Journal Article Annotations
2024, 4th Quarter

Emergency Psychiatry

Annotations by Clayton Barnes Martinez, MD, MPH
January, 2025

Suicidal Thoughts and Behaviors in People on the Autism Spectrum.

Of interest:

A Public Health Approach to Suicide Prevention 2: Restriction of access to means used for suicide.

PUBLICATION #1 — Emergency Psychiatry

Suicidal Thoughts and Behaviors in People on the Autism Spectrum.

Morganne Reid, Daylin Delgado, Julia Heinly, Bridgett Kiernan, Samantha Shapiro, Lisa Morgan, Brenna Maddox, Shari Jager-Hyman.

Abstract: Curr Psychiatry Rep. 2024 Nov 26(11):563-572. doi: 10.1007/s11920-024-01533-0. Epub 2024 Sep 30.

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.

Annotation

The finding:
This review highlights the critical nuances inherent in conducting a suicide risk assessment of an individual with autism spectrum disorder. The authors review the Interpersonal Theory of Suicide and apply the model to unique risk factors for “autistic patients.” For example, autistic patients are often subject to a lack of social connectedness and forced “camouflaging” of their authentic selves. Further, “autistic individuals” are more likely to be subject to various forms of trauma; the authors postulate that this trauma increases an individual’s acquired capability for suicide. Other notable risk factors increasing the risk of self-injurious behaviour include late diagnosis (and therefore lack of early intervention) and mental health co-morbidities. Interestingly, “autistic individuals” differ from the general population in that higher cognitive abilities, marriage, employment, and cohabitation do not serve as prominent protective factors.

Strength and weaknesses:
The paper focuses on recent advances and lingering gaps in the scientific literature by reviewing publications from 2021 and 2022; while earlier literature is included, the review is not and does not attempt to be a comprehensive synthesis of the literature related to autism spectrum and suicide.

Relevance:
A separate study (Vohra, 2017) notes that ED visits for individuals with autism spectrum disorder doubled from 2006 to 2011, with 15% of such visits attributed to psychiatric concerns. The emergency psychiatrist will encounter patients with autism spectrum, and appreciating the unique risk factors of this population will allow for thorough assessment, robust safety planning, and conscientious use of health care resources.

PUBLICATION #2 — Emergency Psychiatry

A Public Health Approach to Suicide Prevention 2: Restriction of access to means used for suicide.

Keith Hawton, Duleeka Knipe, Jane Pirkis.

Abstract: Lancet Public Health. 2024 Oct;9(10):e796-e801. doi: 10.1016/S2468-2667(24)00157-9. Epub 2024 Sep 10.

One of the most effective public health measures to prevent suicide is the restriction of access to means used in suicidal acts. This approach can be especially effective if a method is common and readily accessible. Suicide methods vary widely, and there have been several examples where means restriction has been applied, often with considerable success. Factors contributing to availability of suicide methods can include access to physical means as well as cognitive awareness of methods. In this paper, which is the second in a Series on a public health approach to suicide prevention, we focus primarily on examples of restricting access to physical means of suicide, such as pesticides, firearms, and medication. We also discuss restricting the cognitive availability of means through attention to media and other representations of suicide methods. There are challenges associated with restricting access to means, including resistance to measures required to change the availability of some methods (which might, in part, be commercially determined) and method substitution, whereby one suicide method is replaced by another. Nevertheless, means restriction must be an integral part of all national and local suicide prevention strategies.

Annotation (unstructured)

As part of a series on suicide prevention, the authors discuss the critical elements of lethal means restriction from a public health perspective. The physician who is engaged in advocacy or legislative efforts will find data supporting various international implementation efforts. The clinician, though, is reminded of the importance of lethal means restriction generally, and the importance of recognizing cultural trends in suicide more specifically. For example, the cognitive awareness of hanging as a suicide method increased after the death of actor Robin Williams. This discussion of cultural trends underscores the importance of clinician awareness of media coverage and sociocultural factors when conducting risk assessments and safety plans.