, while patients who required a respirator were categorized as being in serious condition, this was not a strict criterion for physical severity.
K. Kato et al. / General Hospital Psychiatry 35 (2013) 50–53
Our results indicate that ASDs should always be a consideration when dealing with suicide attempts in adults, in particular, in cases of males. Individuals with ASDs attempted suicide using serious methods, and, therefore, they may have a tendency to complete it at a first attempt. This was only a preliminary study. Thus, the clinical features of individuals with ASDs who attempt suicide must be clarified. In addition, interventions focusing on preventing suicide attempts in individuals with ASDs are required. Acknowledgments This study was partially funded by research support from Meiji Seika Pharma Co., Lt., Yoshitomiyakuhin Corporation and Mitsubishi Tanabe Pharma Corporation to Dr. Matsumoto. The funding sources played no role in the design or conduct of the study; in the collection, analysis and interpretation of the data; or in the preparation, review or approval of the manuscript. All authors have no conflicts of interest with relevance to this manuscript. References [1] Health and Welfare Statistics Association. Annual statistical report of national health conditions in Japan. Kouseinoshihyou. Tokyo, Japan: Health and Welfare Statistics Association; 2011. 58 (in Japanese). [2] Wing L. Asperger's syndrome: a clinical account. Psychol Med 1981;11:115-29. [3] Gillberg C. A guide to Asperger syndrome. London: Cambridge University Press; 2002. [4] Mikami K, Inomata S, Hayakawa N, et al. Frequency and clinical features of pervasive developmental disorder in adolescent suicide attempts. Gen Hosp Psychiatry 2009;31:163-6. [5] Balfe M, Tantam D. A descriptive social and health profile of a community sample of adults and adolescents with Asperger syndrome. BMC Res Notes 2010;3:300. [6] Fitzgerald M. Suicide and Asperger's syndrome. Crisis 2007;28:1-3. [7] Raja M, Azzoni A, Frustaci A. Autism spectrum disorders and suicidality. Clin Pract Epidemiol Mental Health 2011;30:97–1085.
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[8] Mikami K, Ohya A, Akasaka K, Matsumoto H. Attempted suicide of youth with Asperger's disorder. Seishinigaku Zasshi 2003;108:587-96 in Japnanese. [9] Spencer L, Lyketsos CG, Samstad E, Dokey A, Rostov D, Chisolm MS. A suicidal adult in crisis: an unexpected diagnosis of autism spectrum disorder. Am J Psychiatry 2011;168:890-2. [10] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000. [11] Sheehan D, Lecrubier Y, Harnett Sheehan K, et al. The Mini International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59:22-33. [12] World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines, WHO; 1992. [13] Baron-Cohen S, Wheelwright S, Skinner R, et al. The Autism-Spectrum Quotient (AQ): evidence from Asperger syndrome/high-functioning autism, males and females, scientists and mathematicians. J Autism Dev Disord 2001;31:5–17. [14] Kurita H, Koyama T, Osada H. Autism-Spectrum Quotient-Japanese version and its short forms for screening normally intelligent persons with pervasive developmental disorders. Psychiatry Clin Neurosci 2005;59:490-6. [15] Ichimura A, Matsumoto H, Aoki T, et al. Characteristics of suicide attempters with depressive disorders. Psychiatry Clin Neurosci 2005;59:590-4. [16] Honda H, Shimuzu Y, Misumi K, et al. Cumulative incidence and prevalence of childhood autism in children in Japan. Br J Psychiatry 1996;169:228-35. [17] Rotheram-Borus MJ, Trautman PD, Dopkins SC, Shrout PE. Cognitive style and pleasant activities among female adolescent suicide attempters. J Consult Clin Psychol 1990;58:554-61. [18] McKeown RE, Garrison CZ, Cuffe SP, Waller JL, Jackson KL, Addy CL. Incidence and predictors of suicidal behaviors in a longitudinal sample of young adolescents. J Am Acad Child Adolesc Psychiatry 1998;37:612-9. [19] Mukaddes NM, Fateh R. High rates of psychiatric co-morbidity in individuals with Asperger's disorder. World J Biol Psychiatry 2010;11:486-92. [20] Lugnegård T, Hallerbäck MU, Gillberg C. Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger syndrome. Res Dev Disabil 2011; 32:1910-7. [21] Dumais A, Lesage AD, Alda M, Rouleau G, Dumont M, Chawky N, et al. Risk factors for suicide completion in major depression: a case–control study of impulsive and aggressive behaviors in men. Am J Psychiatry 2005;162:2116-24. [22] Wing L. Language, social, and cognitive impairments in autism and severe mental retardation. J Autism Dev Disord 1981;11:31-44.
Contents lists available at SciVerse ScienceDirect
General Hospital Psychiatry j o u r n a l h o m e p a g e : h t t p : / / w w w. g h p j o u r n a l . c o m
Clinical features of suicide attempts in adults with autism spectrum disorders Koji Kato, M.D., Katsunaka Mikami, M.D., Ph.D. ⁎, Fumiaki Akama, M.D., Keigo Yamada, M.D., Mizuki Maehara, M.D., Keitaro Kimoto, M.D., Kousuke Kimoto, M.D., Reiko Sato, M.D., Yuki Takahashi, M.D., Ryoko Fukushima, M.D., Atsushi Ichimura, M.D., Ph.D., Hideo Matsumoto, M.D., Ph.D. Department of Psychiatry, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan
a r t i c l e
i n f o
Article history: Received 11 June 2012 Revised 2 September 2012 Accepted 18 September 2012 Keywords: Autism spectrum disorders Suicide attempts Adults Emergency room
a b s t r a c t Objective: The objective of this study was to investigate the frequency and clinical features of suicide attempts in adults with autism spectrum disorders (ASDs). Methods: We enrolled 587 consecutive patients aged 18 or over who attempted suicide and were hospitalized for inpatient treatment. Psychiatric diagnoses, suicide attempt frequency and clinical features were compared between ASD and non-ASD patients. Results: Forty-three (7.3%) of the 587 subjects who attempted suicide had ASDs. The incidence of patients with mood disorders was significantly lower (Fisher's Exact Test, P= .043) and that of those with an adjustment disorder was significantly higher (Fisher's Exact Test, Pb .001) in the ASD group than in the non-ASD group. The average length of stay at both the hospital and intensive care unit in the ASD group was longer than that in the non-ASD group (z=−2.031, P= .042; z=−2.322, P= .020, respectively). Conclusions: ASDs should always be a consideration when dealing with suicide attempts in adults at the emergency room. © 2013 Elsevier Inc. All rights reserved.
1. Introduction The annual suicide rate in 2009 was 24.4 per 100,000, which has remained high in Japan since it initially exceeded 30,000 (31,755) in 1998 [1]. It ranks seventh as a cause of death in Japan [1]. Suicide attempts in individuals with Asperger syndrome (AS) have been described by Wing [2] and Gillberg [3]. According to their descriptions, individuals with AS had a tendency to develop suicidality in adolescence or early adult life. Mikami and colleagues retrospectively reported that 12 of 94 (12.8%) adolescent patients who were hospitalized because of suicide attempts had pervasive developmental disorders [4]. Using questionnaires, Balfe and colleagues investigated social and health profiles in a community sample of adults and adolescents with AS or high-functioning autism. Among 42 responders (mean age, 26.21 years), 15% attempted suicide [5]. Fitzgerald pointed out that AS is one of the most commonly missed diagnoses in adult psychiatry and that the suicide risk is much higher in individuals with AS than previously recognized [6]. A recent study by Raja and colleges examined suicidal behaviors in adult patients affected by autism spectrum disorders (ASDs) and found that 2 of the
⁎ Corresponding author. Department of Psychiatry, Tokai University School of Medicine, 143 Shimokasuya, Isehara-shi, Kanagawa 259-1143, Japan. Tel.: + 81 463 94 1121; fax: + 81 463 94 5532. E-mail address: [email protected] (K. Mikami). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2012.09.006
26 subjects (7.7%) committed suicide, 1 (3.8%) attempted suicide twice and 1 (3.8%) self-harmed by cutting his face and one finger [7]. These studies have gradually accumulated evidence of characteristics concerning suicide risk in individuals with ASDs. However, few reports are available on the characteristics of suicide attempts in individuals with adult ASDs at the emergency room. A few case reports were found on a suicide attempt in an adult with AS [8,9]. The aim of the present study was to investigate the frequency and clinical features of suicide attempts in patients with adult ASDs at the emergency room. 2. Methods 2.1. Subjects This retrospective study was conducted at the Advanced Critical Care Center of Tokai University Hospital, which serves four cities with a total population of approximately 600,000 and offers a full range of primary, secondary and tertiary care services. All individuals brought to the hospital after attempting suicide were referred to the psychiatric department, where three or four psychiatrists were always on duty. In total, we enrolled 587 consecutive patients at the age of 18 years or over who attempted suicide and had been hospitalized at the Advanced Critical Care Center of Tokai University Hospital between April 2010 and December 2011. Interviews with individuals who had made serious but nonfatal suicide attempts could provide valuable information regarding those who had succeeded in the attempt. We
K. Kato et al. / General Hospital Psychiatry 35 (2013) 50–53
51
chose patients who had been admitted to the hospital after suicide attempts for physical treatment (i.e., patients involved in serious suicide attempts) because it excluded cases of minor self-injury.
3. Results
2.2. Assessment
Subjects were divided into two groups: an ASD group and a non-ASD group. Forty-three of the 587 subjects (7.3%) were diagnosed with ASDs. The baseline characteristics of the subjects are summarized in Table 1. The ratio of men to women, the incidence of unmarried individuals and the incidence of living alone in the ASD group were significantly higher than those in the non-ASD group. However, the incidence of presenting with a psychiatric history in the ASD group was significantly lower than that in the non-ASD group. Drug overdose, as a method of attempted suicide in the ASD group, was significantly lower than that in the non-ASD group. Fatal cutting/ stabbing and carbon monoxide intoxication were attempted significantly more often by the ASD group than the non-ASD group. Five of nine cases (55.6%) were due to hara-kiri in cutting/stabbing.
One or two trained psychiatrists routinely examined the patients and obtained their histories by interviewing the patient's relatives. Patients were diagnosed with psychiatric disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) [10]. Psychiatric morbidity was assessed with the Mini International Neuropsychiatric Interview (MINI) [11], which includes Axis I (psychiatric) for DSM-IV and International Classification of Diseases, 10th Revision, diagnoses [12]. The Autism-Spectrum Quotient-Japanese version (AQ-J) targets adults with normal intelligence [13,14]. At a cutoff of 26, the sensitivity and specificity of the AQ-J were 0.76 and 0.71, respectively [14]. We included not only patients diagnosed with ASD by DSM-IV but also those who had a cutoff score of 26 or more on the AQ-J. In addition, we did not consider the information before the age of 3 when ASDs in adults were diagnosed with the DSM-IV because the information was difficult to collect. Physical severity after attempted suicides was divided into serious and nonserious conditions. Patients who required a respirator were categorized as being in a serious condition [15]. 2.3. Statistical analysis Continuous variables are presented as mean (S.D.) or median (interquartile range), and categorical variables were compared using Fisher's Exact Test. Because the number of subjects was not normally distributed, continuous variables were examined using the Mann– Whitney U test. In these analyses, a two-tailed probability b .05 was considered to denote a statistically significant difference. PASW Statistics 18 for Windows (SPSS Inc., Chicago, IL, USA) was used for data analysis. 2.4. Ethics This study was retrospectively conducted by reviewing medical records of the selected patients. The Institutional Review Board for Clinical Research of the Tokai University School of Medicine approved the protocol for this medical record review.
3.1. Background characteristics
3.2. Psychiatric characteristics of suicide attempts in patients with ASDs The proportion of patients with mood disorders was significantly lower in the ASD group than in the non-ASD group (Table 2), whereas no significant difference in the proportion of patients with anxiety disorders was observed between the two groups. On the other hand, the proportion of patients with an adjustment disorder was significantly higher in the ASD group (Table 2). 3.3. Length of stay (LOS) at the hospital or the intensive care unit (ICU) The average LOS at the hospital and ICU was longer in the ASD group than in the non-ASD group. 4. Discussion This is the first study to compare suicide attempts in ASD and non-ASD patients in adults at the emergency room. Forty-three of the 587 subjects (7.3%) who attempted suicide and had been hospitalized due to these attempts were diagnosed with an ASD. The proportion of patients with mood disorders was significantly lower and that of those with an adjustment disorder was significantly higher in the ASD group than in the non-ASD group. The average LOS
Table 1 Background characteristics ASDs group (n= 43)
Non-ASDs group (n= 544)
Test results
Age, mean (S.D.)
33.7 (12.6)
42.5 (17.0)
Gender (male), n (%) Unmarried, n (%) Duration of education, mean (S.D.)
35 (81.4) 33 (76.7) 12.3 (2.2)
165 (30.3) 204 (37.5) 11.7 (2.1)
Jobless, n (%) Living alone, n (%) Psychiatric history, n (%) Family psychiatric history, n (%) Family suicide attempt history, n (%) Suicide attempt history, n (%) Consultation before suicide attempt, n (%) Precipitating eventa, n (%) Alcohol intake at suicide attempt, n (%) Methods of attempted suicide, n (%) Drug overdoses Jumping from a great height Cutting/stabbing Carbon monoxide intoxication
15 (34.9) 18 (41.9) 22 (51.2) 6 (14.0) 2 (4.7) 10 (23.3) 5 (11.6) 16 (37.2) 5 (11.6)
211 103 393 157 55 257 109 292 105
(38.8) (18.9) (72.2) (28.9) (10.1) (47.2) (20.0) (53.7) (19.3)
MWU (z=−3.279) Fisher Fisher MWU (z=−1.596) Fisher Fisher Fisher Fisher Fisher Fisher Fisher Fisher Fisher
15 (34.9) 6 (14.0) 9 (20.9) 9 (20.9)
349 36 37 18
(64.2) (6.6) (6.8) (3.3)
Fisher Fisher Fisher Fisher
Abbreviations: Fisher, Fisher's Exact Test; MWU, Mann–Whitney U test. a The event occurred within 24 h of a patient's admission to a hospital.
P .001 b .001 b .001 .111 .745 .001 .005 .035 .418 .002 .230 .040 .309 b .001 .113 .004 b .001
52
K. Kato et al. / General Hospital Psychiatry 35 (2013) 50–53
Table 2 Psychiatric characteristics of patients with ASD who attempted suicide
Major psychiatric disorders Mood disorders, n (%) Anxiety disorders, n (%) Adjustment disorders, n (%) Substance-related disorders, n (%) Dissociative disorders, n (%) Eating disorders, n (%) Somatoform disorders, n (%) Physical severity Serious conditiona, n (%) LOS In the hospital, days, median (interquartile range), In the intensive care unit, days, median (interquartile range), Hospital transfer, n (%) a
ASD group
Non-ASD group
(n= 43)
(n= 544)
Test results
P
8 (18.6) 7 (16.3) 30 (70.0) 1 (2.3) 0 0 0
186 (34.2) 107 (19.7) 226 (41.5) 42 (7.7) 14 (2.6) 14 (2.6) 8 (1.5)
Fisher Fisher Fisher Fisher Fisher Fisher Fisher
.043 .692 b .001 .355 .614 .614 1.000
20 (46.5)
187 (34.4)
Fisher
.135
6.0 (3.0–13.0) 6.0 (3.0–12.0) 13 (30.2)
4.0 (2.0–8.0) 4.0 (2.0–7.0) 131(24.1)
MWU (z=−2.031) MWU (z=−2.322) Fisher
.042 .020 .361
Patients requiring a respirator were categorized as being in serious condition.
in either the hospital or the ICU was longer in the ASD group than in the non-ASD group. An epidemiological survey of childhood autism conducted by Honda et al. showed that cumulative incidence and prevalence were 16.2 and 21.1 per 10.000, respectively [16]. Compared with this epidemiological survey, the frequency of suicide attempters with ASDs (7.3%) may be higher. Furthermore, Mikami and colleagues reported that 12.8% of patients among adolescent suicide attempters had ASDs [4]. Although it is difficult to determine whether or not the rate of ASDs observed in this study is universal, we believe that ASDs should always be considered when dealing with suicide attempts in adults. The background characteristics had several distinguishing features. First, the mean age of the patients with ASDs was younger. Poor interpersonal problem-solving skills or impulsive behavior, which is characteristic of individuals with ASDs, had been linked with an increased risk of suicidal behavior among youth [17,18]. Gillberg [3] suggests that suicidal acts are more frequent in adolescents with AS, perhaps due to bullying and feelings of inadequacy in coping with the social demands that occur during puberty. Second, a higher incidence of single individuals and individuals living alone in the ASD group could be explained by ASD characteristics such as lack of social reciprocity and/or repeated failure to develop peer relationships since childhood or adolescence. Third, the lower incidence of family psychiatric history in the ASD group may have been reflected by the lower rate of patient's own psychiatric problems, such as mood disorders. Both depression and anxiety have been reported to be common psychiatric problems in adolescents or young adults with ASDs [19,20]. In this study, 70% of ASD patients met the criteria of the diagnosis for adjustment disorders, although an adjustment disorder was not included in the MINI. The individuals with ASDs in this study were compared to control subjects who had also attempted suicide; in other words, the control subjects were not in the general population. There may have been more individuals with mood disorders among these study subjects than among the general population, and, therefore, it may have been possible that the ASD group had higher levels of mood disorders than the general population. In addition, individuals with ASDs were more frequently diagnosed with an adjustment disorder than those with non-ASDs, which suggested that the individuals with ASDs also had symptoms of depression or/and anxiety during suicide attempts. Therefore, there is no certainty that an adjustment disorder with ASDs is a suicidal risk; however, not only mood disorders but also an adjustment disorder may contribute to suicidal behavior in individuals with ASDs. The reason that individuals with ASDs are more likely to choose lethal methods of suicide needs to be examined. One possibility is the higher rate of males in the ASD group. Males in Japan and worldwide
are more likely to succeed at suicide than females [1], even though more females attempt suicide. In addition, impulsive behavior and poor interpersonal problem-solving skills have been linked with an increased risk of suicidal behavior in youth [17,18]. Dumais and colleagues indicated that higher levels of impulsivity and aggression were associated with suicide [21]. Impulsive behavior, which is characteristic of individuals with ASDs, may be related to the higher percentage of choosing lethal methods among individuals with ASDs. Furthermore, a lack of active imagination, frequently observed among individuals with ASDs [22], may be a contributing factor. The choice of lethal methods for suicide among individuals in the ASD group and the resulting more serious bodily harm led to lengthier hospitalizations. In addition to their choosing more serious attempt methods, ASD individuals were less likely to attempt suicide based on events occurring in the last 24 h, which suggests that the stressors are not spontaneous. Moreover, individuals with ASDs had lower incidence of presenting with a history of psychiatric treatment. These results indicate that individuals with ASDs are more likely to succeed in their first attempt at suicide. Therefore, it is important to consider suicidal possibility when dealing with diagnosed ASD individuals with mood disorders or adjustment disorder. The present study had the following limitations that must be acknowledged. First, the number of cases was rather small because only one institution was involved, and, therefore, the accumulation of more data from multiple institutions is necessary. Second, comparisons with control groups are essential in future studies to clarify the features of suicide attempts among patients with ASDs. Third, although trained psychiatrists examined the patients, the examinations for ASDs were not in the form of structured interviews. In addition, information regarding each adult patient at or before the age of 3 was not examined in detail. Without this information, it was not possible to diagnose specific developmental disorders, such as classical autism or AS. Fourth, although AQ-J needs normal intelligences, it was difficult to examine the intelligence of suicide attempters in an emergency room using a test battery such as the Wechsler Adult Intelligence Scale. Therefore, we could not accurately assess the intelligence of the patients, but individuals whose suicidality could not be checked by a verbal interview were excluded from the group of subjects. In addition, individuals with self-injury, such as a part of a pattern of repetitive stereotypes, were excluded from the group of subjects. Furthermore, the mean duration of education in the two groups was about 12 years, which was not significantly different. Taken together, the intelligence level may be concluded to be similar among the study subjects. Fifth, while patients who required a respirator were categorized as being in serious condition, this was not a strict criterion for physical severity.
K. Kato et al. / General Hospital Psychiatry 35 (2013) 50–53
Our results indicate that ASDs should always be a consideration when dealing with suicide attempts in adults, in particular, in cases of males. Individuals with ASDs attempted suicide using serious methods, and, therefore, they may have a tendency to complete it at a first attempt. This was only a preliminary study. Thus, the clinical features of individuals with ASDs who attempt suicide must be clarified. In addition, interventions focusing on preventing suicide attempts in individuals with ASDs are required. Acknowledgments This study was partially funded by research support from Meiji Seika Pharma Co., Lt., Yoshitomiyakuhin Corporation and Mitsubishi Tanabe Pharma Corporation to Dr. Matsumoto. The funding sources played no role in the design or conduct of the study; in the collection, analysis and interpretation of the data; or in the preparation, review or approval of the manuscript. All authors have no conflicts of interest with relevance to this manuscript. References [1] Health and Welfare Statistics Association. Annual statistical report of national health conditions in Japan. Kouseinoshihyou. Tokyo, Japan: Health and Welfare Statistics Association; 2011. 58 (in Japanese). [2] Wing L. Asperger's syndrome: a clinical account. Psychol Med 1981;11:115-29. [3] Gillberg C. A guide to Asperger syndrome. London: Cambridge University Press; 2002. [4] Mikami K, Inomata S, Hayakawa N, et al. Frequency and clinical features of pervasive developmental disorder in adolescent suicide attempts. Gen Hosp Psychiatry 2009;31:163-6. [5] Balfe M, Tantam D. A descriptive social and health profile of a community sample of adults and adolescents with Asperger syndrome. BMC Res Notes 2010;3:300. [6] Fitzgerald M. Suicide and Asperger's syndrome. Crisis 2007;28:1-3. [7] Raja M, Azzoni A, Frustaci A. Autism spectrum disorders and suicidality. Clin Pract Epidemiol Mental Health 2011;30:97–1085.
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