Comment
Kapur and coworkers2 reported previously an increase differ during the study period for patients under the care of
in the number of deaths by suicide among patients
under the care of CRHT teams, and calls have been made
for further study of CRHT teams, including suicidal
behaviour.3 Hunt and colleagues are the first group to
report longitudinal data in patients under the care of
CRHT teams. Over recent years, selection of very seriously
ill patients for care by CRHT teams has possibly started to
take place. In this study, short-term suicide risk was more
likely to be rated as moderate-to-high for patients under
the care of CRHT teams at the point of last service contact,
compared with inpatients (27% vs 18%), a finding that
could point to such a selection effect. CRHT caseloads
include patients with varying degrees of illness severity.
Intensive case management is a care model that
evolved from two original community models of care—
assertive community treatment and case management.
In a Cochrane review of this care model,4 no differences
were reported in mortality by suicide between intensive
case management and standard care (relative risk 0·68,
95% CI 0·31–1·51). In a suicide prevention study,5 a
reduction in suicidal behaviour was noted when repeated
follow-up contacts with patients were introduced as a
preventive measure. In patients who had survived a suicide
attempt and been discharged from hospital,6 reassessment
at home showed changes in patients’ motives for suicide
attempts (towards being less impulsive and having a
greater degree of intent to end their life); furthermore, a
third of individuals had forgotten after-care arrangements
and some patients realised that they needed more help
after discharge than they had thought initially. These
findings suggest that measures can be introduced to
help people at serious risk of suicidal behaviour, and such
interventions are relevant for all types of community care
arrangements—CRHT or otherwise. The proportion of
deaths by suicide within 3 months of discharge did not
Suicide risk in adults with Asperger’s syndrome
In The Lancet Psychiatry, Sarah Cassidy and colleagues1
report a surprisingly high prevalence of lifetime experience
of suicidal ideation and suicide plans or attempts among
adults with Asperger’s syndrome compared with patients
with psychotic disorders in another study.2 This finding
should encourage clinicians to be vigilant in assessment of
the risk of suicide in these patients.
www.thelancet.com/psychiatry Vol 1 July 2014
CRHT teams (32% in 2004–05 vs 33% in 2010–11; I Hunt,
personal communication), which argues against relevant
selection effects over time, although such effects cannot
be excluded. In any case, the decline in the rate of suicide
among patients cared for under CRHT teams suggests that
measures to reduce risk and manage suicidal symptoms
are in place. However, suicide rates in CRHT settings remain
higher than among inpatients and, therefore, measures to
tackle suicidality remain a task for these teams.
Owing to the massive expansion of CRHT services,
patients most in need of help are more likely to be under
the care of CRHT teams nowadays. However, moving
the balance of care too far away from inpatient care
might complicate the clinical task of coping with suicidal
symptoms, which could be better dealt with in inpatient
care settings. Balanced care models7,8 need both a
sufficient provision of high-quality inpatient care and
CRHT teams with high clinical aptitude.
*Thomas Becker, Nicolas Rüsch
Department of Psychiatry II, Ulm University, Ulm, Germany (TB, NR)
t.becker@uni-ulm.de
We declare no competing interests.
1 Hunt IM, Rahman MS, While D, et al. Safety of patients under the care of
crisis resolution home treatment services in England: a retrospective analysis
of suicide trends from 2003 to 2011. Lancet Psychiatry 2014, published
online June 18. http://dx.doi.org/10.1016/S2215-0366(14)70250-0
2 Kapur N, Hunt IM, Windfuhr K, et al. Psychiatric in-patient care and suicide in
England, 1997 to 2008: a longitudinal study. Psychol Med 2013; 43: 61–71.
3 Hubbeling D, Bertram R. Crisis resolution teams in the UK and elsewhere.
J Ment Health 2012; 21: 285–95.
4 Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for
severe mental illness. Cochrane Database Syst Rev 2010: 10: CD007906.
5 Luxton DD, June JD, Comtois KA. Can postdischarge follow-up contacts prevent
suicide and suicidal behavior? A review of the evidence. Crisis 2013; 34: 32–41.
6 Verwey B, van Waarde, Jeroen A, et al. Reassessment of suicide attempters
at home, shortly after discharge from hospital. Crisis 2010; 31: 303–10.
7 Thornicroft G, Tansella M. Components of a modern mental health service:
a pragmatic balance of community and hospital care: overview of
systematic evidence. Br J Psychiatry 2004; 185: 283–90.
8 Thornicroft G, Tansella M. The balanced care model: the case for both hospital-
and community-based mental healthcare. Br J Psychiatry 2013; 202: 246–48.
Until now, the issue of suicide has been neglected in Published Online
June 30, 2014
the scientific literature about autism, possibly because http://dx.doi.org/10.1016/
of the low rate of suicidal behaviour in children and S2215-0366(14)70257-3
preadolescents3 and the underdiagnosis of autism See Articles page 142
spectrum disorders in the adult psychiatric setting.4
Specialists in autism spectrum disorders deal mainly with
children or preadolescents, and rarely examine suicidal
99
 Comment
behaviour and suicide. However, adults with autism
spectrum disorders are seldom seen by mental health
professionals unless they present with mood changes,
obsessive or psychotic symptoms, or behavioural
disorders in addition to autism spectrum disorder. These
adults are usually treated by psychiatrists unfamiliar
with childhood-onset disorders and are often given
an incorrect diagnosis (eg, schizophrenia, schizoid or
schizotypal personality disorder, obsessive-compulsive
disorder, mood disorder, or social phobia), meaning that
suicidal behaviour in adult patients with autism spectrum
disorders is often not linked with the unrecognised
psychopathological autistic dimension. One caveat of
Cassidy and colleagues’ study is that it included data
only from patients who were not diagnosed with
Asperger syndrome until adulthood, because they
grew up before the disorder was formally recognised. A
question for future research is whether patients correctly
diagnosed and treated as children show the same risk
of suicidal ideation, plans, and attempts in adulthood.
Prospective studies are needed to evaluate rates of
suicidal ideation, plans, and attempts in adults with
autism spectrum disorders in different settings, such as
general or psychiatric hospitals, mental health services,
rehabilitation services, and specialist autism centres.
An interesting finding reported by Cassidy and
colleagues is that the depression dimension is distinct
from the suicidality dimension. Although patients
with a history of depression reported more frequent
suicidal ideation and suicide plans or attempts than did
those with no history of depression, far more patients
reported suicidal ideation than reported a previous
diagnosis of depression. Suicidality is also distinct
from depression in patients with mood or psychotic
disorders, and is more closely related to variables such
as impulsivity5 or physical aggressiveness.6 Intensity of
depressive symptoms and risk of suicide are not closely
related. Some patients with mild or no depressive
symptoms present serious suicidal behaviour, whereas
others with extremely severe depression show no
suicidal behaviour.7 Interestingly, in Cassidy and
colleagues’ study, patients reporting suicide plans
or attempts had higher Autism Spectrum Quotient
scores (ie, presented more cognitive-behavioural traits
associated with autism) than did the rest of the cohort,
suggesting a specific role of autistic psychopathology
in fostering of suicidal behaviour.
100
This study highlights the need to develop appropriate
psychological and psychopharmacological therapies.
The rigid thinking style and lack of imagination
(ie, not being able to see any other way out) that is
typical of Asperger’s syndrome might respond well to
psychological interventions. No systematic data about
psychopharmacological treatment of suicidality in
autism spectrum disorders have been reported. The high
risk of suicidal behaviour in these patients suggests an
urgent need to test drugs that have shown efficacy in
the prevention of suicide in other disorders (eg, lithium8
or clozapine9) in these patients. Medical specialists
therefore need to be involved in services for adults with
autism spectrum disorders.
Suicidal behaviour in patients with autism spectrum
disorders might be related to different clinical features
than are those typically noted in patients with mood
or schizophrenia spectrum disorders, which probably
contributes to the difficulty of recognising suicidal risk in
these patients. The identification of specific risk factors for
suicide in patients with autism spectrum disorders would
be clinically useful in view of the fact that many of the
features of these disorders—eg, impaired social interaction
and communication, lack of emotional reciprocity, and
inappropriate or bizarre behaviour—make psychiatric
assessment difficult.
Anecdotal evidence suggests that delusions and
hallucinations in adults with autism spectrum disorders
are associated with a high risk of dying by suicide;10
hopelessness, impulsivity, pervasive obsessive traits, and
physical aggressiveness should also be investigated. A
major question is the role of familial suicidality, because
risk of suicidal behaviour (including attempts and
completion) seems to be transmitted within families as
a trait independent of categorical psychiatric diagnoses.6
Cassidy and colleagues’ study makes an important
contribution to clinical practice by highlighting the risk
of suicide in adults diagnosed with Asperger syndrome.
Future studies should assess which psychopathological
aspects of autism, comorbid mental symptoms, and
behavioural abnormalities are related to suicidality, and
investigate both psychological and pharmacological
interventions to reduce the risk of suicide in this
population.
Michele Raja
Centro Gaetano Perusini, 00136 Rome, Italy
michele.raja@libero.it
www.thelancet.com/psychiatry Vol 1 July 2014

I declare no competing interests.
Copyright © Raja. Open access article distributed under the terms of CC BY.
1 Cassidy S, Bradley P, Robinson J, Allison C, McHugh M, Baron-Cohen S.
Suicidal ideation and suicide plans or attempts in adults with Asperger’s
syndrome attending a specialist diagnostic clinic: a clinical cohort study.
Lancet Psychiatry 2014, published online June 25. http://dx.doi.
org/10.1016/S2215-0366(14)70248-2.
2 Radomsky ED, Haas GL, Mann JJ, Sweeney JA. Suicidal behavior in patients
with schizophrenia and other psychotic disorders. Am J Psychiatry 1999;
156: 1590–95.
3 Dervic K, Brent DA, Oquendo MA. Completed suicide in childhood.
Psychiatr Clin North Am 2008; 31: 271–91.
4 Engström I, Ekström L, Emilsson B. Psychosocial functioning in a group of
Swedish adults with Asperger syndrome or high-functioning autism.
Autism 2003; 7: 99–110.
Implications of the Francis Inquiry for mental health research
The Francis Inquiry1 into failings in care at Mid
Staffordshire National Health Service (NHS) Foundation
Trust is seen by many as the most important event in
recent NHS history. The inquiry was not about mental
health or about research, but its influence on both will
nevertheless be far-reaching. From the 1782 pages and
290 recommendations of the inquiry, several over-riding
themes stand out, and these themes are likely to resonate
through all areas of the NHS, the wider care system, and
reach clinical research, including those who fund or host it.
The Francis Inquiry report, and the Berwick Review2 on
safety in the NHS that followed it, establish that safety is
the first responsibility of health care. The central theme
of these reports is the need to listen to patients and their
families; any organisation that stops doing so has been
distracted from its core purpose. Staff need to be able to
raise concerns about the care they and their colleagues
provide, without fear of consequences to themselves.
A culture of openness, transparency, and candour (each
separately defined by Francis) needs to exist. A safe
service places emphasis on learning and on the health
of the organisation itself, shown by such things as staff
turnover and the way it handles complaints. Crucially,
safety should be built into the system of care so that
prevention of future risks is routine and universal rather
than a targeted response to what has already gone
wrong; evidence in the Francis Inquiry includes the
phrase “benefit of hindsight” 378 times.
The National Confidential Inquiry into Suicide and
Homicide by People with Mental Illness (NCISH)3 is the
largest investigation of safety in mental health care.
Since 1996, detailed information on the antecedents of
www.thelancet.com/psychiatry Vol 1 July 2014
Comment
5 Swann AC, Dougherty DM, Pazzaglia PJ, Pham M, Steinberg JL, Moeller
FG. Increased impulsivity associated with severity of suicide attempt
history in patients with bipolar disorder. Am J Psychiatry 2005;
162: 1680–87.
6 Brent DA, Bridge J, Johnson BA, Connolly J. Suicidal behavior runs in
families. A controlled family study of adolescent suicide victims.
Arch Gen Psychiatry 1996; 53: 1145–52.
7 Koukopoulos A, Koukopoulos A. Agitated depression as a mixed state and
the problem of melancholia. Psychiatr Clin North Am 1999; 22: 547–64.
8 Carney SM, Goodwin GM. Lithium—a continuing story in the treatment of
bipolar disorder. Acta Psychiatr Scand 2005; 426: 7–12.
9 Meltzer HY, Alphs L, Green AI, et al. Clozapine treatment for suicidality in
schizophrenia: International Suicide Prevention Trial (InterSePT).
Arch Gen Psychiatry 2003; 60: 82–91.
10 Raja M, Azzoni A, Frustaci A. Autism spectrum disorders and suicidality.
Clin Pract Epidemiol Ment Health 2011; 7: 97–105.
patient suicide, homicide, and sudden death have been
collected and turned into recommendations for mental
health and primary care.4,5 The database currently stands
at 26 000 patient suicides, 1100 patient homicides, and
TAL COHEN/epa/Corbis
400 sudden deaths.
The question this large project must now address
is how well it represents the Francis Inquiry’s themes.
The project relies on the candour of clinicians who
provide information when a death has occurred, and Published Online
June 18, 2014
it protects their confidentiality. In 2009, the project’s http://dx.doi.org/10.1016/
main output changed from 5-year aggregate reports S2215-0366(14)70242-1
to annual updates on key figures, with the aim of
making the most recent statistics publicly accessible.
NCISH findings have shown the importance of the
broader prospective approach to safety; for example,
a recommendation to remove ward ligature points,
to prevent suicide by hanging, prompted a more
general response from inpatient units and a 70% fall
in inpatient suicide across all suicide methods.6 A peak
in suicide in the first week after hospital discharge led
to a requirement for early community follow-up for all
patients with complex needs.7
Patients with mental health problems are concerned
that placing an emphasis on patient homicide figures
risks increasing public prejudice against mental illness,
even when the number of cases is falling, as recently
reported.4 In response, NCISH has shown that people
who kill strangers are less likely to be mentally ill than
perpetrators of homicide overall.8 Moreover, patients
with mental health problems are at an increased risk
of being victims of homicide as well as perpetrators
compared with the general population.9
101