Copyright Blackwell Munksgaard 2004

Acta Psychiatr Scand 2004: 110: 408415

Printed in UK. All rights reserved
DOI: 10.1111/j.1600-0447.2004.00384.x

ACTA PSYCHIATRICA
SCANDINAVICA

Review article

Attention decit hyperactivity disorder and

suicide: a review of possible associations
James A, Lai FH, Dahl C. Attention decit hyperactivity disorder and
suicide: a review of possible associations.
Acta Psychiatr Scand 2004: 110: 408415. Blackwell Munksgaard 2004.
Objective: To review the evidence of a possible association between
attention decit hyperactivity disorder (ADHD) and suicide.
Design: We searched the electronic data bases: Medline, Psych LIT,
between 1966 and March 2003 looking for articles on ADHD,
attention decit disorder, hyperactivity and suicide.
Results: An association of ADHD and completed suicide was found,
especially for younger males. However, the evidence for any direct or
independent link was modest with an overall suicide rate from longterm follow-up studies of ADHD of 0.630.78%. The estimated
relative risk ratio, compared with US national suicide rates (males 5
24 years) is 2.91 (95% condence interval 1.475.7, v2 9.3, d.f. 1,
P 0.002). ADHD appears to increase the risk of suicide in males via
increasing severity of comorbid conditions, particularly conduct
disorder (CD) and depression.
Conclusion: Identication of those at risk, particularly males with
comorbid ADHD, depression and CD, may represent a useful clinical
means of reducing completed suicide.

A. James1, F. H. Lai2, C. Dahl3

1

Highfield Adolescent Unit, Warneford Hospital, Oxford

OX3 7JX, UK, 2Consultant Psychiatrist, Department of
Psychiatry, Penang Hospital, Malaysia and 3
rztin im
Praktikum, Klinik fr Kinder- und Jugend- Psychiatrie,
Olgahospital, Stuttgart, Germany

Key words: attention deficit hyperactivity disorder;

attention deficit disorder; suicide; adolescence
Dr Anthony James, Highfield Adolescent Unit,
Warneford Hospital, Oxford OX3 7JX, UK.
E-mail: anthony.james@psych.ox.ac.uk
Accepted for publication May 17, 2004

Introduction

Aims of the study

Suicide among teenagers is often the endpoint of

chronic problems. Psychological autopsy studies
(116) suggest that the most signicant predisposing factors to teenage suicides are depressive
disorder, previous suicide attempts, antisocial
behaviour, substance misuse and dependence, and
personality traits such as impulsivity or aggression.
Children with attention decit hyperactivity disorder (ADHD) have a higher risk than other children
of developing psychiatric problems such as depressive disorders, antisocial behaviour, substance
misuse and dependence (17). These comorbid
conditions, as well as impulsivity and aggression,
are recognized predisposing factors for suicide.
This raises the question whether there is a direct
association between ADHD and suicide and, if so,
what are the mechanisms involved? Mental disorders are strongly associated with suicide, however,
a recent systematic review of psychological autopsy
studies (18) revealed the eects of particular
disorders have been insuciently studied to draw
clear conclusions. A focus on specic disorders and
psychosocial factors involved in suicide is needed.

The aim of this review, therefore, is to examine the

evidence for a possible association between ADHD
and suicide and to explore any relevant mechanisms.

408

Material and methods

A literature search was undertaken using the

electronic databases: MEDLINE from (1/1966),
PSYCHLIT from (1/1990), with the key words
[attention
decit
hyperactivity
disorder
(ADHD)], [attention decit disorder (ADD)],
[hyperactivity], [suicide], [psychological autopsy
and suicide] to March 2003. All languages were
included. Using the reference list of identied
articles we hand searched relevant journals.
Where necessary we contacted the lead author
for clarication of details. Two principle sources
of information were used rst: psychological
autopsy studies of teenage and young adult
suicides and second: long-term followup studies
of ADHD children.

Attention decit hyperactivity disorder and suicide

Inclusion criteria

Psychological autopsy studies

All studies had to include subjects with diagnosed

ADHD, ADD, according to the criteria of the
Diagnostic Statistical Manual (DSM) (19) or
hyperactivity according to the International Classication of Diseases (ICD) (20). Follow-up studies
should have continued into early adulthood,
thereby covering an early period of risk for suicide.
To be included studies had to give details on
subjects lost to follow up and to have a low
attrition rate. A requirement for inclusion of the
autopsy studies was the use of DSM or ICD
diagnoses or in the case of early studies a description of hyperactive, impulsive, inattentive behaviours.

Sixteen adolescent psychological autopsy studies

were included (116), in which just about a third
(n 5) identied a possible link between ADHD/
ADD and suicide (3, 7, 12, 13, 14). An early US
case-control psychological autopsy revealed 25.9%
(seven of 27) of 27 adolescent suicides had ADD
(3). In a later case control study of 67 completed
suicides in the US (9) 13.5% of suicide victims were
found to have ADD, the same rate as that amongst
matched community controls. The rate of ADD for
community subjects was, however, high and even
higher in a subsequent study by the same group
(11). Amongst children in the UK under 15 years
old who committed suicide, (12) Shaer described
six cases out of a total of 31 as impulsive- no selfcontrol-volatile-erratic; while non-systematic, this
description shares some characteristics of ADHD.

Statistical analysis

Statistical analysis was performed using EPI Info 6

Version 6.04d (21). The relative risk ratios comparing the annual rates of suicide were examined
using chi-square (v2) test, with 95% condence
intervals (CI), and signicance level for two tailed
P-value > 0.05.
Results
Epidemiological suicide studies

In a study of all suicides in Finland, ADHD was

found in 4% (n 2) of adolescent suicides; both
were males (7). An epidemiological study of
teenage suicides in New York State (13) found
the association to be mainly limited to younger
males: a fth of male suicides (n 6) under
17 years old had a diagnosis of ADD, a rate
reduced to 3% (n 3) in those over 17 years. In
the same study, amongst the 12 girls who committed suicide aged less than 17 years, there was one
case of ADD (one of 12, 8%). A Norwegian
national survey of youth suicides over a 2-year
period (14) revealed 14% (n 2 of 14) of younger
suicides, aged <14 years, had ADHD, one with a
comorbid aective disorder. Overall, the suicide
rate for those with ADHD amongst under 19-year
old was 1.5% (two of 129). Using data from a US
Managed Care database of 55 525 cases of ADHD
and 157 575 controls, Swensen et al. (22) found a
raised rate of suicide attempts amongst the ADHD
group, even after allowing for depression and
substance abuse (odds ratio 2.1, 95% CI 1.62.9,
P < 0.0001), and a three times higher rate of
completed suicide (odds ratio 3.0 95% CI 0.812.0,
P 0.11).

ADHD/ADD/hyperactivity follow up studies

We identied 11 separate prospective, follow-up

studies of ADHD/ADD/hyperactivity into early
adulthood (2333), of which ve (2933) did not
give sucient details about loss of subjects to allow
analysis. Weiss et al (23), in a 15-year follow-up of
63 hyperactive children and 41 controls, found that
six hyperactive subjects made suicide attempts in the
3 years prior to the study ending, and one died vs.
none in the control group (P < 0.04); altogether,
there were possibly two suicides one from an
overdose and another from an accident, estimated
suicide rate from the total original cohort of 104
subjects followed up to the mean age of 25 years
(one of 104 to two of 104) 0.961.92% vs. none in
the control group. In the New York series of two
studies (24, 25) involving 103 and 104 ADHD
subjects respectively, followed up to age 25, there
was one death by suicide one of 103, 1% vs. 0 of 104
in the later study. A 23-year Danish follow-up study
of 135 children with a conrmed diagnosis of
ADHD (26), revealed one suicide (0.74%) and one
death following a drugs overdose. Similarly, an
American follow-up study of 147 children (aged 4
12 years) with ADHD into early adulthood (mean
age 21 years) reported one suicide (0.69%) (27).
There were, however, no suicides in a Swedish study
of ADHD with and without coordination disorder
(n 50) up to the age of 22 years (28).
Overall, the estimated suicide from these studies
is 0.63% (four of 639) to 0.78% (ve of 639).
Taking into account the estimated length of
observation for each individual suicide, with the
oldest subjects being 26, the annual suicide rate is
3239 of 100 000. The most conservative estimated
409

James et al.
relative risk ratio is 2.91 (95% CI 1.475.7, v2
0.3, d.f. 1, P 0.002), based upon the lower
annual suicide rate of 32 of 100 000, and the
highest national suicide rate in the countries
involved in the long-term studies, that is for US,
males aged 524, (11.2 of 100 000 per annum)
(33, 34).
ADHD comorbidity

Whilst there appears to be a association of ADHD

and completed suicide from epidemiological suicide studies, postmortem and ADHD follow-up
studies, especially for younger males, the evidence
for any direct or independent link is modest.
However, there is evidence to suggest that
ADHD, as a comorbid disorder, is an important
factor in completed suicide. First, ADHD is
frequently presents as a comorbid condition (35).
Secondly, suicide in adolescence is strongly associated with comorbid psychiatric diagnoses, particularly mood disorders, disruptive behavioural
disorders and substance abuse (7, 9, 13), which are
common comorbid conditions with ADHD. In an
early study by Brent al (3) ADD was the most
common comorbid diagnosis, in those with a
primary mood disorder who had committed suicide. Third, comorbidity substantially increases the
risk for completed and attempted suicide (36). In a
study of 129 young people making a serious suicide
attempt, the odds ratio of those with two or more
comorbid diagnoses making an attempt compared
with controls was 40.4 (95% CI 17.991.1) (37).
Fourth, more severe symptoms of ADHD are
associated with elevated levels of both internalizing
and externalizing symptoms (38), Fifth, comorbid
disorders, particularly aective disorders, are associated with the persistence of ADHD symptoms
into adolescence (39). Sixth, ADHD makes the
clinical outcome of comorbid disorders worse in
every respect. Renaud et al. (16) argued that ADD
was not a risk factor for suicide per se, but led to
poorer outcomes and suicide risk via comorbid
conduct disorder (CD) and substance abuse. This
argument was based on the nding that, although,
CD, which will contain a proportion of cases with
comorbid ADD, occurs in about a third to a half of
youth suicides (7, 9, 13), the rate of pure ADD in
two suicide studies was similar to controls (9, 15).
Comorbid opposition defiant disorder/conduct disorder.

Naturalistic studies show that just under half

(43%) of community subjects with ADHD children
have persistent hyperactive symptoms, and it is in
this group that there is a high likelihood of
410

developing comorbid psychiatric conditions (40).

Up to 50% of clinic-referred children with ADHD
meet comorbid diagnosis for CD (41) and up to
30% of community samples (42). A meta-analytic
study of 21 community studies using DSM III,
DSM III-R and DSM IV criteria (35) conrmed
the high rates of ADHD comorbidity: ADHD CD
odds ratio 10.7 (95% CI 7.7, 14.9). There appears a
developmental pathway from ADHD via opposition deant disorder (ODD) to CD, with less
convincing evidence of a direct connection to CD
(43). With respect to children with pure ADHD,
children with comorbid ADHD and ODD/CD
demonstrate: a more severe clinical picture (38, 44,
45) with greater persistence of hyperactive and
impulsive behaviours (46, 47); greater genetic
loading (48); earlier onset (38); suer more psychosocial adversity such as greater levels of parental psychopathology, conictual relationships with
parents, peer rejection and school problems (45, 49,
50); are less responsive to treatment with respect to
aggression (51); and have a worse outcome than
either those with ADHD or CD alone (5255).
Hyperactivity, per se, appears a risk factor for
later development, even allowing for comorbid CD
(55), with a high likelihood of later psychiatric
diagnosis, violence, antisocial behaviour and
impaired social adjustment.
In a 15 year follow-up to the age on average of
23 years, 31.5% (six of 19) of hyperactive children
with persistent antisocial behaviour had made a
suicide attempt (56), signicantly more than children with hyperactivity and no antisocial behaviour (0 of 17) (Fischer Exact test P 0.02). CD
occurs in about a third to half of suicides (7, 9, 13)
often in impulsive, aggressive males, a subgroup
where comorbid ADHD is likely to be overrepresented.
Comorbid depression

The most reliable studies indicate the prevalence

rates of depression in children with ADD or
ADHD vary between 15 and 44% (57, 58), with
results from a meta-analysis of 21 community
studies (35) conrming a ADHD-depression odds
ratio of 5.5 (95% CI 3.5, 8.4). The relationship is
not simple. Epidemiological examination shows
the ADHD and depression comorbidity maybe
mediated via anxiety and CD (35) and, as such, the
comorbidity is more an epiphenomenona. A
review of family studies of ADHD and of depression, and a one population-based family study by
Faraone and Biederman (59) strongly support a
familial link between ADHD and depression, the
greatest risk being ADHD families with antisocial

Attention decit hyperactivity disorder and suicide

disorders. There is also evidence that comorbid
depression is linked more to symptoms of inattention, than hyperactivity and impulsivity (17),
however, comorbid ADHD and depression are,
nonetheless, a malignant combination in terms of
outcome (60).
It is clear that the combinaton of CD, depression and alcohol use is very strongly associated
with suicide (7, 9, 13) Using the data form the
Maudsley long-term follow-up of childhood and
adolescent depression, Fombonne et al. (61)
found ADHD occurred signicantly more frequently in those with comorbid major depressive
disorder (MDD) and conduct disorder (MDDCD) (0 of 96 vs. four of 53, P 0.015) than in
MDD. It was in the group with comorbid MDD
and CD that the suicide rate was signicantly
raised (estimated annual suicide rate of 261 per
100 000) compared with the MDD group (estimated annual suicide rate 32.5 per 100 000)
(incidence rate ratio 8.0, 95% CI 1.1191.5,
P 0.03) (62). In the suicide study by Brent et
al. (3) 63% (17 of 27) of victims suered from an
aective disorder and 18.5% (ve of 27) had
comorbid ADD.
Comorbid substance abuse

Substance abuse has been strongly linked to

completed suicide, occurring between 11 and 35%
of cases (13, 16). It is important as a comorbid
disorder, but also notably alcohol is used as a
disinhibiting factor just prior to death (16).
Follow-up studies show that children with
ADHD are at a higher risk of developing alcoholism and substance abuse in later life (24) The
association of ADHD with substance abuse is,
however, not direct, but probably mediated
through high rates of CD (33, 6367). Kuperman
et al. (68), found that nearly three-quarters of the
alcohol-dependent adolescents had at least one
disruptive behaviour disorder diagnosis. In a
developmental pathway, ADHD typically occurred
rst, followed by conduct disorder. Substance use
began with alcohol or tobacco, followed by marijuana and then other street drugs. Alcohol dependence began signicantly later than the onset of
either ADHD or conduct disorder. For male, but
not female, adolescents there appears to be direct
eects of both CD and ADHD on subsequent
alcohol-use disorder (69). A recent follow up study
of 140 ADHD children, however, points to the
possibility of ADHD, even without signicant
comorbidity, increasing the risk of substance
abuse in mid adolescence by a factor of three to
four times (70).

Comorbid bipolar disorder

The relationship between bipolar disorder (BPD)

and ADHD in children and adolescents is a subject
of controversy in the recent literature; some of the
most common clinical dilemmas seem to arise from
overlapping symptomatology of the two disorders
(71). Biederman et al. (72) found BPD occurred in
11% of ADHD children and in an additional 12%
at 4-year follow-up; these rates being signicantly
higher than those of controls at each assessment.
The comorbid condition is likely to be worse;
patients having both BPD and ADHD have more
manic symptoms than those with BPD alone (73).
The presence of ADHD in children of bipolar
probands identies children at highest risk for
development of BPD (74), while family studies
provide some support for a link between ADHD
and BPD (75).
However, Angold and Costello (35) argue from an
epidemiological perspective that the association of
ADHD with BPD is a very rare event indeed and
further follow-up studies of ADHD do not lend
support to a link between ADHD and BPD (33, 63,
76). It is unlikely, therefore, that this comorbidity is
an important factor in any link of ADHD and
suicide, although BPD has been associated with
suicide in some studies (3, 9, 11, 13), but not all (7).
Conclusion

An association of ADHD and completed suicide

was found, especially for younger males, in four,
possibly ve, out of 16 psychological autopsy
studies of children, adolescents and young adults,
and in four out of six longitudinal ADHD followup studies into adulthood. However, the evidence
for any direct or independent link was modest with
a estimated suicide rate from the long-term followup studies of ADHD (2328) of between 0.63 and
0.78% over approximately a 20-year period
(annual suicide rate 3239 of 100 000). One must
be cautious because of the small numbers of
subjects identied, however, this rate is nearly
three times higher than the comparable US
national suicide rate for males between the ages
of ve and 24. The natural remission rate of
ADHD is nearly 50% in adolescence (40, 77),
therefore, the estimates of risk rate may be need to
doubled, as it is likely that the risk is contained in
the group with persistent ADHD. In comparison
with juvenile depression, one of the diagnoses most
strongly linked to suicide, the rate of suicide in
ADHD is about a third of that (2.4%) of depressed
children and adolescents in the Maudsley followup study over a 20-year period. (62).
411

James et al.
The review has been mainly limited to males, as
the rates of ADHD are higher in males, and a
majority of studies, particularly the longer-term
follow-up of ADHD subjects, have included over
90% males (2325, 27, 28). The Danish long-term
study (26), which included 25% females, found
females with ADHD to be if anything more
disturbed, with a greater likelihood of adult psychiatric admission, but nevertheless with no reported
suicides. A further diculty in studying any
ADHD/suicide link is the low base rate of adolescent suicide, with an even lower rates in females (78),
However, there is an indication that the psychopathology in females who do commit suicide may be
more severe than in their male counterparts. (8).
If there exists a link between ADHD and suicide,
although small, why then has this not been more
commonly reported? There are a number of
factors, which may serve to obscure or lessen any
association. First, psychological autopsy studies
are a powerful investigatory tool, particularly for
determining psychiatric morbidity immediately
prior to death (79), however, they are prone to
limitations of recall and parent-child disagreements
over childhood symptoms and diagnoses. As a
proxy estimate, the agreement on conduct diagnoses between parents and adolescents who have
taken serious overdoses is only between 0.310.41
kappa (j) (80). Secondly, ADHD is an early
childhood disorder, typically diagnosed pre-pubertally, while the rates of suicide do not increase
signicantly until late teenage years. Thirdly,
follow-up studies of childhood ADHD, particularly if of only a few years duration, may not
include the period of risk (8184). Fourthly, in
most of the follow-up studies there was a considerable loss of cases, particularly in community
surveys, which may obscure any ndings. Fifthly,
children with ADHD are noted to be at risk of
accidents including fatal ones (23), however, suicidal intent may not be recognized.
Overall, it appears that ADHD increases the risk
of suicide in males via increasing severity of
comorbid conditions, particularly conduct disorder
and depression. The combination of MDD, CD
and ADHD appears a particular risk, especially if
there is also substance abuse. In addition ADHD
may be an important biological trait underlying the
impulsivity and aggression found in cases of
completed suicide (85).
In terms of suicide prevention, it could be argued
that identication of a high-risk group of males
with CD and MDD is important, particularly
those males with a history of ADHD. A developmental pathway, identied at follow-up of ADHD
children, indicates that over a quarter (26%) of
412

ADHD children develop MDD by age 21, and that

the risk of this is mediated through CD in
adolescence (86). Preventive measures may include
early treatment of ADHD with the aim of reducing
the impact of comorbid disorders and subsequent
deviant development. There is some evidence that
treatment of ADHD with methylphenidate in the
long-term, particularly at higher doses, is associated with fewer suicide attempts (87) and three to
four times reduced rate of substance abuse disorder
(70). More immediate measures would include the
recognition of ADHD and depression in boys with
conduct disorder and the use of appropriate
psychological and pharmacological treatments,
such as stimulants and selective serotonin reuptake inhibitors (SSRIs), for depressive and
impulsive symptoms (88).
In conclusion, there does appear to be a modest
association between ADHD and suicide, the major
part of which is through comorbid conditions,
particularly CD. The strength of this association is
dicult to determine with available evidence.
Further long-term cohort studies of children and
adolescents with ADHD, and detailed examination
of childhood precursors of psychiatric disorders
and comorbid disorders in adolescent suicide,
would be necessary to answer more fully the
question of any ADHD-suicide link.
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