A call to improve mental health support to reduce the risks of self-harm and suicide in autistic individuals

Autistic females (assigned sex at birth) have an 83% increased risk of self-harm leading to emergency health care relative to non-autistic people, according to a new study from ICES and the Center for Addiction and Mental Health (CAMH).

Autistic males also had a 47% greater risk of self-harm events and had the highest incidence of suicide death compared to autistic females and non-autistic individuals.

The study, "Self-Harm Events and Suicide Deaths Among Autistic Individuals in Ontario, Canada," was published today in JAMA Network Open and is the first in Canada to explore suicide rates and self-harm events in autistic versus non-autistic individuals factoring sex, sociodemographic and clinical risk factors.

"The presence of psychiatric illnesses substantially accounts for these increased risks," says lead author Meng-Chuan Lai, staff psychiatrist and senior scientist at CAMH. "We know that many self-harm and suicide-related events could be prevented when people have access to tailored mental health supports and services, and this is crucial for autistic people."

The study included cohorts of 379,630 and 334,690 individuals in Ontario, Canada to understand the incidence of self-harm events and suicide death, respectively. Autistic and non-autistic individuals were followed for self-harm events that resulted in emergency care (from 2005 to 2020) and death by suicide (from 1993 to 2018).

Study findings show:

• There were significantly more self-harm events leading to emergency health care in autistic compared to non-autistic people, across both males (47% increased risk) and females (83% increased risk), after adjusting for neighborhood income and urban/rural status, intellectual disabilities, and psychiatric diagnoses.
• Although both autistic females and males showed higher incidence of suicide death than non-autistic females and males, these increased suicide death risks in both sexes were explained by the presence of psychiatric diagnoses.

"In my twenties, I accessed the emergency room a number of times seeking help for suicidal thoughts and ideations. During that time, I struggled with accessing mental health counseling and support in my city that didn't have at least a six-month-long waiting list or were affordable, and I waited a over a year to access a psychiatrist," says Megan Pilatzke, an advocate and autistic woman.

"This is a wake-up call," says Yona Lunsky, Adjunct Scientist at ICES and Director of the Azrieli Adult Neurodevelopmental Center at CAMH. "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."

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

"Our health care system should take a two-pronged approach to support autistic people," says Lai: "Enhancing access to mental health services, and autism-informed accommodations for those services. For example, we can support autistic individuals who come into the health care settings by offering calming spaces, providing maximal predictability possible, understanding their communication styles and preferences, meeting their sensory needs, and supporting them if they wish to come accompanied by a person they trust."

The CAMH Azrieli Adult Neurodevelopmental Center offers resources and tools aimed at individuals, their families, and clinicians to support the mental health of autistic people.

One limitation of the study is that the number of autistic individuals may be underestimated, because individuals who had yet to receive a formal diagnosis, or whose diagnosis was made by private practice psychologists may not have been included. Autistic people could have been miscategorized in the non-autistic group, which would have underestimated suicide-related outcomes in the autistic group.

Finally, many self-harm events are not captured by health records, as individuals may not visit the emergency department for health care in these situations.