ADHD Atten Def Hyp Disord (2014) 6:153158
DOI 10.1007/s12402-014-0150-1
REVIEW ARTICLE
Adult ADHD and suicide
Karolina Furczyk Johannes Thome
Received: 8 March 2014 / Accepted: 7 July 2014 / Published online: 26 July 2014
Springer-Verlag Wien 2014
Abstract While suicidal behaviour has been implicated
in a plethora of psychiatric disorders including depression,
psychoses and substance abuse, its association with adult
ADHD is largely under-researched. Given that emotional
instability and the high prevalence of comorbid conditions
such as mood disorders and alcohol/drug dependence are
typical for ADHD, the question of suicide risk must not be
neglected in this patient group. A review of the current
literature focusing on this issue provides strong evidence
that ADHD patients are at a significant risk for experi-
encing suicidal ideations and committing suicide. For daily
clinical practice, it is therefore essential to incorporate this
aspect into the diagnostic and therapeutic process and to
take preventive measures.
Keywords Attention deficit hyperactivity disorder

Comorbidity
Course of disease
Depression
Outcome

Psychiatry
Self-harm
Suicidal ideation
Introduction
Suicide represents the worst possible outcome of any
psychiatric disorder. Suicide prevention is therefore one of
the most important tasks of all mental health professionals.
While there is a large body of literature on suicide risk in
depression, psychotic illnesses, personality disorders,
alcohol dependence and drug addiction, relatively little is
known about suicidal behaviour in adult ADHD patients
despite its high worldwide prevalence of more than 5 %
K. Furczyk
J. Thome (&)
Department of Psychiatry, University of Rostock,
Gehlsheimerstrae 20, 18147 Rostock, Germany
e-mail: johannes.thome@med.uni-rostock.de
(Polanczyk et al. 2007). ADHD symptoms occur during
childhood, persist into adulthood in a majority of patients
(Biederman 1998) and are associated with functional
impairment and increased risk of depression, substance
abuse, antisocial behaviour, and cognitive impairments in
inhibitory control and executive function (Toplak et al.
2005; Purper-Ouakil et al. 2011; Mantyla et al. 2012).
Roughly, 3.4 % of the adult population suffers from
ADHD (Fayyad et al. 2007).
Because of both its clinical features and its frequent
psychiatric comorbidities, it is conceivable that ADHD
patients suffer from an increased suicide risk. The fol-
lowing paper therefore provides a selective review on the
most important currently known associations between
ADHD and suicidality, and provides possible explanations
for this link. As such, it will be of considerable clinical
relevance for psychiatrists and general practitioners pro-
viding support for ADHD patients.
Suicide risk in ADHD
An increased risk of suicide in children and adolescents
with ADHD has been repeatedly identified. In 1977, Rohn
et al. (1977) described a significantly higher rate of mini-
mal brain dysfunction, a clinical concept that included
what was later named ADHD, in adolescents who
attempted suicide (Rohn et al. 1977), an observation later
confirmed by several groups (Goldston et al. 2009; Manor
et al. 2010; Chronis-Tuscano et al. 2010; Hurtig et al.
2012). Examining a group of 900 subjects diagnosed with
ADHD, Galera et al. found an association between
hyperactivityinattention symptoms and the risk of lifetime
suicide plans/attempts in male adolescents, whereas no
association was found for female patients (Galera et al.
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154
2008). Lam found significant associations between suicide
and self-harm, as well as assault-related injuries, and the
diagnosis of attention deficit disorder in children and
adolescents hospitalized for physical injuries (Lam 2005).
Goodman et al. (2008) reported that children presenting
with suicidal behaviour were more likely to be diagnosed
with ADHD, while the relationship between ADHD and
suicidality was expressed by the children manifesting
aggression. Given this tendency of children and adoles-
cents with ADHD towards suicidal behaviour, and as
ADHD symptoms have been shown to persist into adult-
hood in many cases, it is very likely that the higher suicide
risk also prevails in adults with ADHD. Consistent with
this hypothesis, Hinshaw (2012) observed that young
women with a childhood history of ADHD exhibited higher
rates of suicide behaviour and self-injury than controls. In
their study of a Korean population, Park et al. (2011)
reported a strong association between adult ADHD symp-
toms and suicidality. In a study of long-term outcomes of
ADHD in a population-based study comparing adults
diagnosed with childhood ADHD with controls, Barbaresi
et al. (2013) found significantly higher suicide rates in the
ADHD group. A study in a French adult population also
showed a significant increase in suicidality in subjects
suffering from ADHD (Nicoli et al. 2012).
In order to identify predictors of suicidality, Putnins
(2005) examined 900 young offenders in detention centres
in South Australia, and reported both a concurrent and
prospective association between ADHD and suicidal
behaviour. The relationship remained significant even after
controlling for prior suicide attempt status, a possibly
confounding factor as past suicide attempts are signifi-
cantly predictive of future ones. Similar results were
reported by Westmoreland et al. (2010), who also found a
significantly higher risk of suicidal behaviour in a group of
offenders diagnosed with ADHD. Another study on prison
inmates admitted to a special unit of a public hospital for
treatment of self-inflicted wounds showed an association of
self-mutilation with the history of childhood hyperactivity
(Fulwiler et al. 1997). Interestingly, a retrospective study of
58 suicide victims based on the interviews with their next-
of-kin showed indications of childhood hyperactivity in
19 % of the male suicide cases (Runeson 1998).
Possible explanations of the increased suicide risk
in ADHD
Explanations for the increased suicide risk connected with
ADHD focused on its typical comorbidities as possible risk
factors for suicide, as well as on the cognitive impairment
and specific personality traits commonly found in ADHD
patients that might predispose to suicidal behaviour. Of
123
K. Furczyk, J. Thome
importance are also neurobiological changes associating
ADHD with suicide and the influence of medication pre-
scribed to treat ADHD symptoms.
Comorbidities
Park et al. (2011) reported significant associations between
ADHD symptoms and alcohol abuse/dependence, nicotine
dependence, mood disorders, major depressive disorder,
bipolar disorder, anxiety disorders, obsessivecompulsive
disorder, post-traumatic stress disorder, social phobia, specific
phobia, somatoform disorder and sleep disturbances after
controlling for gender and age in an adult Korean sample.
Kereszteny et al. (2012) compared the number of
comorbid diagnoses in children and adolescent patients
with ADHD and found it to be significantly higher in the
adolescents. The increase observed over time may be
attributed to the failure to cope with emotional and social
problems associated with ADHD.
A study on a cohort of 125 children with ADHD at
46 years of age showed that they were at greatly
increased risk for meeting DSM-IV criteria for major
depression or dysthymia and for attempting suicide
through the age of 18 years relative to a control group.
Further, there was a significant gender difference with
girls being at even greater risk of developing depression
and suicidal behaviour than boys (Hurtig et al. 2012). A
comparison study of two groups of patients with different
ADHD subtypes [inattentive type (I) versus combined
type with both attention deficit and hyperactivity (C)]
showed that both groups presented with a greater likeli-
hood of developing different psychiatric comorbidities
and were more likely to have received mental health
services than control adults. Also, in comparison with
ADHD-I, adults with ADHD-C were more likely to have
attempted suicide, which points to possible differences
between the ADHD subtypes in terms of their association
with suicidality (Murphy et al. 2002).
Nasser and Overholser (1999) reported that comorbid
depression and ADHD predisposed to more lethal suicide
attempts in adolescents. The patients in the comorbid group
also expressed the strongest desire to end their lives. Bie-
derman et al. (2008) showed adolescent and young adult
females with ADHD had a 2.5 times higher risk of devel-
oping major depression. Depression comorbid with ADHD
was associated with a higher rate of suicidality. Further, a
study of college students presenting with depressed mood
showed an association of hyperactivity/inattention symp-
toms with a stronger relationship between depressed mood
and suicidal ideation and attempts (Patros et al. 2013).
Consequently, the authors concluded that comorbid ADHD
symptoms might represent an increased suicide risk for
depressed subjects.
Adult ADHD and suicide
Looking at the comorbidity of schizophrenia and adult
ADHD (although severe psychotic disorders occur proba-
bly do not occur significantly more frequently in ADHD
patients than in the general population), Donev et al. (2011)
found 15 of 27 patients with schizophrenia also suffered
from attention deficit/hyperactivity disorder. The patients
with ADHD comorbidity presented with an increase in
suicidal behaviour in comparison with those with schizo-
phrenia only.
Substance abuse, a frequent comorbidity in ADHD, is
also associated with an increased risk of suicide. In a study
looking at substance use disorder in patients in South
London, the prevalence of undiagnosed ADHD was esti-
mated to reach around 12 % (Huntley et al. 2012), and the
patients with both diagnoses had significantly higher self-
rated impairments across several domains of daily life,
higher rates of substance abuse and alcohol consumption,
suicide attempts and depression. Arias et al. (2008) inter-
viewed 1,761 adults with a lifetime diagnosis of cocaine
and/or opioid dependence using the Semi-Structured
Assessment for Drug Dependence and Alcoholism, and
reported a lifetime prevalence of ADHD in this sample of
5.22, versus 0.85 % in the control group. ADHD was found
to be associated with a greater likelihood of attempted
suicide. A case comparison study of alcohol-dependent
adults showed the prevalence of comorbid ADHD to be
higher in the group with maternal and paternal history of
alcoholism in comparison with alcohol-dependent patients
with paternal alcoholism only. The first group was also at
higher risk of developing suicidal behaviour (Cottencin
et al. 2009).
The symptoms of post-traumatic stress disorder in a
group of 117 children were significantly correlated with
ADHD and the presence of suicidal ideation (Famularo
et al. 1996). In adults, trauma is a significant predictor of
attention deficit/hyperactivity as well as suicide risk based
on a sample of 320 offenders (Gunter et al. 2012).
Saez-Franca`s et al. (2012) reported a prevalence of adult
ADHD in a sample of 158 chronic fatigue syndrome (CSF)
patients at 29.7 %. CSF patients with both diagnoses had
an earlier CSF onset, more severe anxiety and depression
symptoms, and a higher risk of suicide than those with CSF
only. Semiz et al. (2008) interviewed 105 adult male
offenders with antisocial personality disorder, finding 65 %
to suffer from comorbid ADHD. The subjects with both
diagnoses had earlier onset and increased rate of self-
injurious behaviour and suicide attempts.
As mentioned before, the comorbidities seem to play an
important role in the increased risk of suicide associated
with ADHD. While many above-mentioned papers report
being diagnosed with ADHD as an independent risk factor
for suicide, other findings suggest this association rather to
be mediated by the symptoms of comorbid conditions, such
155
as affective disorders, anxiety disorders, and substance
abuse (Balazs et al. 2014).
Cognitive impairment and personality traits
Impaired decision-making was associated with the vulner-
ability to suicidal behaviour in a large psychiatric popula-
tion (Jollant et al. 2007). As shown by neurocognitive tests
results, ADHD is associated with impairment in decision-
making in children, adolescents and adults (Toplak et al.
2005; Masunami et al. 2009). Miller et al. (2013) observed
an association of childhood ADHD diagnosis with disad-
vantageous decision-making in a group of young fema-
le adults. Adult ADHD patients tend to risky decision-
making and delayed discounting (Miller et al. 2013).
One of the ADHD core symptoms is deficient attention.
Keilp et al. (2013) compared measures of attention in
depressed patients with and without a history of suicidal
behaviour and in a control group without depression. They
found that impairment of attention was significantly worse
in depressed patients with suicide history than in the both
other groups (depressed patients without suicide history
and controls).
Impulsivity, another core symptom of ADHD, plays an
important role in the impairment of the decision-making
process in ADHD patients. It is a personality trait that
involves behaviour which is characterized by little or no
forethought, reflection or consideration of the conse-
quences. Being poorly conceived, premature, sometimes
risky, or situation-inappropriate, impulsive actions often
result in undesirable consequences, impairing the
achievement of long-term goals and the development of
strategies for success. In children, a possible role of
impulsivity and hyperactivity in developing suicidal
behaviour was described by Rosenthal and Rosenthal
(1984). Greening et al. (2008) observed an indirect path
from impulsivity to suicidal ideation through aggressive
and depressive symptoms in an inpatient sample of boys.
Corruble et al. (2003) measured impulsivity in 77 depres-
sed inpatients, finding that it was positively correlated with
the number of lifetime suicide attempts. Swann et al.
(2008) observed a strong correlation between suicidality
and impulsivity in adult subjects with bipolar disorder.
Depressed bipolar patients who scored higher on an
impulsivity scale also presented more often with anhedonia
and hopelessness. In a study of 104 adult suicide attemp-
ters, the personality trait of impulsivity contributed to
attempting suicide (Kumar et al. 2013).
Because of their impaired decision-making, attentional
deficits and impulsivity, ADHD patients may tend to
decide hastily, often in a risky manner, acting on an
impulse, choosing an immediate gain over a long-term
benefit when being faced with lifes dilemmas and crises
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156
The most fatal and tragic effect of these cognitive incli-
nations may be choosing suicide as an immediate escape
from a difficult or stressful situation.
Common neurobiology of ADHD and suicide
On the neurobiological level, ADHD is a complex disorder
having multiple roots including genetic and epigenetic
factors, resulting in changes in signalling pathways, neu-
rotransmission systems, gene expression processes and
neuroplasticity. The effectiveness of psychostimulants
noradrenaline reuptake inhibitors in treating this disorder
suggests a role for dopaminergic and noradrenergic neu-
rotransmission, but also to possible involvement of sero-
tonergic systems (Thakur et al. 2010). One study showed
that adult bipolar disorder patients with a history of ADHD
presented with significantly lower cerebrospinal fluid
concentration of the dopamine metabolite homovanillic
acid (HVA) as well as of the serotonin metabolite 5-hy-
droxyindoleacetic acid (5-HIAA) (Ryden et al. 2009).
Interestingly, low CSF levels of 5-HIAA were shown to be
associated with an increased risk of suicide in mood dis-
order patients (Asberg et al. 1976; Nordstrom et al. 1994).
As a serotonin-related deficiency has been proposed to be
one of the neurobiological changes underlying the patho-
physiology of suicide, this points to a possible mechanism
conditioning increased suicide risk in ADHD.
ADHD is sometimes considered as being part of a so-
called reward deficiency syndrome spectrum. This reward
deficiency is associated with a deficiency of dopaminergic
transmission in the brain reward system, resulting in
abnormal craving for reward-providing substances, such
as illicit drugs or alcohol, and, consequently, in
increased susceptibility to substance abuse (Blum et al.
2008). A decreased level of dopamine in the nucleus ac-
cumbens, a component of the reward system, was also
measured in the post-mortem brains of depressed suicide
victims (Bowden et al. 1997).
ADHD treatment and suicide
Two therapeutic options for ADHD are the psychostimu-
lant methylphenidate and the selective norepinephrine re-
uptake inhibitor atomoxetine. Both have been shown to
relieve the symptoms of ADHD in both children and adults,
improving the patients level of functioning. However,
some reports raised concerns about the safety of ADHD
treatment. In 2005, both the United States Food and Drug
Administration and Health Canada warned of increased
rates of suicidal ideation among children taking atomoxe-
tine in placebo-controlled trials. The later published meta-
analysis that prompted the warnings after reviewing 12
studies comparing outcomes in children treated with
123
K. Furczyk, J. Thome
atomoxetine or placebo. Suicidal ideation was reported to
have occurred in 5 (0.37 %) of 1,357 children given ato-
moxetine, but in none of 851 children receiving placebo
(Bangs et al. 2008). As a result, health providers were
advised to closely monitor children and adolescents treated
with atomoxetine for aggravation of symptoms such as
agitation, irritability, suicidal thinking or behaviours and
unusual changes in behaviour. In 2008, Paxton and
Cranswick (2008) published the only case report to date of
acute agitation and suicidal ideation in an 11-year-old boy
after commencing atomoxetine.
European guidelines on managing the potential adverse
effects of medication for ADHD point to the fact that in the
United Kingdom the rate of self-harm in 1115-year olds
with hyperkinetic disorder was 8.5 %, the prevalence of
suicide-related behaviour in children treated with ADHD
drugs from randomised controlled trials was reported to be as
low as 0.4 % (Graham et al. 2011). The authors concluded
that while the low observed event rate in trials is likely to
reflect the exclusion of suicidal subjects from entering trials, a
short time base, and a lack of systematic assessment and
reporting, there is little or no compelling evidence to suggest
that the observed rate of suicide-related events in children
treated with ADHD drugs is greater than expected in the
general population. Moreover, the demonstration of causality
requires experimental and comparison studies and generally
accepted criteria for defining, detecting and recording sui-
cidal ideation, suicidal behaviour and completed suicide are
still missing. Importantly, in adults treated with atomoxetine,
there was no evidence of increased suicidal risk.
With regard to the treatment of adult ADHD, there are
adequate data demonstrating short-term efficacy and safety
of the medications used, but there are still no long-term
studies on the subject (Santosh et al. 2011).
To date, only one study has examined the adult out-
comes of childhood stimulant medication in a rela-
tively small group of 32 subjects, finding that for 20 young
adults, the childhood treatment had no lasting effect, but
for 11 others, the positive effects lasted long after treatment
was discontinued. Higher dosage of medication was asso-
ciated with fewer diagnoses of alcoholism and with fewer
suicide attempts. Also, the longer the medication was
given, the better was the cognitive performance of the
patients (Paternite et al. 1999). Future research in adult
ADHD should investigate not only the outcomes and the
extent to which medication may improve functioning lev-
els, but also the influence of treatment on suicide risk.
Conclusions
There is a sufficient body of evidence supporting an asso-
ciation between ADHD (including adults with ADHD) and
Adult ADHD and suicide
increased suicide risk, and that it is probably at least par-
tially directly linked to or mediated by comorbidities. It is
essential to raise awareness in health professionals of the
problem of suicide risk in adult ADHD patients, especially
psychiatrists and general practitioners, who often provide
first-line support to these patients. Similarly, it is necessary
to expand the knowledge about ADHD and its intrinsic risks
in the general population, specifically within families
including ADHD patients and within the occupational
environment. Early detection and treatment of ADHD as
well as of its comorbid conditions may reduce the risk of
suicide attempts and improve the prognosis considerably.
However, further research of the long-term outcomes of the
treatment in adults is urgently needed.
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