Mental health difficulties are experienced by up to 80% of autistic adults, and depression and anxiety in this population are associated with suicidal thoughts, behaviours, and sometimes even death from suicide (Kolves et al., 2021). Autism spectrum conditions also remain over-represented in the figures of individuals who die from suicide each year. Globally, it’s estimated that there are around 700,000 deaths by suicide among autistic individuals each year (WHO, 2021). Cassidy et al. (2021) suggest that evidence of autism or possible autism is present in about 41% of those who die, but a theory that accurately captures the experience of suicidal thoughts among autistic individuals remains absent.

The interpersonal theory of suicide (ITS) suggests that suicidal thoughts evolve from the interaction of perceived burdensomeness and thwarted belonging (Joiner, 2005), but we have little evidence specifically on the mechanisms between autism and suicide or suicidal thoughts, and it is important to investigate how those connections in autistic individuals arise.

Using a network approach that allows investigation of the interactions and individual symptoms, Pelton et al. (2023) examined:

1. how autism may be a risk marker for suicide, and
2. whether pathways to suicidal thoughts are consistent between autistic and non-autistic individuals.

No previous network analyses have included autistic samples, however the authors expected to find that autistic individuals are more likely to experience anxiety, depression, thwarted belonging, perceived burdensomeness and suicidal thoughts than non-autistic individuals.

Methods

805 complete electronic records were taken from an online survey of the general population, including both autistic and non-autistic individuals. Autistic adults were recruited using UK autism and West Midlands organisations, and non-autistic participants were recruited via suicide-focused websites, social media, and psychology research participation schemes. Participants self-reported their age, employment status, gender, mental health difficulties and neurodevelopmental conditions.

Two autistic adults were involved in reviewing the study materials, interpreting the results and developing the model.

Depression, anxiety, thwarted belonging, perceived burdensomeness, autism (and related characteristics), and suicidal thoughts and behaviours (including self-harm) were measured using validated tools.

Network analysis was used to investigate whether being autistic is connected to experience of suicidal thoughts. Network comparison tests were then carried out to test whether differences between autistic and non-autistic networks exist.

Results

In total, 95% of autistic adults (compared to 68% of non-autistic adults) reported experience of suicidal thoughts and behaviours in their lifetime, and 35% (compared to 10% of non-autistic adults) reported previous suicide attempts. Mean scores for PHQ-9 were significantly higher for autistic adults in comparison to non-autistic adults, reaching the clinical cut-off for potential clinical depression.

• Being autistic was directly connected to:
  • lacking caring and supportive friends,
  • feeling like an outsider,
  • movement differences (e.g. restlessness), and
  • anxiety.
• Feeling like an outsider and lacking caring and supportive friends connected to suicide and self-harm through feeling like they do not belong and feeling like a failure.
• Differences in movement were directly connected to thoughts of suicide and self-harm.
• Anxiety was connected to suicide and self-harm through feeling hopeless and depressed, which suggests that simultaneous pathways from being autistic to experience of suicidal and self-harm exist.
• In both the autistic and non-autistic groups, feeling hopeless was the strongest connection to thoughts of suicide and self-harm.

Significant differences between groups were found, for example, mood symptoms were associated with somatic experiences among non-autistic people, but were independent for autistic people. Furthermore, experiences of thwarted belonging with mood symptoms/burdensomeness for non-autistic people were not observed in autistic individuals’ network. Thwarted belonging may have a different association with the experience of affective symptoms/burdensomeness in autistic individuals.

Overall, an increase of daily stressors in combination with reduced coping skills may lead to suicidal thoughts in autistic individuals.

Conclusions

A very high prevalence of autistic adults reported suicidal thoughts in their lifetime. This study illustrates the complex interplay between the factors that connect autism and suicidal thoughts, which highlights autism as a distal risk marker for suicidal thoughts and behaviours.

Autistic individuals have higher scores for potential clinical depression, and have several pathways to thoughts of suicide and self-harm. Additionally, being autistic may increase the likelihood of experiencing daily stressors and having reduced coping skills, which can negatively affect individuals’ well-being. Feeling like an outsider, anxiety, and movement differences in autistic individuals were identified as unique risk markers.

These findings contribute to the development of a theory of suicidal thoughts and behaviours that is representative of autistic individuals’ experiences, which will be beneficial when developing and adapting suicide prevention programs. Longitudinal study designs with lived experience involvement should be used to further explore the findings of this study, and to effectively capture the experiences of autistic people.

Strengths and limitations

This is the first study to explore the development of suicidal thoughts and suicidal behaviours in autistic individuals using network analysis. The authors demonstrate an alternative approach to overcome barriers in previous studies which only included non-autistic samples (Lombardo et al., 2019). Furthermore, network analysis provides a unique insight with its transdiagnostic approach into more than one risk marker (Millner et al., 2020). Consequently, new insight into how suicidal thoughts and behaviours develop in autistic individuals can provide an explanation for how daily stressors may negatively affect individuals’ quality of life (Mason et al., 2018). Thus, these results may help to identify and develop tailored interventions suitable for autistic individuals.

Despite that, the following limitations should be considered. Cassidy et al. (2022) argue that individuals who are at greatest risk of suicide are inclined to experience a wide range of risk markers for suicide. Considering that the models only included a subset of risk markers, the findings may not capture all the unique risk markers for autistic individuals. Given that the measurements and constructs used were previously developed for non-autistic individuals, the findings are limited in their ability to make inferences for autistic adults. The network analysis was also conducted with a small sample size at group level (van Borkulo, 2017), meaning that the findings reported for autistic individuals should be interpreted with caution.

Implications for practice

The network model demonstrated risk markers for suicidal thoughts and self-harm behaviours in autistic individuals and this may be useful in the development of interventions. Since autistic individuals are more likely to experience suicidal thoughts and behaviours than non-autistic individuals, having appropriate support and referral pathways that enables communication with professionals may help to intervene before a crisis point. Furthermore, autistic individuals reported that the lack of caring friends and family, and feeling like an outsider contributed to the development of suicidal thoughts and self-harm behaviours. Making clinicians aware of this to promote a supportive environment in which autistic individuals feel accepted is key to improve outcomes in practice.

Implications for research

Considering that autistic individuals are significantly more likely to report depression, anxiety, suicidal thoughts, and behaviours than non-autistic individuals, these results should be used as a starting point for the development of an interpersonal suicide theory that reflects autistic individuals’ experiences. Since concerns about the accuracy of measurements for suicidal thoughts and theory in autistic individuals using constructs created by non-autistic individuals remain (Bringmann et al., 2022), using autistic individuals experience may help in the development of more meaningful constructs (Jones, 2022). In employing a longitudinal design, more accurate targets can be identified to develop interventions (Rath et al., 2019). Establishing a model that accurately captures autistic individuals experience of suicide and self-harm will help to implement tailored suicide prevention interventions.

Statement of interests

None.

Links

Primary paper

Pelton, M. K., Crawford, H., Bul, K., Robertson, A. E., Adams, J., De Beurs, D., … & Cassidy, S. (2023). The role of anxiety and depression in suicidal thoughts for autistic and non‐autistic people: A theory‐driven network analysis. Suicide and Life‐Threatening Behavior. https://doi.org/10.1111/sltb.12954

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