Management Strategies for Autistic Patients Expressing Suicidal Thoughts

Assessment and Risk Stratification

The American Academy of Child and Adolescent Psychiatry recommends obtaining information from multiple sources, not just the patient, regardless of the apparent mildness of suicidal behavior 1, 2
High risk factors requiring immediate intervention include persistent wish to die or clearly abnormal mental state, recent suicide attempt with high probability of lethality, current intent to kill themselves, recent suicidal ideation with current agitation or severe hopelessness, impulsivity with dysphoric mood, previous suicide attempts, evidence of serious depression or other psychiatric illness, substance use or active substance use disorder, and low impulse control 1, 2, 3

The American Academy of Pediatrics recommends arranging for immediate mental health professional evaluation during the office visit, with options including hospitalization, emergency department transfer, or same-day appointment with a mental health professional, for moderate to high-risk patients 3, 4
Remove access to lethal means, including explicitly instructing parents to remove firearms and lethal medications from the home, locking up all medications, and warning about the dangerous disinhibiting effects of alcohol and other drugs 1, 2, 3

Cognitive-Behavioral Therapy (CBT) is effective for reducing suicidal ideation and behavior, helps identify and change problematic thinking patterns, and can reduce risk of post-treatment suicide attempt by half compared to treatment as usual 5, 6
Dialectical Behavior Therapy (DBT) combines CBT, skills training, and mindfulness techniques, helps develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance, and reduces both suicidal and non-suicidal self-directed violence 5, 6

Develop a collaborative crisis response plan, including identification of clear signs of crisis, self-management skills for distraction from stressors, identification of social support contacts, review of crisis resources, and recommendations for treatment 3, 6
Maintain contact with suicidal autistic patients even after referrals are made, schedule definite, closely spaced follow-up appointments, and be flexible in arranging appointments if a crisis arises 3, 8