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©The Author(s) 2017.
World J Psychiatr. Mar 22, 2017; 7(1): 44-59
Published online Mar 22, 2017. doi: 10.5498/wjp.v7.i1.44
Published online Mar 22, 2017. doi: 10.5498/wjp.v7.i1.44
Table 1 Included relevant articles examining attention-deficit/hyperactivity disorder and suicidality from January 2011 to January 2015: Attention-deficit/hyperactivity disorder in suicidal patients
| ADHD in suicidal patients | |||||||
| Ref. | Country | Study design | Sample | Population at onset | Population’s age at onset | Measures for ADHD, comorbid conditions and suicidality | Main findings |
| Ben-Yehuda et al[24] | Israel | Cross-sectional | Clinical sample | The survey involved all minors (age < 18) (n = 266) who were referred to a psychiatric emergency department due to a suicide attempt or suicidal ideation during a 3-yr period (2005-2007) | Children: Age range: ≤ 12 yr Adolescents: Age range: > 12 yr | The diagnosis was made by the examiner in the emergency department: diagnoses were coded using the ICD-10 | The distribution of psychiatric diagnoses differed significantly in the two age groups ADHD was significantly more prevalent among suicidal children, while mood disorders were more prevalent among suicidal adolescents The second most prevalent diagnosis among suicidal children was ADHD (25.6%) (following adjustment disorder/38.5%/and followed by conduct disorders/23.1%) In adolescents ADHD was not among the most common diagnoses: it was found in only 5.7% in the adolescent group |
| Evren et al[25] | Turkey | Cross-sectional | Community sample | A representative sample of 10th grade students: n = 4938 (male ratio: 52.7%) | Mean age: 15.58 yr (SD = 2.85) | PSTA | Those with a lifetime suicidal thoughts had a higher mean ADHD symptom score than those without. Suicidal thoughts predicted the symptoms of ADHD |
| Soole et al[26] | Australia | Cross-sectional | Community sample | 469 deaths by external causes were recorded in the Queensland CDR for children and adolescents aged 10-17 between 2004 and 2012 | Between 2004 and 2012, 149 suicides were recorded: 34 of children aged 10-14 yr and 115 of adolescents aged 15-17 yr | Causes of death were categorized using the ICD-10 | Mental and behavioral disorders were observed in 50% of children and 57.3% of adolescents who died by suicide. Disorders usually diagnosed in infancy, childhood, and adolescence, such as ADHD, were significantly more frequent in children than in adolescents. Mood disorders, such as depression, were significantly more common in adolescents compared with children |
Table 2 Included relevant articles examining attention-deficit/hyperactivity disorder and suicidality from January 2011 to January 2015: Suicidality in patiens with attention-deficit/hyperactivity disorder
| Suicidality in patiens with ADHD | |||||||
| Ref. | Country | Study design | Sample | Population at onset | Population’s age at onset | Measures for ADHD, comorbid conditions and suicidality | Main findings |
| Agosti et al[27] | United States | Cross-sectional | Clinical sample | Current ADHD: 365 adults: With Suicide attempts: n = 59 No suicide attempts: n = 306 | Age range: 18-66 yr | CIDI, ACDS, DIS-IV | Sixteen percentage of participants with current ADHD diagnosis had previous suicide attempt. While ADHD increased the risk of previous suicide attempt only 1.5 fold, having one or more comorbid disorders increased the risk of previous suicide attempt 4 to 12 fold |
| Balazs et al[28] | Hungary | Cross-sectional | Clinical sample | ADHD and subthreshold ADHD children: n = 220 ADHD and subthreshold ADHD adolescents: n = 198 | Children: Age range: 3-11 yr Mean age: 7.67 yr (SD = 2.03) Adolescents: Age range: 12-17 yr Mean age: 14.31 yr (SD = 1.67) | MINI-KID | The relationship between ADHD and suicidality was fully mediated by comorbid psychiatric disorders. In children, symptoms of anxiety disorders mediated this relationship, while in the adolescent group, symptoms of major depressive episode, dysthymia, and substance abuse/dependence were found to be significant mediators |
| Barbaresi et al[29] | United States | Cross-sectional | Community sample | Adults with childhood ADHD: n = 232 Non-ADHD controls: n = 335 | ADHD group: Mean age: 27 yr Non-ADHD group: Mean age: 28.6 yr | MINI | The rate of death from suicide was significantly higher among adults with childhood ADHD compared to non-ADHD adults |
| Cheng et al[30] | Taiwan | Cross-sectional | Community sample | 5405 University students: n = 5405 (male ratio: 64.8%) ADHD symptoms were elevated in 8.6% of the sample: (male ratio: 75.1%) | University students | ASRS, BSRS-5 | Individuals with higher levels of ADHD symptoms were more likely to have higher suicidal ideation |
| Huntley et al[31] | United Kingdom | Cross-sectional | Clinical Sample | Participants from two in-patient alcohol and drug detoxification units: n = 226 (male ratio: 76.5%) Patient with alcohol/drug intoxication + ADHD: n = 11 Patient with alcohol/drug intoxication without ADHD: n = 183 | Mean age: 39.0 yr (SD = 10.3) | DSM-IV 18-item self-report ADHD screening questionnaires for both current and childhood behavior Impairment questions from the Barkley scales DIVA | Patients with both substance use disorders and ADHD had significantly higher rates of prior suicide attempts than patients with substance use disorder without ADHD |
| Hurtig et al[32] | Finland | Longitudinal: 16 yr. First follow up: at ages 7, 8, second follow up at ages 15, 16 | Community sample | ADHD adolescents: n = 104 Non-ADHD adolescents: n = 169 | Adolescents from the same birth cohort | At 8 yr of age: Rutter B2 During the 15-16 yr follow up: SWAN, K-SADS-PL | Adolescents with ADHD had more suicide ideation, acts than adolescents without ADHD. The effect of ADHD on suicidal ideation remained strong after controlling for other variables |
| Kavakci et al[33] | Turkey | Cross-sectional | Community sample | 980 university students (male ratio: 55.9%) ADHD: n = 48 Non-ADHD: n = 932 | Age range: 17-44 yr Mean age: 21.4 yr (SD = 2.3 yr) | ASRS SCID I, SCID II, Adult ADHD Module of MINI Plus | Adolescents with ADHD reported significantly more lifetime suicide attempts than those without ADHD |
| Keresztény et al[34] | Hungary | Cross-sectional | Clinical sample | Children: n = 168 (male ratio: 87.5%) Adolescents: n = 43 (male ratio: 62.8%) | Children: Age range: 3-12 yr Mean age: 8.23 yr (SD = 2.22) Adolescents: Mean age: 14.65 yr (SD = 1.6 yr) boys: 27 (62.8%) | MINI-KID | The most common comorbid diagnoses with ADHD were oppositional defiant disorder, conduct disorder and suicide behavior in both age-groups. The rate of suicide behavior was 17% among children and 58% among adolescents |
| Ljung et al[35] | Sweden | Cross-sectional | Patient and prescribed drug registers and population-based registers | ADHD: n = 51707 (male ratio: 69.8%) Control: n = 258535 | Age range: 3-40 yr | Discharge diagnosis of ADHD | Participants with ADHD had an increased risks of both attempted and completed suicide compared with control participants. This result was the same even after adjusting for comorbid psychiatric conditions. While the highest familial risk was reported among first-degree relatives, lower risk was observed among more genetically distant relatives. The results suggests that shared genetic factors are important for this association |
| Mayes et al[36] | United States | Cross-sectional | Community and clinical sample | 1706 children and adolescents with psychiatric disorders and typical development: ADHD-C: n = 566 (male ratio: 74.6%) ADHD-I: n = 235 (male ratio: 57.4%) Other psychiatric disorders (autism, depression/ anxiety, eating disorder, intellectual disability): n = 719 (male ratio: 67.2%) Typical: n = 186 (male ratio: 43.5%) | Age range: 6-18 yr | All participants had a clinical diagnosis of ADHD made by a licensed PhD psychologist. The clinical diagnosis was based on a comprehensive psychological evaluation including diagnostic inter- views with the parent and child, parent and teacher rating scales, review of educational and medical records, extensive psychological testing PBS | All psychiatric groups had far more suicide behavior than typically developed children. ADHD-C: 20.7% had suicide ideation, 6.0% attempt ADHD-I: 7.3% had suicide ideation, 2.6% attempt |
| Mayes et al[37] | United States | Cross-sectional | Clinical sample | Children and adolescents with ADHD: n = 925 (male ratio: 68.5%) ADHD-C: n = 666 ADHD-I: n = 259 | Age range: 3-16 yr Mean age: 8.8 yr (SD = 2.6) | All participants had a clinical diagnosis of ADHD made by a licensed PhD psychologist. The clinical diagnosis was based on a comprehensive psychological evaluation including diagnostic inter- views with the parent and child, parent and teacher rating scales, review of educational and medical records, extensive psychological testing PBS - suicide ideation and attempt items | For the total sample with ADHD, 15.8% had suicide ideation (sometimes or more) and 5.5% had attempts Ideation and attempts were more than twice as prevalent among participants with ADHD-C than among participants with ADHD-I ADHD-C: 19% had suicide ideation, 7% attempt ADHD-I: 7% had suicide ideation, 3% attempt Those, who had ADHD alone: 6% had suicide ideation and 2% had suicide attempt. Those, who had ADHD + co-occurring sadness and ODD, 46% had ideation and 21% had attempts |
| Park et al[38] | South Korea | Cross-sectional | Community sample | A total of 6081 subjects: Non-ADHD symptom group: n = 6012 ADHD symptom group: n = 69 | Age range: 18-59 yr | K-CIDI Adult ADHD Self-Report Scale | Adult ADHD symptoms are significantly associated with lifetime suicidality. However, the association disappeared after adjusting for other comorbid psychiatric disorders |
| Swanson et al[39] | United States | Longitudinal: 10 yr: First 5 yr follow up and second 10 yr follow-up | Community and clinical sample | ADHD girls: n = 140 Non-ADHD girls: n = 88 | Age range: 6-12 yr at ascertainment Mean age at 5 yr follow-up: 14.2 yr Mean age at 10 yr follow-up: 19.6 yr (range 17-24 yr) | At ascertainment: DISC-IV First follow up: SNAP-IV, Second follow up: SIQ, Barkley Suicide Questionnair, DISC-IV-YA | Women with a childhood diagnosis of ADHD-C, compared with those with ADHD-I and control group, were at higher risk for suicide attempts. Furthermore, women with a persistent ADHD diagnosis were at higher risk than women with a transient diagnosis and the control group |
| Van Eck et al[40] | United States | Cross-sectional | Community sample | Undergraduate psychology students: n = 627 (male ratio: 40%) | Mean age: 20.23 yr (SD = 1.40) | CSS BSI | ADHD indirectly increased suicidal ideation through depression. The moderator factors in the indirect effect of ADHD on suicidal ideation were emotion regulation deficits of accepting negative emotions, emotional awareness, and goal-oriented behavior |
Table 3 Included relevant articles examining attention-deficit/hyperactivity disorder and suicidality from January 2011 to January 2015: Suicidality in patients with psychiatric disorders who have attention-deficit/hyperactivity disorder comorbidity
| Suicidality in patients with psychiatric disorders who have ADHD comorbidity | |||||||
| Ref. | Country | Study design | Sample | Population at onset | Population’s age at onset | Measures for ADHD, comorbid conditions and suicidality | Main findings |
| Bácskai et al[41] | Hungary | Cross-sectional | Clinical sample | 198 patients with drug dependence (male ratio: 76%) Drug dependent patients without ADHD: n = 154 Drug dependent patients with ADHD: n = 44 | Age range: 18-40 yr Mean age of the whole sample: 27 yr (SD = 6.31) | ASRS, EuroADAD, BDI | Drug dependent patients with ADHD showed a significantly higher proportion of suicidal ideation, suicidal attempts and self-injuries associated with suicidal attempts than drug dependent patients without ADHD |
| Berkol et al[42] | Turkey | Cross-sectional | Clinical sample | Patients with BD type I and II Adult BP with ADHD: n = 23 Adult BP without ADHD: n = 32 | BP adults with ADHD: Mean age: 35.1 yr (SD = 10.7) BP adults without ADHD: Mean age: 41.3 yr (SD = 13.0) | ADHD scale Mood disorder modul of SCID-I-CV | In the BP with ADHD group, the rate of suicide attempts (47.8%) was significantly higher than in the BP without ADHD group (21.9%) |
| Donev et al[43] | Germany | Cross-sectional | Clinical sample | Patients with schizophrenia according to ICD-10 criteria: n = 27 (14 male) Patients with schizophrenia and no ADHD: n = 15 Patients with schizophrenia and ADHD: n = 12 | Age range: 18-44 yr Mean age: 25.7 yr (SD = 7.6) | ADHD-HKS Questionnaire | Among patients with both schizophrenia and ADHD there were significantly higher number of suicide attempts than among those with schizophrenia without ADHD |
| Huntley et al[31] | United Kingdom | Cross-sectional | Clinical sample | Participants from two in-patient alcohol and drug detoxification units: n = 226 (male ratio: 76.5%) Patient with alcohol/drug intoxication + ADHD: n = 11 Patient with alcohol/drug intoxication without ADHD: n = 183 | Mean age: 39.0 yr (SD = 10.3) | DSM-IV 18-item self-report ADHD screening questionnaires for both current and childhood behavior Impairment questions from the Barkley scales DIVA | Patients with both substance use disorders and ADHD had significantly higher rates of prior suicide attempts than patients with substance use disorder without ADHD |
| Patros et al[44] | United States | Cross-sectional | Community sample | College students: n = 1056 (male ratio: 38.5%) | Age range: 18 yr of age or older; 96.4% aged 18-24 yr | CSS, HDSQ | Higher hyperactive/attention symptoms were associated with increase in suicidal thoughts, suicide attempts, and need for medical attention after suicide attempts, among participants with depressed mood |
| Penney et al[45] | Canada | Cross-sectional | Clinical sample | Clients who presented for treatment at an addictions facility: n = 5990 (male ratio: 63.1%) Clients who reported being hospitalized for attempting suicide in the past year: n = 76 All other clients: n = 5914 | Age range: 11-86 yr Mean age: 32.60 yr (SD = 14.55) | Clients reported whether or not they had been diagnosed by a mental health professional in the last 12 mo and in heir lifetime | Compared to all other clients, clients who attempted suicide in the past year were significantly more likely to have ADHD (9.2% vs 2.5%) |
| Sáez-Francàs et al[46] | Spain | Cross-sectional | Clinical sample | Adult CFS patients: n = 158 CFS patients with adult ADHD: n = 33 (male ratio: 3.0%) CFS patients without adult ADHD (male ratio: 6.4%) | CFS + ADHD: Mean age: 47.55 yr (SD = 7.99) CFS: Mean age: 48.60 yr (SD = 8.88) | CAADID Suicide risk was studied with the Plutchick Risk of Suicide Scale (Plutchik et al, 1989), a 15-item self-report scale with dichotomous responses. Values above the cut-off point of 6 indicate a risk of suicide | CFS patients with adult ADHD had a higher risk of suicide than CFS patients without ADHD |
Table 4 Included relevant articles examining attention-deficit/hyperactivity disorder and suicidality from January 2011 to January 2015: Suicidality in attention-deficit/hyperactivity disorder patients who have psychiatric comorbidity
| Suicidality in ADHD patients who have psychiatric comorbidity | |||||||
| Ref. | Country | Study design | Sample | Population at onset | Population’s age at onset | Measures for ADHD, comorbid conditions and suicidality | Main findings |
| Agosti et al[27] | United States | Cross-sectional | Clinical sample | Current ADHD: 365 adults: With Suicide attempts: n = 59 No suicide attempts: n = 306 | Age range: 18-66 yr | CIDI, ACDS, DIS-IV | Sixteen percentage of participants with current ADHD diagnosis had previous suicide attempt. While ADHD increased the risk of previous suicide attempt only 1.5 fold, having one or more comorbid disorders increased the risk of previous suicide attempt 4 to 12 fold |
| Balazs et al[28] | Hungary | Cross-sectional | Clinical sample | ADHD and subthreshold ADHD children: n = 220 ADHD and subthreshold ADHD adolescents: n = 198 | Children: Age range: 3-11 yr Mean age: 7.67 yr (SD = 2.03) Adolescents: Age range: 12-17 yr Mean age: 14.31 yr (SD = 1.67) | MINI-KID | The relationship between ADHD and suicidality was fully mediated by comorbid psychiatric disorders. In children, symptoms of anxiety disorders mediated this relationship, while in the adolescent group, symptoms of major depressive episode, dysthymia, and substance abuse/dependence were found to be significant mediators |
| Daviss et al[47] | Lebanon | Cross-sectional | Clinical sample | Youth with ADHD: n = 101 (male ratio: 63.4%) Lifetime SBs n = 28 (male ratio: 42.9%) No lifetime SBs: n = 73 (male ratio: 71.2%) | Age range in the whole sample: 11-18 yr Lifetime SBs: Mean age: 14.6 yr (SD = 2.1) No lifetime SBs: Mean age: 13.5 yr (SD = 1.8) | K-SADS-PL ADHD Rating Scale | In this ADHD sample, after controlling for the age, female sex, and comorbid disorders, lifetime SB remained significantly associated with parent-child conflict, and impairment in nonacademic domains of function and breadth of exposure to victimization events Past and current ADHD symptoms and signs were not associated with lifetime SB |
| Ljung et al[35] | Sweden | Cross-sectional | Patient and prescribed drug registers and population-based registers | ADHD: n = 51707 (male ratio: 69.8%) Control: n = 258535 | Age range: 3-40 yr | Discharge diagnosis of ADHD | Participants with ADHD had an increased risks of both attempted and completed suicide compared with control participants. This result was the same even after adjusting for comorbid psychiatric conditions. While the highest familial risk was reported among first-degree relatives, lower risk was observed among more genetically distant relatives. The results suggests that shared genetic factors are important for this association |
| Mayes et al[36] | United States | Cross-sectional | Community and clinical sample | 1706 children and adolescents with psychiatric disorders and typical development: ADHD-C: n = 566 (male ratio: 74.6%) ADHD-I: n = 235 (male ratio: 57.4%) Other psychiatric disorders (autism, depression/ anxiety, eating disorder, intellectual disability): n = 719 (male ratio: 67.2%) Typical: n = 186 (male ratio: 43.5%) | Age range: 6-18 yr | All participants had a clinical diagnosis of ADHD made by a licensed PhD psychologist. The clinical diagnosis was based on a comprehensive psychological evaluation including diagnostic inter- views with the parent and child, parent and teacher rating scales, review of educational and medical records, extensive psychological testing PBS | All psychiatric groups had far more suicide behavior than typically developed children. ADHD-C: 20.7% had suicide ideation, 6.0% attempt ADHD-I: 7.3% had suicide ideation, 2.6% attempt |
| Mayes et al[37] | United States | Cross-sectional | Clinical sample | Children and adolescents with ADHD: n = 925 (male ratio: 68.5%) ADHD-C: n = 666 ADHD-I: n = 259 | Age range: 3-16 yr Mean age: 8.8 yr (SD = 2.6) | All participants had a clinical diagnosis of ADHD made by a licensed PhD psychologist. The clinical diagnosis was based on a comprehensive psychological evaluation including diagnostic inter- views with the parent and child, parent and teacher rating scales, review of educational and medical records, extensive psychological testing PBS - suicide ideation and attempt items | For the total sample with ADHD, 15.8% had suicide ideation (sometimes or more) and 5.5% had attempts. Ideation and attempts were more than twice as prevalent among participants with ADHD-C than among participants with ADHD-I. ADHD-C: 19% had suicide ideation, 7% attempt ADHD-I: 7% had suicide ideation, 3% attempt Those, who had ADHD alone: 6% had suicide ideation and 2% had suicide attempt |
| Park et al[38] | South Korea | Cross-sectional | Community sample | A total of 6081 subjects: Non-ADHD symptom group: n = 6012 ADHD symptom group: n = 69 | Age range: 18-59 yr | K-CIDI Adult ADHD Self-Report Scale | Those, who had ADHD + co-occurring sadness and ODD, 46% had ideation and 21% had attempts Adult ADHD symptoms are significantly associated with lifetime suicidality. However, the association disappeared after adjusting for other comorbid psychiatric disorders |
| Swanson et al[39] | United States | Longitudinal: 10 yr: First 5 yr follow up and second 10 yr follow-up | Community and clinical sample | ADHD girls: n = 140 Non-ADHD girls: n = 88 | Age range: 6-12 yr at ascertainment Mean age at 5 yr follow-up: 14.2 yr Mean age at 10 yr follow-up: 19.6 yr (range 17-24 yr) | At ascertainment: DISC-IV First follow up: SNAP-IV, Second follow up: SIQ, Barkley Suicide Questionnaire, DISC-IV-YA | Women with a childhood diagnosis of ADHD-C, compared with those with ADHD-I and control group, were at higher risk for suicide attempts. Furthermore, women with a persistent ADHD diagnosis were at higher risk than women with a transient diagnosis and the control group |
| Taylor et al[48] | New Zealand | Cross-sectional | Community sample | 66 adults (43 men, 23 women ADHD: n = 35 (male ratio: 65.7%) Non-ADHD: n = 31 (male ratio: 64.5%) | Age range: 18-65 yr Mean age: 31.9 yr (SD = 1.6) | CAARS DSHI SCID-I (suicidality) CAADID | There was a significant associations between ADHD symptom severity and self-reported suicidal ideation and suicide attempts. These associations between suicidal behaviours and ADHD symptom severity were significantly and differentially mediated by psychosocial variables such as comorbidities (mood, anxiety, drug, and alcohol abuse disorders) and emotion-focussed coping style |
Table 5 Assessments for measuring attention-deficit/hyperactivity disorder
| Ref. | Scale | Abbriviation |
| [49] | Adult ADHD Clinic Diagnostic Scale | ACDS |
| [50] | Adult Self-Report Scale | ASRS |
| [51] | Adult ADHD DSM-IV-Based Diagnostic Screening and Rating Scale, ADHD-C: ADHD combined type, ADHD-I: ADHD inattentive type, ADHD-HKS Questionnaire | ADHD scale |
| [52] | Conners’ Adult ADHD Diagnostic Interview for DSM-IV | CAADID |
| [53] | Conners’ Adult ADHD Rating Scale | CAARS |
| [54] | Diagnostic Interview for ADHD in Adults | DIVA |
| [55] | Strengths and Weaknesses of ADHD symptoms and Normal Behaviors | SWAN |
Table 6 Assessments for measuring suicidality and comorbid conditions
| Ref. | Scale | Abbriviation |
| [56] | Beck Depression Inventory | BDI |
| [57] | Brief Symptoms Inventory | BSI |
| [58] | Brief Symptoms Rating Scale | BSRS-5 |
| [59] | Composite International Diagnostic Interview | CIDI |
| [60,61] | Current Symptoms Scale-Self-Report Form | CSS |
| [62] | Deliberate Self-Harm Inventory | DSHI |
| [63] | Diagnostic Interview Schedule for DSM-IV | DIS-IV |
| [64] | Diagnostic Interview Schedule for Children | DISC-IV |
| [65] | Diagnostic Interview Schedule for Children 4th ed., Young Adult version | DISC-IV-YA |
| [66,67] | European Version of the Adolescent Assessment Dialogue | EuroADAD |
| [68] | Hopelessness Depression Symptom Questionnaire-Suicidality Subscale | HDSQ |
| [69] | Korean version of Composite International Diagnostic Interview | K-CIDI |
| [70] | Schedule for Affective Disorder and Schizophrenia for School-Age Children- Present and Lifetime Version | K-SADS-PL |
| [71] | Psychological Screening Test for Adolescents | PSTA |
| [72] | Rutter's Behaviour Scale for Children (Teacher’s Scale) | Rutter B2 |
| [73] | Mini International Neuropsychiatric Interview | MINI |
| [73,74] | Mini International Neuropsychiatric Interview Kid | MINI Kid |
| [75] | Pediatric Behavior Scale | PBS |
| [76,77] | Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version | SCID-I-CV |
| [78] | Structured Clinical Interview for DSM-III-R Personality Disorders | SCID-II |
| [79] | Self-Injury Questionnaire | SIQ |
| [80] | Swanson, Nolan, and Pelham Rating Scale 4th ed. | SNAP-IV |
- Citation: Balazs J, Kereszteny A. Attention-deficit/hyperactivity disorder and suicide: A systematic review. World J Psychiatr 2017; 7(1): 44-59
- URL: https://www.wjgnet.com/2220-3206/full/v7/i1/44.htm
- DOI: https://dx.doi.org/10.5498/wjp.v7.i1.44