Letters to the Editor
Suicidality in Adolescents and Adults With Fetal Alcohol Spectrum Disorders
Dear Editor:
Suicide is the ninth leading cause of death in the US and the third leading cause for Americans aged 15 to 24 years (1). In Canada, suicide rates are higher (2). Fetal alcohol spectrum disorders (FASD) are common and preventable developmental disabilities with a prevalence of 1 in 100 (3). Previous reports suggest that individuals with FASD are at risk for suicide (4,5). An individual with a typical clinical profile for FASD will evidence several risk factors for suicide (for example, impulsivity, a comorbid mood disorder, and substance abuse problems) and should be monitored closely, irrespective of intellectual ability.
We report pilot study data and 2 case studies to illustrate the underappreciated risk of suicide in adolescents and adults with FASD and its clinical manifestation. A pilot study (6) examined 11 adults with FASD (3 men and 8 women, aged 18 to 30 years, with IQs ranging from 72 to 113) drawn from the Fetal Alcohol Syndrome Follow-up Study database of the University of Washington Fetal Alcohol and Drug Unit. It found that approximately one-half the subjects reported at least 1 lifetime suicide attempt on the Lifetime Parasuicide/Suicide Attempt Count (LPS, 7). History of mental illness was not a selection criterion, and only one subject was receiving any mental health treatment (medication management only) at the time of the interview. When each subject’s most serious self-harm incident was evaluated for intent and lethality (8), 2/11 subjects (18%) had a severe suicide attempt, 3/11 (27%) had a moderate-risk attempt, 1/11 (9%) had a low-risk attempt, and 5/11 (46%) had no lifetime attempts. These rates of lifetime suicide attempts are higher than the general population rate of 4.6% reported in the National Comorbidity Study (9).
The following case studies illustrate that the lethality of a suicide attempt or self-harm behaviour often does not correlate with degree of intent in patients with FASD.
Case Report 1
The first case is that of an adopted Native man, aged 19 years, with full fetal alcohol syndrome, normal intellectual abilities, and a long history of attention-deficit hyperactivity disorder and affective instability. He was enraged with his parents because he felt they were “smothering him” by setting strict curfews. However, he was unable to express his feelings verbally and instead expressed them through a suicide attempt. Intending to kill himself, he took 8 to10 methylphenidate tablets (10 mg) and slashed his right shoulder, but he did not understand that he had taken a sublethal dose. In a family session the day after his suicide attempt, he was better able to verbalize his feelings and expressed overwhelming suicidal urges arising from his feeling “trapped.” His self-destructive feelings were acknowledged, and he now lives in a respite home with his sister’s family.
Case Report 2
The second case is that of a white man, aged 21 years, with alcohol-related neurodevelopmental disorder and schizoaffective disorder (depressed type). He felt socially isolated and wanted to live away from home, but he lacked the resources to do so. He did not intend to kill himself, but he systematically starved himself to the point of needing medical intervention to treat physical electrolyte and nutritional problems. In fact, he had a severe persistent melancholic depression that subsequently responded to parentral fluanxol.
References
1. Moscicki E. Identification of suicide risk factors using epidemiologic studies. Psychiatr Clin North Am 1997;20:499–517.
2. Sakinofsky I, Leenaars A. Suicide in Canada with special reference to the difference between Canada and the United States. Suicide Life Threat Behav 1997;27:112–26.
3. Sampson P, Streissguth A, Bookstein F, Little R, Clarren S, Dehaene P, and others. Incidence of fetal alcohol syndrome and prevalence of alcohol-related neurodevelopmental disorder. Teratology 1997;56:317–26.
4. Lemoine P, Lemoine PH. Avenir des enfants de mPrPs alcooliques (etudes de 105 cas retrouvés B l’âge adulte) et quelques constations d’intérLt prohaylactiques. Annals de Pediatric 1992;39:226–35.
5. Streissguth A, Barr H, Kogan J, Bookstein F. Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). Final report to the Centers for Disease Control and Prevention (CDC). Technical report No 96-06. Seattle (WA): University of Washington; 1996.
6. Huggins, JE, Connor PD, O'Malley K, Barr HM, Streissguth AP. Suicide/parasuicide behavior in adults with fetal alcohol spectrum disorders (FASD). Poster presentation at Research Society on Alcoholism 24th Annual Meeting; 2001 June 23–28; Montreal (QC).
7. Linehan M. Suicidal behaviors questionnaire. Seattle (WA): University of Washington Behavior Research and Therapy Clinic; 1989.
8. Clark D, Fawcett J. An empirically based model of suicide risk assessment for patients with affective disorders. In: Jacobs D, editor. Suicide and clinical practice. Washington (DC): American Psychiatric Press; 1992. p 55–73.
9. Kessler R, Borges G, Walters E. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 1999;56:617–26.
Kieran O’Malley, MB, DABPN(P)
Janet Huggins, PhD
Seattle, Washington
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