Autistic People Are at Risk of Self-Harm or Suicide

The results of a large Canadian study have experts calling for better mental health accessibility and support for autistic people and their families.

The population-based matched cohort study from the Institute for Clinical Evaluative Sciences (ICES) and the Centre for Addiction and Mental Health (CAMH) examined the rates of self-harm and suicide-related deaths in autistic people and those without autism spectrum disorder (ASD).

The research, published on August 8 in JAMA Network Open, included over 700,000 people in Ontario, Canada, and utilized data from health administrative databases and all physician-recorded autism diagnoses. In addition, the researchers examined self-harm events from 2005 to 2020 and fatal suicide events from 1993 to 2018.

The scientists also looked at demographic information, such as income levels, and whether the participants had mental health conditions or intellectual disabilities.

Their analysis found that autistic females had an 83% increased risk, and autistic males had a 47% higher risk of self-harm than individuals without ASD. These findings were independent of other factors such as income, intellectual disabilities, and mental health diagnoses.

What's more, autistic females had a 98% increased risk and autistic males had a 34% higher risk of suicide death compared to nonautistic people. However, these increases were strongly associated with having a co-occurring mental health condition.

Among females with ASD, mood and anxiety disorders, schizophrenia spectrum disorders, and personality disorders were most associated with an increased risk of suicide death. Moreover, these mental health conditions, as well as substance use disorders, appeared to increase the risks in autistic males.

Lead author Meng-Chuan Lai, a staff psychiatrist and senior scientist at the CAMH, told Healthnews, "These are associations, so we cannot make causal inferences that the psychiatric conditions directly increase the risk. Also, for some diagnoses, it could in some cases be a mis-label for autistic people, such as personality disorder diagnoses."

However, the study also found that the presence of intellectual disabilities appeared to reduce the risk of suicide among autistic individuals. The authors suggest that autistic people with intellectual disabilities may have less access to lethal means or receive more support, which might explain these findings.

High risks among people with autism

Most likely, autistic people are more vulnerable to experiencing psychiatric illnesses, and psychiatric illnesses increase these suicide and self-harm related risks. As to why autistic people are more likely to experience psychiatric illnesses, it is multi-factorial, but [there are] possible themes.

- Lai

These themes may include:

• Autistic people are more vulnerable to unsatisfactory employment and poor education and face more misunderstanding and discrimination in neurotypical societies.
• Autistic individuals tend to be vulnerable to adverse life events, especially bullying victimization, significantly increasing mental health risks.
• The cognitive styles associated with autism, such as executive function or communication difficulties, might make it difficult to process life challenges.

"There could also be a range of shared biological underlying factors (e.g., genetic factors) associated with autism and some psychiatric conditions (e.g., depression, psychotic disorders)," Lai adds.

In a news release, Megan Pilatzke, an advocate and autistic woman, explains, "Autistic people are continually forced to mask and hide who we are to accommodate a world that generally does not accept our traits. I want people to understand that autistic people are struggling because our needs are just not being met throughout society."

The researchers say that although they included all identifiable autistic individuals in Ontario, the number of autistic people is likely underestimated. Moreover, the study may have underestimated suicide outcomes among autistic individuals as some participants with ASD could have been miscategorized into the non-autistic group. In addition, because many self-harm events do not result in emergency care, the study may not have captured all these events.

Additionally, Lai notes the administrative data used for analysis did not include information about autism severity levels. So, it's unknown if self-harm and suicide risks differ among level 1 (requires support), 2 (requires substantial support), or 3 (requires very substantial support) autism.

"This is a wake-up call," Yona Lunsky, Adjunct Scientist at ICES and Director of the Azrieli Adult Neurodevelopmental Centre at CAMH, said in the news release. "As mental health providers, we need to do more in terms of mental health promotion, and we have to work together with autistic people and their families to make sure that timely mental health supports are accessible, and adapted to meet their needs."