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Suicidal ideation and suicide plans or attempts in adults with Asperger's syndrome attending a specialist diagnostic clinic: a clinical cohort study
Open accessAbstract
BACKGROUND: Asperger's syndrome in adulthood is frequently associated with depression, but few studies have explored the lifetime experience of self-reported suicidal ideation and suicide plans or attempts in this clinical group. We aimed to assess this prevalence in a clinical cohort of patients in the UK. METHOD: In a clinical cohort study, we undertook a retrospective analysis of clinical survey data from adults newly diagnosed with Asperger's syndrome at a specialist diagnostic clinic between Jan 23, 2004, and July 8, 2013, in England. Patients completed a self-report questionnaire before clinical assessment, recording lifetime experience of depression, suicidal ideation, and suicide plans or attempts, along with self-reported measures of autistic traits and empathy. We compared the rate of suicidal ideation in the sample with published rates of suicidal ideation in the general population and other clinical groups. We also assessed associations between depression, autistic traits, empathy, and likelihood of suicidal ideation and suicide plans or attempts. FINDINGS: 374 adults (256 men and 118 women) were diagnosed with Asperger's syndrome in the study period. 243 (66%) of 367 respondents self-reported suicidal ideation, 127 (35%) of 365 respondents self-reported plans or attempts at suicide, and 116 (31%) of 368 respondents self-reported depression. Adults with Asperger's syndrome were significantly more likely to report lifetime experience of suicidal ideation than were individuals from a general UK population sample (odds ratio 9·6 [95% CI 7·6-11·9], p<0·0001), people with one, two, or more medical illnesses (p<0·0001), or people with psychotic illness (p=0·019). Compared with people diagnosed with Asperger's syndrome without depression, people with Asperger's syndrome and depression were more likely to report suicidal ideation (p<0·0001) and suicide plans or attempts (p<0·0001). INTERPRETATION: Our findings lend support to anecdotal reports of increased rates of suicidal ideation in adults with Asperger's syndrome, and depression as an important potential risk factor for suicidality in adults with this condition. Because adults with Asperger's syndrome often have many risk factors for secondary depression (eg, social isolation or exclusion, and unemployment), our findings emphasise the need for appropriate service planning and support to reduce risk in this clinical group. FUNDING: The Three Guineas Trust, the Baily Thomas Foundation, the Medical Research Council, NIHR-CLAHRC-EoE, Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), and the Autism Research Trust.
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“In line with high depression prevalence, suicidal ideation (66%) and suicidal behaviour (35%) were also common among autistic adults (Cassidy et al., 2014).”
From Diagnosis of autism in adulthood: A scoping review (2020) · cites this paper as Cassidy et al., 2014
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“Studies most commonly discussed depression, anxiety, and psychotic disorders, comparing autistic adults with the general population (e.g. Cassidy et al., 2014; Kanai, Iwanami, Hashimoto, et al., 2011) and/or adults who were assessed but not diagnosed with autism (e.g. Happé et al., 2016; Wilson et al., 2016).”
From Diagnosis of autism in adulthood: A scoping review (2020) · cites this paper as Cassidy et al., 2014
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“32% reported a history of depression, 66% suicidal ideation, 35% suicide plans or attempts.”
From Diagnosis of autism in adulthood: A scoping review (2020) · cites this paper as Cassidy et al. (2014)
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“have increased vulnerability to mental ill‐health (Lai et al., 2019), including high rates of suicide (Cassidy et al., 2014; Kirby et al., 2019).”
From Annual Research Review: Shifting from ‘normal science’ to neurodiversity in autism science (2022) · cites this paper as Cassidy et al., 2014
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“One group at substantially higher risk of suicidality and mental illness are autistic people [10, 11].”
From A 'choice', an 'addiction', a way 'out of the lost': Exploring self-injury in autistic people without intellectual disability (2019) · cites this paper as [10]
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“ASD with depression has even higher rates with 85% suicidal ideation and 49% suicidal plans and attempts [5, 6].”
From The effect of dialectical behaviour therapy in autism spectrum patients with suicidality and/or self-destructive behaviour (DIASS): Study protocol for a multicentre randomised controlled trial (2020) · cites this paper as [6]
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“Cassidy and colleagues showed that depression is an important risk factor for suicidality and that social isolation is also associated with suicidal behaviour in autism [6].”
From The effect of dialectical behaviour therapy in autism spectrum patients with suicidality and/or self-destructive behaviour (DIASS): Study protocol for a multicentre randomised controlled trial (2020) · cites this paper as [6]
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“There are elevated rates of suicidality in adults diagnosed with autism spectrum conditions (ASC) [1–5].”
From Risk markers for suicidality in autistic adults (2018) · cites this paper as [2]
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“Suicidal ideation and behaviour were associated with depression.”
From Diagnosis of autism in adulthood: A scoping review (2020) · cites this paper as Cassidy et al. (2014)
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“Suicidal ideation is significantly higher than previous data on the general population, people with medical illnesses, and people with psychotic disorders.”
From Diagnosis of autism in adulthood: A scoping review (2020) · cites this paper as Cassidy et al. (2014)
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“Indeed, in a sample of recently diagnosed autistic adults without ID, 66% self-reported suicidal ideation and 35% self-reported plans or attempts of suicide (Cassidy et al., 2014).”
From Feasibility, Acceptability and Preliminary Efficacy of Dialectical Behavior Therapy for Autistic Adults without Intellectual Disability: A Mixed Methods Study (2022) · cites this paper as Cassidy et al., 2014
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“Standardised tools for assessing depression are frequently developed for neurotypical populations, meaning they may not adequately capture autism-specific features of depressive symptoms, such as heightened sensory sensitivities or unique patterns of social withdrawal (Cassidy et al., 2014).”
From Rethinking psychological interventions in autism: Toward a neurodiversity‐affirming approach. (2025) · cites this paper as Cassidy et al., 2014
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“Traits characteristic of autism are also significantly associated with suicidality in those with [2], and without ASC diagnosis [16–18].”
From Risk markers for suicidality in autistic adults (2018) · cites this paper as [2]
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“Results are consistent with previous findings that autistic adults are at significantly increased risk of suicidality compared to the general population [2].”
From Risk markers for suicidality in autistic adults (2018) · cites this paper as [2]
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“However, lifetime experience of depression in the general population (44.9%) and ASC group (80%) were much higher than previous estimates [2, 22, 54], despite participants not being recruited because of experience with mental health problems.”
From Risk markers for suicidality in autistic adults (2018) · cites this paper as [2]
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“Lifetime suicide attempts in the general population (8%) and ASC group (38%) are similar to previous studies [2, 17], which suggests that the sample was not biased in this respect.”
From Risk markers for suicidality in autistic adults (2018) · cites this paper as [2]
In the citing paper
“There is significant overrepresentation of mental health needs in people with autism.6,7”
From Current practice and adaptations being made for people with autism admitted to in-patient psychiatric services across the UK (2021) · cites this paper as [6]
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“Cassidy et al. (2014) similarly reported high rates of suicidal ideation (66%), plans or attempts (35%), and depression (31”
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“This may be explained by the higher prevalence of depression (63%) in our sample compared to the previous study (32%) [Cassidy et al., 2014].”
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Self-citationSuicidality in Autistic Spectrum Disorders: A Systematic Review
Zahid, S., & Upthegrove, R. (2017) · Crisis · doi:10.1027/0227-5910/a000458 · Cited by 115
“Prevalence of Suicidal Ideation in ASD Four papers examined both suicide attempts and suicidal ideation (Cassidy et al., 2014; Mayes, Gorman, Hillwig-Garcia, & Syed, 2013; Mukaddes & Fateh, 2010; Raja, Azzoni, & Frustaci, 2011a). The rates of suicide attempts and suicidal ideation varied from 3.8% to 66%. Raja et al.…”
BackgroundResultInfluentialNewell, V., Phillips, L., Jones, C., Townsend, E., Richards, C., & Cassidy, S. (2023) · Molecular Autism · doi:10.1186/s13229-023-00544-7 · Cited by 143
“An influential study of late diagnosed autistic adults found 66% had experienced suicidal ideation, which was nine times higher than the general population, and 35% had a suicide plan or had made a suicide attempt [10].”
BackgroundSelf-citationBernardin, C. J., Lewis, T., Bell, D., & Kanne, S. (2021) · Autism · doi:10.1177/1362361321997284 · Cited by 185
“Anxiety may lead to increase in social withdrawal among autistic individuals, and comorbid depression is associated with increased suicidality (Cassidy et al., 2014).”
BackgroundAdults with Autism: Changes in Understanding Since DSM-111
Howlin, P. (2021) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-020-04847-z · Cited by 157
Mazefsky, C. A. (2015) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-015-2602-7 · Cited by 103
“functioning ASD (Cassidy et al. 2014).”
BackgroundCassidy, S. A., Bradley, L., Bowen, E., Wigham, S., & Rodgers, J. (2018) · Clinical Psychology Review · doi:10.1016/j.cpr.2018.05.002 · Cited by 104
“(ASC without language delay or intellectual disability) reported having contemplated suicide, significantly higher than the UK general population (17%); and 35% reported that they had planned or attempted suicide (Cassidy et al., 2014).”
BackgroundInfluentialSelf-citationJourney to diagnosis for women with autism
Zener, D. (2019) · Advances in Autism · doi:10.1108/aia-10-2018-0041 · Cited by 108
Moseley, R. L., Gregory, N. J., Smith, P., Allison, C., & Baron-Cohen, S. (2019) · Molecular Autism · doi:10.1186/s13229-019-0267-3 · Cited by 97
Self-citationPelton, M., Crawford, H., Robertson, A., Rodgers, J., Baron‐Cohen, S., & Cassidy, S. (2020) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-020-04393-8 · Cited by 119
Self-citationSchiltz, H. K., McVey, A. J., Dolan, B. K., Haendel, A. D., Stanley, R. E., Arias, A. A., Gordon, N. S., & Hecke, A. V. V. (2020) · Autism · doi:10.1177/1362361320967789 · Cited by 98
“Anxiety and depression in autism are associated with an increased risk for suicidality (Hooijer & Sizoo, 2019), and recent findings reveal concerningly high rates of suicidality among people on the autism spectrum (Cassidy et al., 2014; Griffiths et al., 2019; Hirvikoski et al., 2020), highlighting the importance of p…”
BackgroundRealizing a diagnosis of autism spectrum disorder as an adult
Lewis, L. F. (2016) · International Journal of Mental Health Nursing · doi:10.1111/inm.12200 · Cited by 95
Mood symptoms and suicidality across the autism spectrum
Dell'Osso, L., Carpita, B., Muti, D., Morelli, V., Salarpi, G., Salerni, A., Scotto, J., Massimetti, G., Gesi, C., Ballerio, M., et al. (2019) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2019.03.004 · Cited by 93
“[45] identified an increased rate of suicidal ideation in adults with Asperger's disorder, reporting also MD as a significant risk factor among adults with this condition.”
BackgroundTakara, K., & Kondo, T. (2014) · Annals of General Psychiatry · doi:10.1186/s12991-014-0033-z · Cited by 93
“Several studies have consistently reported that many individuals with AS experience suicide-related behaviors [7-10].”
BackgroundAutism and autistic traits in those who died by suicide in England
Cassidy, S., Au‐Yeung, S. K., Robertson, A., Cogger-Ward, H., Richards, G., Allison, C. L., Bradley, L., Kenny, R., O’Connor, R. C., Mosse, D., et al. (2022) · The British Journal of Psychiatry · doi:10.1192/bjp.2022.21 · Cited by 91
Self-citationHorowitz, L. M., Thurm, A. E., Farmer, C., Mazefsky, C. A., Lanzillo, E. C., Bridge, J. A., Greenbaum, R., Pao, M., & Siegel, M. S. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-017-3180-7 · Cited by 90
“The few studies on suicidal ideation or behavior in ASD have been limited by small sample sizes, variations in methods, or a frequent focus on adults and those with Asperger Disorder (Balfe and Tantam 2010; Cassidy et al. 2014; Mandell et al. 2005; Raja et al. 2011; Shtayermman 2007) (see Table 1).”
ResultInfluentialKwan, C., Gitimoghaddam, M., & Collet, J. (2020) · Brain Sciences · doi:10.3390/brainsci10110786 · Cited by 110
Autistic traits in adults who have attempted suicide
Richards, G., Kenny, R., Griffiths, S., Allison, C. L., Mosse, D., Holt, R., O’Connor, R. C., Cassidy, S., & Baron‐Cohen, S. (2019) · Molecular Autism · doi:10.1186/s13229-019-0274-4 · Cited by 89
Self-citationUljarević, M., Richdale, A. L., McConachie, H., Hedley, D., Cai, R. Y., Merrick, H., Parr, J. R., & Le Couteur, A. (2018) · Autism Research · doi:10.1002/aur.1872 · Cited by 85
“7%) was somewhat lower than rates of depression reported in previous studies with adults with ASD [Cassidy et al., 2014; Hofvander et al., 2009; Lever et al., 2016]; however, this finding was most likely due to the younger age of participants in our study and due to the fact that our study used dedicated measure of de…”
ResultBotha, M., Dibb, B., & Frost, D. M. (2022) · Autism · doi:10.1177/13623613221080248 · Cited by 99
“…connectedness’ relationship to mental health and wellbeing in other minority communities (Kaniuka et al., 2019), it might prove a useful concept to understand in relation to autism given the high rate of mental ill-health (Hannon & Taylor, 2013; Lai et al., 2019) and suicide (Cassidy et al., 2014).”
Measuring Depression in Autistic Adults: Psychometric Validation of the Beck Depression Inventory–II
Williams, Z. J., Everaert, J., & Gotham, K. O. (2020) · Assessment · doi:10.1177/1073191120952889 · Cited by 84
“” Interestingly, this finding runs counter to previous results suggesting that autistic adults may endorse suicidal ideation at a relatively high rate even when not reporting depression (Cassidy et al., 2014).”
ResultCassidy, S., Bradley, L., Cogger-Ward, H., & Rodgers, J. (2021) · Molecular Autism · doi:10.1186/s13229-021-00449-3 · Cited by 84
“Autistic people who have experienced delay in autism diagnosis until adulthood show the highest estimates of lifetime suicidal thoughts (66%), and suicide attempt(s) (35–36%) [9, 10].”
BackgroundSelf-citationWarrier, V., & Baron‐Cohen, S. (2019) · Molecular Psychiatry · doi:10.1038/s41380-019-0550-x · Cited by 89
Self-citationPark, S. H., Song, Y. J. C., Demetriou, E. A., Pepper, K. L., Thomas, E. E., Hickie, I. B., & Guastella, A. J. (2020) · Psychiatry Research · doi:10.1016/j.psychres.2020.113300 · Cited by 97
Culpin, I., Mars, B., Pearson, R. M., Golding, J., Heron, J., Bubak, I., Carpenter, P. K., Magnusson, C., Gunnell, D., & Rai, D. (2018) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2018.01.023 · Cited by 91
Drug development for Autism Spectrum Disorder (ASD): Progress, challenges, and future directions
McCracken, J. T., Anagnostou, E. A., Arango, C., Dawson, G., Farchione, T. R., Mantua, V., McPartland, J. C., Murphy, D., Pandina, G., & Veenstra-VanderWeele, J. M. (2021) · European Neuropsychopharmacology · doi:10.1016/j.euroneuro.2021.05.010 · Cited by 89
Annabi, H., & Locke, J. J. (2019) · Journal of Management & Organization · doi:10.1017/jmo.2018.79 · Cited by 82
Ozsivadjian, A., Hollocks, M. J., Magiati, I., Happé, F., Baird, G., & Absoud, M. (2021) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.13295 · Cited by 81
Patel, S., Day, T. N., Jones, N., & Mazefsky, C. A. (2017) · Autism · doi:10.1177/1362361316633566 · Cited by 82
“Depression may confer substantial added impairment as well as particularly high suicidal ideation rates among individuals with ASD (Cassidy et al., 2014).”
BackgroundKerns, C. M., Roux, A. M., Connell, J. E., & Shattuck, P. T. (2016) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2016.06.002 · Cited by 90
Conner, C. M., Golt, J., Righi, G., Shaffer, R., Siegel, M., & Mazefsky, C. A. (2020) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-020-04370-1 · Cited by 77
“2013), while the rates of suicidal behavior/attempts are lower than those reported in adult ASD samples (Cassidy et al. 2014).”
Montgomery, C. B., Allison, C. L., Lai, M., Cassidy, S., Langdon, P. E., & Baron‐Cohen, S. (2016) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-016-2698-4 · Cited by 88
“Recent studies have shown experiences of suicidal ideation to be more than nine times higher in adults with AS than in the general population in England (Cassidy et al. 2014).”
Self-citationUnrelenting Depression and Suicidality in Women with Autistic Traits
South, M., Beck, J. S., Lundwall, R. A., Christensen, M., Cutrer‐Párraga, E. A., Gabrielsen, T. P., Cox, J. C., & Lundwall, R. A. (2019) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-019-04324-2 · Cited by 83
What are the views and experiences of autistic teachers? Findings from an online survey in the UK
Wood, R., & Happe, F. G. E. (2021) · Disability & Society · doi:10.1080/09687599.2021.1916888 · Cited by 76
Links between self-injury and suicidality in autism
Moseley, R. L., Gregory, N. J., Smith, P., Allison, C., & Baron-Cohen, S. (2020) · Molecular Autism · doi:10.1186/s13229-020-0319-8 · Cited by 76
Self-citationPłatos, M., & Pisula, E. (2019) · BMC Health Services Research · doi:10.1186/s12913-019-4432-3 · Cited by 89
“anxiety, and other mental health problems [6, 7] and higher rates of suicidal ideation in this population [8].”
BackgroundMeasurement Properties of the Suicidal Behaviour Questionnaire-Revised in Autistic Adults
Cassidy, S., Bradley, L., Cogger-Ward, H., Shaw, R., Bowen, E., Glod, M., Baron‐Cohen, S., & Rodgers, J. (2020) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-020-04431-5 · Cited by 78
Self-citationRisk for Premature Mortality and Intentional Self-harm in Autism Spectrum Disorders
Jokiranta‐Olkoniemi, E., Gyllenberg, D., Sucksdorff, D., Suominen, A., Kronström, K., Chudal, R., & Sourander, A. (2020) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-020-04768-x · Cited by 84
Hedley, D., Uljarević, M., Bury, S. M., & Dissanayake, C. (2019) · Autism Research · doi:10.1002/aur.2064 · Cited by 84
Timing of diagnosis, depression and self-harm in adolescents with autism spectrum disorder
Hosozawa, M., Sacker, A., & Cable, N. (2020) · Autism · doi:10.1177/1362361320945540 · Cited by 72
“…study among adults diagnosed as Asperger’s syndrome suggested the importance of late diagnosis being a potential risk factor for suicidal behaviours (Cassidy et al., 2014); however, the question of whether earlier identification of ASD could reduce the risk of developing depression and…”
BackgroundCounterventions: a reparative reflection on interventionist HCI
Williams, R. M., Boyd, L., & Gilbert, J. E. (2023) · Proceedings of the 2023 CHI Conference on Human Factors in Computing Systems · doi:10.1145/3544548.3581480 · Cited by 74
“Eunjung Kim explains that curative projects (those that seek to restore the sick and injured or to overcome an embodied defcit) can produce violence when they engage in “the exercise of force to erase diferences for the putative better-ment of the Other” [28:14].”
BackgroundSchiltz, H. K., McVey, A. J., Dolan, B. K., Willar, K. S., Pleiss, S. S., Karst, J. S., Carson, A. M., Caiozzo, C. N., Vogt, E. M., Yund, B. D., et al. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-017-3396-6 · Cited by 75
“suicidal ideation and 35% reported plans or attempts at suicide (Cassidy et al. 2014).”
Advancing Our Understanding of Self-harm, Suicidal Thoughts and Behaviours in Autism
Cassidy, S. A., Robertson, A., Townsend, E., O’Connor, R. C., & Rodgers, J. (2020) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-020-04643-9 · Cited by 68
Self-citationHand, B. N., Benevides, T. W., & Carretta, H. J. (2019) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-019-04345-x · Cited by 70
Bemmouna, D., Coutelle, R., Weibel, S., & Weiner, L. (2022) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-021-05317-w · Cited by 64
Rubenstein, E., & Furnier, S. M. (2020) · Autism in Adulthood · doi:10.1089/aut.2020.0031 · Cited by 65
“26 With the importance of acting quickly to change policy and practice, 32 using efficient online surveys in an unbiased and methodologically sound manner becomes more vital.”
Cyborg Perspectives on Computing Research Reform
Williams, A., & Gilbert, J. E. (2019) · CHI Conference Extended Abstracts on Human Factors in Computing Systems (CHI EA) · doi:10.1145/3290607.3310421 · Cited by 69
“Autistic adult STB rates have estimated at 66-75% compared to the general population’s 17% [6,7].”
BackgroundPsychiatric and Medical Profiles of Autistic Adults in the SPARK Cohort
The SPARK Consortium, Fombonne, E., Green Snyder, L., Daniels, A., Feliciano, P., & Chung, W. (2020) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-020-04414-6 · Cited by 65
Costa, A. P., Loor, C., & Steffgen, G. (2020) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-020-04433-3 · Cited by 62
Autism Spectrum Disorder and Co-occurring Substance Use Disorder – A Systematic Review
Arnevik, E. A., & Helverschou, S. B. (2016) · Substance Abuse Research and Treatment · doi:10.4137/sart.s39921 · Cited by 61
Metadata
- Authors
- Cassidy, S., Bradley, P., Robinson, J., Allison, C., McHugh, M., & Baron-Cohen, S.
- Affiliations
- University of Cambridge (GB)
- Cambridgeshire and Peterborough NHS Foundation Trust (GB)
- Corresponding author
- Cassidy, Sarah
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2014-07
- Volume
- 1
- Issue
- 2
- Pages
- 142-147
- ISSN
- 2215-0366 (ISSN-L)
- OpenAlex
- W2126021938
- Cited by
- 432
- References
- 30
- Citations by year
- 2026: 33 · 2025: 43 · 2024: 40 · 2023: 41 · 2022: 41 · 2021: 45 · 2020: 65 · 2019: 44 · 2018: 25 · 2017: 24 · 2016: 17 · 2015: 10 · 2014: 3
- FWCI
- 21.30
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- The Lancet Psychiatry (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Repository@Nottingham (University of Nottingham) (publishedVersion, other-oa)
- Coventry University Open Collections (Coventry university) (submittedVersion)
- The Open Collections (Coventry University) (submittedVersion)
- Funders
- National Institute for Health and Care Research
- Medical Research Council
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Down syndrome and intellectual disability research
- Keywords
- Asperger syndrome, suicidal ideation, suicide attempts, suicide planning, depression, autistic traits, empathy, suicide risk factors, social isolation, unemployment, social exclusion, secondary depression, psychiatric comorbidity
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