Does Suicidal Behavior Occur in Persons with Down Syndrome?
Robert J. Pary, M.D.
Associate Professor of Psychiatry
Southern Illinois University, School of Medicine
P.O. Box 19230
751 Rutledge Street
Springfield, IL 62794-9230
The Habilitative Mental Healthcare Newsletter
May/June 1996, Vol. 15, No. 3.
© 1997 Pysch-Media, Inc.
Reprinted with permission of Psych-Media, Inc., publishers of Psychiatric Aspects of Mental Retardation Reviews, Habilitative Mental Healthcare Newsletter, and the journal Mental Health Aspects of Developmental Disabilities.
Editor-in-Chief: Anne D. Hurley, Ph.D
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I was told about an individual with Down syndrome who threatened to set herself on fire. This vignette raised the issue of suicidal ideation in persons with Down syndrome. The issue is not esoteric. In the general population, there is a 15% risk of completed suicide in untreated, recurrent major depressive episodes.3 Unfortunately, it is not possible to predict accurately whether or when an individual with a major depressive episode will attempt suicide.1
In individuals with mental retardation, the determination of suicidal behavior is even more complex. One of the earliest reviews of affective disorder in persons with mental retardation discussed two case reports of persons with Down syndrome and depression.6 Suicidal behavior is not mentioned in either case. In a later review of seven cases of persons with Down syndrome and major depression, only one case report mentions thoughts of suicide.7 Szymanski and Biederman8 describe a 33-year-old man with Down syndrome and mild mental retardation who had been referred after a year of crying spells, excessive guilt for bad deeds, sleep and appetite disturbance, and a preoccupation with thoughts of death and funerals. When he was evaluated, however, he denied any suicidal thoughts. He was treated with doxepin and when his medicine was reduced, he became symptomatic. It is unknown if he developed suicidal ideations when he became symptomatic. Nevertheless, Szymanski and Biederman did not emphasize suicidal ideation or suicidal behavior in their discussion.
Subsequent to Sovner and Pary's review,7 several articles were published. Warren et al10 reported on five individuals with Down syndrome and major depression. The authors mention that diagnoses of major depression can be made from similar clinical features as in the general population. One of the clinical criterion of major depression is recurrent thoughts of death, or current suicide ideation without a plan, or a suicidal attempt or a specific plan for committing suicide. Nevertheless, Warren et al did not document any suicidal ideation or behavior in any of the five individuals.
In other articles, the possibility of suicidal ideation, however, is raised. Lazarus et al4 describe a 50-year-old woman with Down syndrome and mild mental retardation. She had fifteen hospitalizations for recurrent depression. They mention that her episodes of depression would begin with tearfulness and frequent questions "Am I going to be OK?" She would follow her sister around the house and such behavior often progressed to anorexia, insomnia, dysphoria, and self-mutilation. The self-mutilation is not specified, nor are there references to any specific suicidal behavior. In this case, however, the self-mutilation raises the possibility of approximating suicidal behavior.
In perhaps the largest sample of persons with Down syndrome and depression, the DSM-IV depressive symptoms of 40 patients were described.5 Thoughts of dying or suicidal behavior are not mentioned. Some of the sample did have self-injurious behavior (SIB), but it is unclear if SIB approximated suicidal behavior.
In a study of depression and dementia in adults with and without Down syndrome, suicidal ideation was reported.2 Suicidal ideation was not a focus of the article and the results require some intuition. In seven individuals with clinical depression and Down syndrome, the overall level of severity for suicidal ideation was 0.1. This was based on a 0-3 scale with 0 being absent and 3 being severe. Suicidal ideation was the lowest ranked symptom. For comparison, sadness was rated at 2.4 and crying spells were 2.7. It is not known how suicidal ideation was assessed, but one can conclude it was not prominent in this sample of seven individuals. Even in the control group of six persons without Down syndrome, suicidal ideation was rated only 0.3.
In one case report of a person with Down syndrome, the suicidal behavior is unequivocal.9 L.C. had Down syndrome, severe mental retardation, and epilepsy. His speech was difficult to understand. However, when he was 28-years-old, he had a knife in his hand and threatened to take his own life. Two years later, he was observed to put a leather belt around his neck and tighten it. Other symptoms that were described included: screaming outbursts, breaking windows, throwing crockery and furniture, hysterical giggling and talking incoherently to himself, smelling objects, tearing clothes, banging his head and being hostile to others. Walters does not describe treatment. L.C. developed syncopal episodes and was given a pacemaker at age 33 years. It is unknown what role, if any, having seizures or the treatment for seizures, played in the suicidal behavior.
It is somewhat surprising that there are not more documented cases of suicidal behavior given that major depression occurs in persons with Down syndrome. Only one article focused on suicidal ideation and in that article only one case was a person with Down syndrome. Three explanations are possible. First, suicidal behavior is clinically overlooked and occurs more often than has been documented in the literature. For example, some types of self-injurious acts may be the equivalent of suicidal behavior. Alternatively, the speech dysarthria that some persons have may make suicidal ideation difficult to understand. Second, the literature is an accurate reflection of the reduced prevalence of suicidal behavior in persons with Down syndrome who also have major depression. It is possible that for some unknown reason persons with Down syndrome are protected from becoming suicidal when they become depressed. Third, and perhaps the most likely scenario at this time, there is insufficient attention paid to suicidal behavior in previously published studies. Evaluation about suicidal ideation may have been included. Authors, however, may not be documenting the presence or absence of suicidal behavior unless it is the focus of the paper. It is recommended that authors of future articles about depression should include the presence or absence of thoughts of dying, suicidal behavior, and self-injurious behavior. If SIB occurs, then the clinician should determine if it is an equivalent to suicidal behavior.
It is important to know if suicidal behavior is less common in persons with Down syndrome because it may help to understand the relationship between major depression and suicidal behavior. Alternately, if suicidal behavior is not significantly less common in persons with Down syndrome, then clinicians need to determine how best to assess it in persons who may have difficulty verbalizing those thoughts.
American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association, 1994.
Burt DB, Loveland KA. Lewis KR. Depression and the onset of dementia in adults with mental retardation. Am J Ment Retard 1992;96:502-511.
Janicak PG, Davis JM. Preskorn SH, Ayd PJ. Suicide. In Principles and Practice of Psychopharmacology. Baltimore: Williams & Wilkins, 1993;201-207.
Lazarus A, Jaffe RL, Dubin WR. Electroconvulsive therapy and major depression in Down's syndrome. J Clin Psychiatry 1990;51:422-425.
McGuire DE, Chicoine BA. Depressive disorders in adults with Down syndrome. Habil Ment Healthcare Newslett 1996;15:1-7.
Sovner R, Hurley AD. Do the mentally retarded suffer from affective illness? Arch Gen Psychiatry 1983;40:61-67.
Sovner R, Pary RJ. Affective disorders in developmentally disabled persons. In Matson JL, Barrett RP (eds), Psychopathology in the Mentally Retarded, Second Edition. Boston: Allyn and Bacon, 1993;87-148.
Szymanski LS, Biederman J. Depression and anorexia nervosa of persons with Down syndrome. Am J Ment Defic 1984;89:246-251.
Walters RM. Suicidal behaviour in severely mentally handicapped patients. Br J Psychiatry 1990;157:444-446.
Warren AC, Holroyd S, Folstein MF. Major depression in Down's syndrome. Br J Psychiatry 1989;155:202-205.
Robert J. Pary, M.D. is an Associate Professor of Psychiatry, Southern Illinois University, Springfield, IL.