Research report
Does Attention Deficit Hyperactivity Disorder increase the risk of suicide attempts?

https://doi.org/10.1016/j.jad.2011.05.008Get rights and content

Abstract

Objective

To determine if Attention Deficit Hyperactivity Disorder (ADHD) is a risk factor for suicide attempts.

Methods

Data were drawn from the National Comorbidity Replication Survey (NCS-R), a nationally representative sample of adults (N = 8098).

Results

Of the 365 adults with current ADHD, 16% attempted suicide. After controlling for the presence of comorbid disorders, logistic regression analyses revealed that the ADHD was not a not a strong predictor of suicide attempts; having one or more comorbid disorders was associated with fourfold to twelvefold elevated risk.

Limitations

The small sample size of respondents with ADHD who attempted suicide significantly reduced the probability of determining which specific comorbid disorders were correlated with parasuicide.

Conclusions

Early treatment of ADHD and comorbidity may reduce the risk of suicide attempts and improve its prognosis.

Section snippets

Prevalence of comorbidity in ADHD

Elevated rates of co-occurring mental disorders have been found among populations with ADHD in the general community. Studies conducted in the United States, have found that between 20% and 30% of children with ADHD have had an episode of major depression (Anderson et al., 1987, Bird et al., 1988). Among children and adolescents, Bird et al. (1993) noted the following rates of comorbid disorders: depression (26.8%), anxiety disorders (50.8%) and conduct/oppositional disorders (93%). In a

Consequences of comorbidity

The presence of comorbidity in ADHD is correlated with poorer prognosis. Biederman et al. (1996), in a prospective four-year follow-up study of clinically referred boys with ADHD, found that those with comorbid anxiety disorders, mood disorders, conduct disorder or oppositional disorder had poorer psychosocial outcomes compared to subjects without comorbid disorders. Among adult outpatients with ADHD, those with conduct disorder and bipolar disorders had an earlier onset of substance use

ADHD association with death by suicide

In a literature review paper James et al. (2004) concluded that ADHD alone was not associated with an increased probability of attempting suicide, but when combined with other psychiatric conditions, ADHD was a risk factor. Hence, we analyzed a large general population survey database to empirically test this conclusion.

Sample

The National Comorbidity Survey Replication (NCS-R) is a nationally representative survey of English-speaking household residents ages 18 and older carried out between February 2001 and April 2003. Face to face interviews were completed with 9282 respondents. The response rate was 70.9%. Consent was verbal. The Human Subjects Committee of Harvard Medical School and the University of Michigan both approved recruitment and consent procedures. The interview was administered in two parts. Part l

ADHD diagnosis

The NCS-R assessment of childhood ADHD was based on the Diagnostic Interview Schedule for DSM-IV (Robins and Helzer, 1985). The clinical reappraisal interviews, in comparison, included comprehensive evaluations of ADHD based on the Adult ADHD Clinic Diagnostic Scale (ACDS) V 1.2 (Adler and Cohen, 2004, Adler and Spence, 2004), a semi-structured interview that includes the ADHD Rating Scale (ADHD-RS) (DuPaul et al., 1998) to evaluate current adult ADHD. The ACDS has been used in several clinical

Comorbid diagnosis

Comorbid DSM-IV disorders were retrospectively assessed using Version 3.0 of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) (Kessler and Ustun, 2004), a fully structured lay-administered diagnostic interview that assesses the lifetime prevalence and age-of-onset of anxiety disorders (panic disorder, generalized anxiety disorder, specific phobia, social phobia, agoraphobia, obsessive–compulsive disorder, post-traumatic stress disorder, separation anxiety

Suicidal behavior

Respondents who acknowledged having ever attempted suicide were classified as parasuicides, regardless of lethality of intention. For the purposes of this study, we did not define suicide attempt by distinguishing gestures from serious intention to die.

Analysis

All analyses were conducted using Statistical Analysis Software (SAS) version 9.1 and employed the appropriate NCS-R statistical weights to ensure the sample was representative of the general US population.

First, we used univariate associations to compare the sociodemographic and clinical characteristics of adults with ADHD who did or did not attempt suicide. Second, we used multivariate logistic regression techniques to evaluate the relationship between ADHD and parasuicide, controlling for

Bivariate associations

Attempters were less likely to have completed high school, be married, but more likely to have conduct disorder, oppositional defiant disorder, bipolar disorders, substance use disorders, and anxiety disorders. Surprisingly major depression and dysthymia were not found to be risk factors (Table 1).

Given the small number of suicide attempts (N = 59) among persons with ADHD and the large number of diagnostic categories, we lacked sufficient statistical power to determine which specific comorbid

Discussion

This study confirmed James et al. (2004) conclusion, based upon a literature review, that ADHD alone was not strongly associated with an increased probability of attempting suicide. The presence of comorbid conditions was a much more powerful predictor of parasuicide. Compared to ADHD alone, having one or more mental disorders conferred a fourfold to twelvefold greater risk of parasuicide. These data highlight the importance of controlling for other psychiatric disorders when exploring

Role of the funding source

The funding sources did not play any role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

The authors have no conflict of interest.

Acknowledgements

We wish to thank the NIMH (grant U01-MH-60220) with supplemental support from the National Institute on Drug Abuse and Mental Health Services Administration, the Robert Johnson Foundation (grant 044780), and the John Alden Trust for funding the National Comorbidity Survey Replication.

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