Assessing Suicidality in Adult ADHD Patients: Prevalence and Related Factors 

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However, suicidality was generally assessed categorically and without validated instruments, which have led to heterogeneous or even conflicting evidence: the prevalence of both suicidal ideation and attempts vary considerably, and risk factors are not clear. Our study investigated suicidality in ADHD using a dimensional approach and a validated and internationally recognized instrument. Our primary aim was to evaluate the prevalence of suicidal ideation (SI), severe suicidal ideation (SSI), suicidal behavior (SB) and non suicidal self-injury behavior (NSSIB) in a sample of adult patients with ADHD. The second objective was to identify sociodemographic and clinical features associated with increased risk of suicidality in these patients. Methods: The sample included 74 adult patients with clinical diagnosis of ADHD. Suicidality was assessed by administering the Columbia-Suicide Severity Rating Scale. Logistic regressions were used to examine predictors of SI, SSI, SB and NSSIB. Results: The lifetime prevalence of SI and SSI were 59,5% and 16,2%, respectively. The 9,5% of patients showed lifetime SB, while NSSIB was found in 10,8% of the subjects. Lifetime SI was associated with severity of inattentive symptoms during adulthood, low self-esteem and impairment in social functioning. Lifetime SSI appeared related to severity of inattentive symptoms during childhood, attentional impulsiveness and number of hospitalizations, while physical activity appeared to be protective. The prevalence of lifetime SB and NSSIB didn’t appear significantly related to any socio-demographic or clinical feature. Conclusions: Adults with ADHD are to be considered at risk of suicide and it is important to determine which patients are at higher risk, in order to guide preventive interventions. The association between ADHD and suicidal ideation didn’t appear to be influenced by psychiatric comorbidities, but rather by inattention itself, which represents the core symptom of ADHD. Attention-deficit hyperactivity disorder suicidal ideation suicidal behavior suicide attempts risk factors. Figures Figure 1 Figure 2 1. Introduction According to the World Health Organization, suicide is the fourth leading cause of death within the 15 to 29 age group. (WHO 2019). ADHD (Attention-deficit hyperactivity disorder) is a neurodevelopmental disorder which arise in childhood and often lasts into adulthood [ 1 ]. Symptoms of ADHD include not only inattention and hyperactivity, but also impulsivity and emotional dysregulation [ 2 ]. Furthermore, ADHD often co-occurs with other psychiatric disorders such as mood disorders, substance use disorder and personality disorders [ 3 ]. For these reasons, the association between ADHD and suicidality has been a subject of interest for research in the recent years. However, there are several limitations that have led to heterogeneous or even conflicting findings in literature. The first methodological limitation lies in how suicidality was conceptualized and categorically assessed. Suicide is a complex and dynamic phenomenon that goes from suicidal ideation (SI) to suicidal behavior (SB). Therefore, it requires specific instruments of evaluation, such as the Columbia-Suicide Severity Rating Scale (C-SSRS), which allows dimensional analysis of suicidality [ 4 ]. However, the vast majority of studies on suicidality in ADHD have relied on open-ended questions or questionnaires, that were not specifically designed or validated for this purpose, or simply on diagnostic codes to assess suicidality. We managed to find only two studies on adult patients where C-SSRS (or other validated instruments) were used [ 5 , 6 ]. Furthermore, while several studies documented the incidence of suicide attempts in ADHD, there is a lack of evidence on other dimensions of suicidality, such as SI, and on clinical or sociodemographic features which may moderate the risk for suicide in ADHD. It is also important to note that some studies did not utilize clinical or diagnostic interviews, relying solely on non-specific screening tools, diagnostic codes, or the prescription of stimulants to identify patients with ADHD [ 6 , 7 , 8 ]. Finally, a considerable part of the studies included only male or underage patients, along with specific populations (such as prison inmates, substance abusers, learning disability subjects) [ 9 , 10 , 11 ]. These methodological limitations and differences in studies design and samples make the results difficult to interpret and compare, besides generating a considerable variability between the results themselves. In literature lifetime SB in adult ADHD patients rates range from 9.1% [ 11 ] to 51,5% [ 12 ], while lifetime SI rates range from 15,8% [ 13 ] to 66.3% [ 10 ]. Some authors have investigated risk factors for suicidality in ADHD, with gender being one of the most explored. The majority of the studies highlighted an higher risk of both SI and SB (but not of completed suicide) in adult female with ADHD [ 7 , 14 , 15 , 16 , 17 ]. Instead, no differences arised in underage patients [ 18 , 19 ]. Few data regarding other important dimensions, such as symptoms severity, ADHD subtype, and impulsiveness, are available. Only recently, a meta-analysis underlined ADHD symptoms severity and persistence, family history of ADHD, parental influences and social functioning as risk factors for suicidality in adult patients with ADHD [ 14 ]. Regarding the potential impact of psychiatric comorbidities on the association between ADHD and suicidality, Septier and colleagues ran a meta-analysis which highlighted an association mostly independent by variables (such as psychiatric comorbidities) [ 20 ]. Other studies suggested an overall significant association, even when adjusting for socio-demographic and clinical variables [ 7 , 9 , 15 ], while other studies didn’t replicate these evidences [ 5 , 6 , 10 , 21 ]. Therefore, the prevalence of suicidality in ADHD and factors related remain unclear, as it remains controversial whether this association is direct or mediated by psychiatric comorbidities. Our study investigated suicidality in ADHD using a dimensional approach and a validated and internationally recognized instrument. Our primary aim was to evaluate the prevalence of SI, severe suicidal ideation (SSI), SB and non-suicidal self-injurious behavior (NSSIB) in a sample of adult patients with ADHD. The second objective was to identify sociodemographic and clinical features associated with increased risk of suicidality in these patients. 2. Material and methods 2.1 Study design and sample This is a cross-sectional observational study. The sample consisted of 74 adults (≥ 18 years of age) outpatients with a diagnosis of ADHD according to DSM-5-TR criteria [ 22 ], who were referred to the regional reference center for ADHD in the Psychiatry Unit of San Luigi Gonzaga University Hospital, Orbassano (Turin). Potential participants were thoroughly explained aims and study procedures and had to give their written consent before participation; exclusion criteria included age < 18 and refusal to consent participating in the study. The protocol was approved by the local Ethical Committees. 2.2 Assessment Data were obtained through a semi-structured interview, which format covered the following areas: 1) Sociodemographic data: age, sex, marital status, education level and occupational status. 2) Clinical features of ADHD: ADHD subtype; severity of symptoms in childhood and in adulthood (according to the “Diagnostic Interview for ADHD in adults” - DIVA) [ 23 ]; current occurrence of symptoms (measured through ADHD rating scale IV – ADHD-RS IV) [ 24 ]; impulsiveness (measured through “Barratt Impulsiveness Scale” – BIS-11) [ 25 ]; ADHD related symptoms (such as mood swings, anger outbursts, low self-esteem, low tolerance for frustrations, sleep onset insomnia); areas of functional impairment; age at ADHD diagnosis; age at first ADHD treatment; family history of psychiatric disorders. 3) Psychiatric comorbidities: psychiatric comorbidities were determined according to the Italian version of the Structured Clinical Interview for DSM-5 Axis I Disorders (SCID-5) [ 26 ]. Personality status was assessed using the Millon Clinical Multiaxial Inventory (MCMI-III) [ 27 ]. Diagnoses made with DSM-IV-TR criteria were updated to meet the DSM-5-TR criteria [ 22 ]. 4) Suicidality: all the patients were assessed using the Italian version of the Columbia-Suicide Severity Rating Scale (C-SSRS) Lifetime/Recent version [ 4 ], a semi-structured clinical interview that rates SI and SB through four subscales (ideation severity, ideation intensity, behavior and lethality). The first subscale measures the SI severity with a 5-point ordinal scale ranging from 1 (wish to be dead) to 5 (active suicidal ideation with specific plan and intent). Patients with no SI receive a 0. The second subscale, completed only by the patients with a severity scale ≥ 1, investigates the intensity of ideation and consists of five items: frequency, duration, controllability, deterrents and reasons for ideation. Each of these items is rated on an ordinal scale (with total scores ranging from 2 to 25). The third subscale assesses SB (actual, interrupted and aborted suicide attempts, preparatory behaviors for a suicide attempt) and NSSIB. The fourth subscale, lethality, assesses actual attempts: actual lethality is rated on a 6-point scale; if actual lethality is 0, the potential lethality of attempts is rated on a 3-point scale. For the purpose of this study, suicidality was assessed regarding SI and SB. Lifetime SI was considered a score ≥ 1 in the severity subscale, while lifetime SSI was considered a severity score ≥ 4. This dichotomization has been used previously [ 28 , 29 ] and allows the identification of high-risk patients, relying on the assumption that the intent to act (the extent to which one is ready to act on thoughts of killing oneself) could be a predictive factor for future SB [ 4 ]. Lifetime SB was considered a score ≥ 1 in the behavior subscale, as other studies previously did [ 4 , 28 ]. This dichotomy was based on the fact that engaging in suicidal acts is associated with an increased risk of subsequent suicide attempts [ 30 ]. NSSIB was assessed with a specific item in the behavior subscale. 2.3 Statistical analysis The sociodemographic and clinical features of the patients were summarized as mean and SD for continuous variables and as frequency and percentage for categorical variables. We tested the distribution of continuous variables with the Kolmogorov-Smirnov test. The sample was divided, one at a time, in the following subgroups: ADHD with SI (score ≥ 1 on the suicidal severity subscale) vs. ADHD without SI (score = 0); ADHD with SSI (score ≥ 4 on the suicidal severity subscale) vs. ADHD without SSI (score < 4); ADHD with SB (preparatory acts or aborted/interrupted/actual attempts) vs. ADHD without SB; ADHD with NSSIB vs. ADHD without NSSIB. Because the distribution was not normal (P < 0.001), comparisons were performed using χ 2 tests for categorical variables and Kruskal-Wallis test for continuous variables. Binary logistic regression was used to identify explanatory variables associated with lifetime SI/SSI/SB/NSSIB, considering the presence of lifetime SI/SSI/SB/NSSIB as the dependent variable. Significant variables were selected using a forward stepwise procedure. A probability of 0.05 was required for inclusion in the equation. The group comparison results were presented as two-sided p-values rounded to three decimal places. The criterion for statistical significance in all comparison was a p value < 0.05. All statistical analyses were performed by SPSS software version 29.0.1.0. 3. Results A total of 74 adult patients with a diagnosis of ADHD were enrolled in the study. The sample’s demographic and clinical features are shown in Table 1 . Table 1 Sociodemographic and clinical characteristics of the total sample (n = 74) Sex, n (%) Male Female 50 (67,6) 24 (32,4) Age, mean (SD) 30,05 (10,8) Marital status, n (%) Single Married Separated Widowed 61 (82,4) 11 (14,9) 2 (2,7) 0 (0) Education (years), mean (SD) 12,8 (3,4) Paid employment, n (%) Yes No 56 (75,7) 18 (24,3) Family history of ADHD, n (%) Yes No 9 (12,2) 65 (87,8%) Adult ADHD subtype, n (%) Inattentive subtype Combined subtype 32 (43,2) 42 (56,8) Age at diagnosis (years), mean (SD) 25,9 (11) Age at first ADHD treatment (years), mean (SD) 26,1 (10,3) DIVA 2.0, mean (SD) Inattentive symptoms in childhood Hyperactivity symptoms in childhood Inattentive symptoms in adulthood Hyperactivity symptoms in adulthood 7,4 (1,1) 5,2 (2,9) 7,4 (1,2) 5,54 (2,5) ADHD-RS, mean (SD) 36 (8,6) BIS-11, mean (SD) Attentional impulsiveness Motor impulsiveness Non-planning impulsiveness 70,4 (11,6) 20,3 (4) 22,5 (4,7) 27,6 (5,2) Lifetime psychiatric comorbidities, n (%) Any comorbid disorder Major depressive disorder Bipolar disorders Substance use disorders Personality disorders Anxiety disorders Autism spectrum disorders 51 (68,9) 27 (36,5) 3 (4,1) 19 (25,7) 8 (10,8) 6 (8,1) 5 (6,7) Areas of functional impairment, n (%) Social functioning Relational functioning Academic functioning Occupational functioning 45 (60,8) 53 (71,6) 69 (93,2) 53 (71,6) Related symptoms, n (%) Mood swings Anger outbursts Low self-esteem Low tolerance for frustractions Sleep onset insomnia 52 (70,3) 35 (47,3) 55 (74,3) 51 (68,9) 51 (68,9) The lifetime prevalence of SI and SSI were 59,5% (n = 44) and 16,2% (n = 12), respectively. The 9,5% of patients (n = 7) showed lifetime SB, while NSSIB was found in 10,8% of the subjects (n = 8). Figures 1 and 2 show the severity of lifetime SI and the different types of lifetime SB in the sample. The results of the binary logistic regression models are described in Tables 2 and 3 . Table 2 The relationship between potential explanatory variables and lifetime suicidal ideation: results from the binary logistic regression analysis (n = 74) B SE Wald p-value OR 95%CI Severity of inattentive symptoms in adulthood 0,829 0,360 5,317 0,021 2,291 0,164-2,884 Low self-esteem 1,374 0,614 5,013 0,025 3,953 0,104-3,283 Impairment in social functioning 1,075 0,548 3,856 0,049 2,931 0,037 − 2,672 Constant 2,405 0,680 12,512 < 0,001 11,080 - Total number of variables initially entered in the model: n = 5 Table 3 The relationship between potential explanatory variables and lifetime severe suicidal ideation: results from the binary logistic regression analysis (n = 74) B SE Wald p-value OR 95%CI Severity of inattentive symptoms in childhood Attentional impulsiveness 1,772 0,845 0,815 0,406 4,725 4,327 0,030 0,038 5,880 2,327 0,291 − 65,893 0,039 − 2,176 Number of hospitalizations 0,587 0,261 5,050 0,025 1,799 0,030–38,569 Physical activity -2,641 1,069 6,104 0,013 0,071 -80,768- -0,594 Constant -14,133 4,646 9,254 0,002 0,000 - Total number of variables initially entered in the model: n = 6 The incidence of lifetime SI appeared related to severity of inattentive symptoms during adulthood (p = 0,021, OR 2,291, 95%CI 0,164-2,884), low self-esteem (p = 0,025, OR 3,953, 95%CI 0,104-3,283) and impairment in social functioning (p = 0,049, OR 2,931, 95%CI 0,037 − 2,672). Lifetime SSI was significantly associated to the severity of inattentive symptoms during childhood (p = 0,030, OR 5,880, 95%CI 0,291 − 65,893), attentional impulsiveness (p = 0,038, OR 2,327, 95%CI 0,039 − 2,176) and number of hospitalizations (p = 0,025, OR 1,799, 95%CI 0,030–38,569). Physical exercise showed to be related with a significant lower lifetime prevalence of SSI (p = 0,013, OR 0,071, 95%CI − 80,768- -0,594). No socio-demographic features resulted significantly associated to the occurrence of SI and SSI. The prevalence of lifetime SB didn’t appear significantly related to any socio-demographic or clinical feature (including any psychiatric comorbidity), also when stratified in the different types of SB. Similarly, no factor significantly linked with higher prevalence of NSSIB emerged. 4. Discussion This observational study aimed to evaluate the prevalence of suicidality in adult patients with ADHD using a dimensional approach and a validated instrument; we also analyzed socio-demographic and clinical factors potentially related to occurrence of SI or SB in these patients. The Columbia-Suicide Severity Rating Scale (C-SSRS) has allowed us to better define and quantify a complex phenomenon such as suicidality, which can’t be resumed in a single question. As highlighted by Posner and colleagues in the original validation results of this scale, a generic wish to be dead does not present a comparable risk factor to SB when compared to active suicidal ideation. [ 4 ]. Furthermore, considering the high levels of impulsiveness in ADHD patients and the resulting risk of acting-out, identify those with active SI could play an important role in preventing suicide. We identified a high prevalence of suicidality in adult patients with ADHD. Specifically, 59,5% of our sample reported wishing to be dead at least once in their life; moreover, 9,5% of the participants reported at least one lifetime SB. A considerable proportion of individuals with ADHD can be considered at high risk for suicide: 16,2% of our sample scored ≥ 4 on the severity scale of the C-SSRS, presenting lifetime active SI with a specific plan and intent (6,8%) or active SI with some intent to act but no plan (9,4%). Concerning SB, only a minority of our patients had actually attempted suicide (6,8%); many others, however, engaged in some SB, such as interrupted attempts (1,4%), aborted or self-interrupted attempts (2,7%), or in preparatory acts or behaviors (5,4%). Moreover, a considerable part of our sample (10,8%) engaged in NSSIB. Our results are reasonably in line with findings from a recent meta-analysis which evidenced a lifetime SI and SB prevalences of 40% and 18,9%, respectively [ 20 ]. The identification of a high suicidality risk among adults with ADHD underscores the necessity for focused assessment and careful monitoring within clinical practice. Regular clinical assessments and implementation of psychoeducational interventions, not only for patients but also for their familial and caregiving networks, can be crucial tools in addressing this complex clinical concern. The severity of inattentive symptoms in adulthood appeared significantly associated with lifetime SI, while the severity of hyperactivity/impulsivity symptoms didn’t result to have an impact on suicidality (both SI, SSI, SB and NSSIB). This evidence suggests that the association between ADHD and suicidality could be mediated by inattention, which represents the core symptom of ADHD. In accordance with this hypothesis, the only type of impulsiveness (measured through BIS-11) which resulted associated with suicidality (specifically with SSI) in our sample was attentional impulsiveness. This has been defined as an inability to focus attention or concentrate, and it assesses task-focus, intrusive thoughts, and racing thoughts. Instead, motor impulsiveness (acting without thinking) and non-planning impulsiveness (lack of futuring or forethought) didn’t result to affect both SI and SB, confirming that the risk of suicide in ADHD patients could depend on inattention rather than impulsivity itself. Furthermore, while lifetime SI appeared related to the severity of inattentive symptoms in adulthood, we found that lifetime SSI was associated with the severity of inattentive symptoms during childhood. This result endorses the potential impact in adulthood of the symptoms during childhood, suggesting they may be prognostic factors. Prior research findings highlighted some predictive factors for suicidality in ADHD such early externalizing behaviors, adverse child experiences and negative father–daughter interactions, without focusing on inattentive symptomatology [ 31 ]. Therefore, considering SSI as the proper risk factor for suicide, exploring symptoms of attention deficit in childhood should be a target in ADHD patients. However, in clinical practice, identifying this cluster in childhood can be challenging due to the occasional unavailability of caregivers and the less overt presentation of inattention, which is not always the predominant feature of ADHD, particularly in children. It is important to underline that in our sample SI, SSI, SB and NSSIB didn’t appear associated with any psychiatric comorbidity, in line with prior research findings from Septier’s meta-analysis [ 20 ]. Furthermore, we did not find any clinical or socio-demographic factors significantly associated with SB and NSSIB in adult patients with ADHD, indicating a direct correlation between these phenomena. Unlike SB and NSSIB, other clinical factors were found to be associated with SI and SSI in addition to the previously mentioned inattentive symptoms and attentional impulsiveness. Patients with SI exhibited significantly more frequent impairments in social functioning, though not in other areas. This finding, consistent with existing literature, supports the notion of a causal link between social isolation and suicide, as well as the protective influence of social support against suicide [ 32 ]. Physical activity appeared to be associated with a lower lifetime prevalence of SSI, suggesting that being physically active could reduce suicidal risk. This evidence, in line with a recent meta-analysis ran on psychiatric patients [ 33 ], is relevant given that there are only few interventions which proved to be effective against suicide and they aren’t always available in public health system. Low self-esteem is a known risk factor for suicide, especially in emerging adulthood [ 34 ]. It appeared significantly related with lifetime SI (it was found in 84,1% of the patients with suicidality history), but it is important to underline how frequently it occurs also in patients without an history of suicidality (60%), being one of the most associated symptoms in ADHD. No gender differences arised regarding both SI, SSI, SB and NSSIB in our sample. Our study has several strengths, including a well characterized clinical sample, the use of standardized validated assessments and a dimensional approach. However, our study should be considered in light of some limitations. First, the cross-sectional design does not allow causal relationships to be inferred or etiological factors to be assessed. Moreover, the sample did not include completed suicides, meaning that we are unable to test whether the results are generalizable to suicide deaths. Another study limitation is represented by the small number of participants: thus, the results about potential predictors of SB/NSSIB should be considered as preliminary. Despite these limitations, our findings are noteworthy since they highlight that a significant proportion of patients with ADHD have lifetime SI/SB. Moreover, this association appeared not to be affected by psychiatric comorbidities. Instead, our findings suggest that the risk of suicide in ADHD patients could depend on inattention itself. In conclusion, adult patients with ADHD are to be considered at risk of suicide and it is important to determine which patients should be considered at higher risk, in order to guide preventive pharmacological or psychological treatments and psychoeducational interventions. Therefore, for adult ADHD patients, alongside pharmacological therapy, the utilization of psychotherapeutic interventions, particularly cognitive-behavioral and psychoeducational approaches, is crucial. These interventions aid patients in gaining a deeper understanding of their condition, enhancing self-esteem, and guiding them towards adopting healthy and protective lifestyles, such as regular physical activity. Declarations Acknowledgments All authors confirm that this manuscript has not been previously published nor is it currently under consideration by any other journal. This research did not received any specific grants from funding agencies in the publica, commercial, or not-for-profit sectors. Disclosure All authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Gianluca Rosso has been a speaker and/or consultant from Angelini, Lundbeck, Janssen and Otsuka outside of the current work. Giuseppe Maina has been a consultant/speaker and/or has received research grants from Angelini, Boheringer, Innovapharma, Janssen, Fb Health, Otsuka, Lundbeck, Italfarmaco and Sanofi. Gabriele Di Salvo has been a speaker for Lundbeck and Angelini. Nevertheless, all authors report that this did not result in conflicts of interest for the present study. Authors contributions All authors have read and approved the final version submitted and take public responsibility for all aspects of the work. Gabriele Di Salvo, Giuseppe Maina and Gianluca Rosso designed the study. Gabriele Di Salvo, Camilla Perotti, Lorenzo Filippo and Camilla Garrone collected the patients’ data. Gabriele Di Salvo and Camilla Perotti managed literature search and Gabriele Di Salvo and Camilla Perotti analyzed the data. Gabriele Di Salvo wrote the draft. Giuseppe Maina and Gianluca Rosso provided substantial comments and helped drafting the manuscript in its final form. References Leffa DT, Caye A, Rohde LA. ADHD in Children and Adults: Diagnosis and Prognosis. Curr Top Behav Neurosci. 2022;57:1-18. Weibel S, Menard O, Ionita A, Boumendjel M, Cabelguen C, Kraemer C, et al. Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults. Encephale. 2020;46(1):30-40. doi: 10.1016/j.encep.2019.06.005. Katzman MA, Bilkey TS, Chokka PR, Fallu A, Klassen LJ. Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC Psychiatry. 2017;17(1):302. doi: 10.1186/s12888-017-1463-3. Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168:1266-77. doi: 10.1176/appi.ajp.2011.10111704. Giupponi G, Innamorati M, Rogante E, Sarubbi S, Erbuto D, Maniscalco I, et al. The Characteristics of Mood Polarity, Temperament, and Suicide Risk in Adult ADHD. Int J Environ Res Public Health. 2020;17(8):2871. doi: 10.3390/ijerph17082871. Olsson P, Wiktorsson S, Strömsten LMJ, Salander Renberg E, Runeson B, et al. Attention deficit hyperactivity disorder in adults who present with self-harm: a comparative 6-month follow-up study. BMC Psychiatry. 2022;22(1):428. doi: 10.1186/s12888-022-04057-0. Fuller-Thomson E, Rivière RN, Carrique L, Agbeyaka S. The Dark Side of ADHD: Factors Associated With Suicide Attempts Among Those With ADHD in a National Representative Canadian Sample. Arch Suicide Res. 2022;26(3):1122-1140. doi: 10.1080/13811118.2020.1856258. Stickley A, Koyanagi A, Ruchkin V, Kamio Y. Attention-deficit/hyperactivity disorder symptoms and suicide ideation and attempts: Findings from the Adult Psychiatric Morbidity Survey 2007. J Affect Disord. 2016;189:321-8. doi: 10.1016/j.jad.2015.09.061. Ruchkin V, Koposov RA, Koyanagi A, Stickley A. Suicidal Behavior in Juvenile Delinquents: The Role of ADHD and Other Comorbid Psychiatric Disorders. Child Psychiatry Hum Dev. 2017;48(5):691-698. doi: 10.1007/s10578-016-0693-9. Arias AJ, Gelernter J, Chan G, Weiss RD, Brady KT, Farrer L, et al. Correlates of co-occurring ADHD in drug-dependent subjects: prevalence and features of substance dependence and psychiatric disorders. Addict Behav. 2008;33(9):1199-207. doi: 10.1016/j.addbeh.2008.05.003. Brook U, Boaz M. Attention deficit and hyperactivity disorder/learning disabilities (ADHD/LD): parental characterization and perception. Patient Educ Couns. 2005;57(1):96-100. doi: 10.1016/j.pec.2004.03.018. Westmoreland P, Gunter T, Loveless P, Allen J, Sieleni B, Black DW. Attention deficit hyperactivity disorder in men and women newly committed to prison: clinical characteristics, psychiatric comorbidity, and quality of life. Int J Offender Ther Comp Criminol. 2010;54(3):361-77. doi: 10.1177/0306624X09332313. Haavisto A, Sourander A, Multimäki P, Parkkola K, Santalahti P, Helenius H, et al. Factors associated with ideation and acts of deliberate self-harm among 18-year-old boys. A prospective 10-year follow-up study. Soc Psychiatry Psychiatr Epidemiol. 2005;40(11):912-21. doi: 10.1007/s00127-005-0966-2. Austgulen A, Skram NKG, Haavik J, Lundervold AJ. Risk factors of suicidal spectrum behaviors in adults and adolescents with attention-deficit / hyperactivity disorder - a systematic review. BMC Psychiatry. 2023;23(1):612. doi: 10.1186/s12888-023-05099-8. Kakuszi B, Bitter I, Czobor P. Suicidal ideation in adult ADHD: gender difference with a specific psychopathological profile. Compr Psychiatry. 2018;85:23–29. doi: 10.1016/j.comppsych.2018.06.003. Babinski DE, Neely KA, Ba DM, Liu G. Depression and suicidal behavior in young adult men and women with ADHD: evidence from claims data. J Clin Psychiatry. 2020;81(6):22578. doi: 10.4088/JCP.19m13130. Ljung T, Chen Q, Lichtenstein P, Larsson H. Common etiological factors of attention-deficit/hyperactivity disorder and suicidal behavior. JAMA Psychiat. 2014;71(8):958. doi: 10.1001/jamapsychiatry.2014.363. Mayes SD, Calhoun SL, Baweja R, Feldman L, Syed E, Gorman AA, et al. Suicide ideation and attempts are associated with co-occurring oppositional defiant disorder and sadness in children and adolescents with ADHD. Journal of Psychopathology and Behavioral Assessment, 2015;37(2), 274–282. https://doi.org/10.1007/s10862-014-9451-0. Balazs J, Miklósi M, Keresztény A, Dallos G, Gádoros J. Attention-deficit hyperactivity disorder and suicidality in a treatment naïve sample of children and adolescents. J Affect Disord. 2014;152-154:282-7. doi: 10.1016/j.jad.2013.09.026. Septier M, Stordeur C, Zhang J, Delorme R, Cortese S. Association between suicidal spectrum behaviors and Attention-Deficit/Hyperactivity Disorder: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2019;103:109-118. doi: 10.1016/j.neubiorev.2019.05.022. Park S, Cho MJ, Chang SM, Jeon HJ, Cho SJ, Kim BS, et al. Prevalence, correlates, and comorbidities of adult ADHD symptoms in Korea: results of the Korean epidemiologic catchment area study. Psychiatry Res. 2011;186(2-3):378-83. doi: 10.1016/j.psychres.2010.07.047. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Kooij JJS, Francken MH. (2010) DIVA 2.0. Diagnostic Interview Voor ADHD in Adults bij volwassenen [DIVA 2.0 Diagnostic Interview ADHD in Adults]. DIVA Foundation. DuPaul, Power, Anastopoulos, Reid (1998) ADHD Rating Scale-IV. Patton JH, Stanford MS, Barratt ES (1995). Barratt Impulsiveness Scale-11 (BIS-11) First MB, Williams JBW, Karg RS, Spitzer RL. Structured Clinical Interview for DSM-5 Disorders, Clinician Version (SCID-5-CV). Arlington, VA, American Psychiatric Association, 2016. Millon T: Clinical Multiaxial Inventory (MCMI-III), 1997. Conway PM, Erlangsen A, Teasdale TW, Jakobsen IS, Larsen KJ. Predictive validity of the Columbia-Suicide Severity Rating Scale for short-term suicidal behavior: a Danish study of adolescents at a high risk of suicide. Arch Suicide Res. 2017;21:455-69. doi: 10.1080/13811118.2016.1222318. Bramante S, Maina G, Borgogno R, Pellegrini L, Rigardetto S, Albert U. Assessing suicide risk in patients with obsessive-compulsive disorder: a dimensional approach. Braz J Psychiatry. 2023;45(1):28-37. doi: 10.47626/1516-4446-2022-2632. Greist JH, Mundt JC, Gwaltney CJ, Jefferson JW, Posner K. Predictive Value of Baseline Electronic Columbia-Suicide Severity Rating Scale (eC-SSRS) Assessments for Identifying Risk of Prospective Reports of Suicidal Behavior During Research Participation. Innov Clin Neurosci. 2014;11(9-10):23-31. Meza JI, Owens EB, Hinshaw SP. Childhood predictors and moderators of lifetime risk of self-harm in girls with and without attention-deficit/hyperactivity disorder. Dev Psychopathol. 2021;33(4):1351-1367. doi: 10.1017/S0954579420000553. Motillon-Toudic C, Walter M, Séguin M, Carrier JD, Berrouiguet S, Lemey C. Social isolation and suicide risk: Literature review and perspectives. Eur Psychiatry. 2022;65(1):e65. doi: 10.1192/j.eurpsy.2022.2320. Vancampfort D, Hallgren M, Firth J, Rosenbaum S, Schuch FB, Mugisha J, et al.. Physical activity and suicidal ideation: A systematic review and meta-analysis. J Affect Disord. 2018;225:438-448. doi: 10.1016/j.jad.2017.08.070. Pereira AS, Willhelm AR, Koller SH, Almeida RMM. Risk and protective factors for suicide attempt in emerging adulthood. Cien Saude Colet. 2018;23(11):3767-3777. doi: 10.1590/1413-812320182311.29112016. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Nov, 2024 Read the published version in Annals of General Psychiatry → Version 1 posted Editorial decision: Revision requested 23 Jul, 2024 Editor assigned by journal 25 Jun, 2024 Submission checks completed at journal 25 Jun, 2024 First submitted to journal 25 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4634231","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":322232695,"identity":"a3a7bc2b-2bf0-479a-8887-dd43aced19c7","order_by":0,"name":"Gabriele Salvo","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Gabriele","middleName":"","lastName":"Salvo","suffix":""},{"id":322232696,"identity":"900cb622-4023-4301-a7b4-b093b440cb3b","order_by":1,"name":"Camilla Perotti","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Camilla","middleName":"","lastName":"Perotti","suffix":""},{"id":322232697,"identity":"b68d201b-2dab-45e9-a035-da02a645e065","order_by":2,"name":"Lorenzo Filippo","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Lorenzo","middleName":"","lastName":"Filippo","suffix":""},{"id":322232701,"identity":"809f702c-257c-45bb-a763-89c3ce14a848","order_by":3,"name":"Camilla Garrone","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Camilla","middleName":"","lastName":"Garrone","suffix":""},{"id":322232703,"identity":"69c392ea-c49a-4a10-a9db-3e5908292897","order_by":4,"name":"Gianluca Rosso","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYDACZiB+gODaQEQYDAhoSUBw04AiICEDfHpQtRxmIGiNvDvzsweJbXbyDNKHD3/8UXE+cTs7/8EHDAV/cGoxPMxmbpDYlmzYwJeWJs1z5nbizmZmZgN8DjNsZjCTSGw7wNjAw2PGzNh2O3HDYWY2Cfxa2L+BtNgDtRh//Nl2jrAWeWYesC2JQC0GErxABkEtBsw8ZRIJ55KT23jYQH5JNgZqMTZIMDDGbUv/8W0SH8rsbPt5mEEhZie74fzBhw8+/JHDbcsBKIMNRTgBpwagLQ14JEfBKBgFo2AUgAEA+BxI/t58qLUAAAAASUVORK5CYII=","orcid":"","institution":"University of Turin","correspondingAuthor":true,"prefix":"","firstName":"Gianluca","middleName":"","lastName":"Rosso","suffix":""},{"id":322232705,"identity":"4c3261b8-aa6f-4363-ae7c-5389d09b0f5c","order_by":5,"name":"Giuseppe Maina","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Giuseppe","middleName":"","lastName":"Maina","suffix":""}],"badges":[],"createdAt":"2024-06-25 07:10:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4634231/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4634231/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12991-024-00528-8","type":"published","date":"2024-11-01T16:13:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60630296,"identity":"1336d551-2a88-4f6e-99a8-5ff9056e8b38","added_by":"auto","created_at":"2024-07-19 00:41:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33292,"visible":true,"origin":"","legend":"\u003cp\u003eCumulative distribution of the severity of suicidal ideation in individuals with ADHD (n=74)\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4634231/v1/c42e19c07ba2f93d59abe098.jpg"},{"id":60630295,"identity":"5cb4754b-ec3e-40a8-add8-6afe17f8d27f","added_by":"auto","created_at":"2024-07-19 00:41:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":27254,"visible":true,"origin":"","legend":"\u003cp\u003eDifferent types of suicidal behaviors in individuals with ADHD (n=74)\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4634231/v1/729b82a80ad38aef110cc656.jpg"},{"id":68207428,"identity":"388f11ed-8f71-4310-8b20-e6c85ed77ce3","added_by":"auto","created_at":"2024-11-04 16:37:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":522995,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4634231/v1/98114fa3-2380-428f-accf-215bcc432a83.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing Suicidality in Adult ADHD Patients: Prevalence and Related Factors ","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAccording to the World Health Organization, suicide is the fourth leading cause of death within the 15 to 29 age group. (WHO 2019).\u003c/p\u003e \u003cp\u003eADHD (Attention-deficit hyperactivity disorder) is a neurodevelopmental disorder which arise in childhood and often lasts into adulthood [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Symptoms of ADHD include not only inattention and hyperactivity, but also impulsivity and emotional dysregulation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Furthermore, ADHD often co-occurs with other psychiatric disorders such as mood disorders, substance use disorder and personality disorders [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor these reasons, the association between ADHD and suicidality has been a subject of interest for research in the recent years. However, there are several limitations that have led to heterogeneous or even conflicting findings in literature.\u003c/p\u003e \u003cp\u003eThe first methodological limitation lies in how suicidality was conceptualized and categorically assessed. Suicide is a complex and dynamic phenomenon that goes from suicidal ideation (SI) to suicidal behavior (SB). Therefore, it requires specific instruments of evaluation, such as the Columbia-Suicide Severity Rating Scale (C-SSRS), which allows dimensional analysis of suicidality [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, the vast majority of studies on suicidality in ADHD have relied on open-ended questions or questionnaires, that were not specifically designed or validated for this purpose, or simply on diagnostic codes to assess suicidality. We managed to find only two studies on adult patients where C-SSRS (or other validated instruments) were used [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, while several studies documented the incidence of suicide attempts in ADHD, there is a lack of evidence on other dimensions of suicidality, such as SI, and on clinical or sociodemographic features which may moderate the risk for suicide in ADHD.\u003c/p\u003e \u003cp\u003eIt is also important to note that some studies did not utilize clinical or diagnostic interviews, relying solely on non-specific screening tools, diagnostic codes, or the prescription of stimulants to identify patients with ADHD [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Finally, a considerable part of the studies included only male or underage patients, along with specific populations (such as prison inmates, substance abusers, learning disability subjects) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese methodological limitations and differences in studies design and samples make the results difficult to interpret and compare, besides generating a considerable variability between the results themselves. In literature lifetime SB in adult ADHD patients rates range from 9.1% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] to 51,5% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], while lifetime SI rates range from 15,8% [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] to 66.3% [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome authors have investigated risk factors for suicidality in ADHD, with gender being one of the most explored. The majority of the studies highlighted an higher risk of both SI and SB (but not of completed suicide) in adult female with ADHD [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Instead, no differences arised in underage patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFew data regarding other important dimensions, such as symptoms severity, ADHD subtype, and impulsiveness, are available. Only recently, a meta-analysis underlined ADHD symptoms severity and persistence, family history of ADHD, parental influences and social functioning as risk factors for suicidality in adult patients with ADHD [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding the potential impact of psychiatric comorbidities on the association between ADHD and suicidality, Septier and colleagues ran a meta-analysis which highlighted an association mostly independent by variables (such as psychiatric comorbidities) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Other studies suggested an overall significant association, even when adjusting for socio-demographic and clinical variables [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], while other studies didn\u0026rsquo;t replicate these evidences [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, the prevalence of suicidality in ADHD and factors related remain unclear, as it remains controversial whether this association is direct or mediated by psychiatric comorbidities.\u003c/p\u003e \u003cp\u003eOur study investigated suicidality in ADHD using a dimensional approach and a validated and internationally recognized instrument. Our primary aim was to evaluate the prevalence of SI, severe suicidal ideation (SSI), SB and non-suicidal self-injurious behavior (NSSIB) in a sample of adult patients with ADHD. The second objective was to identify sociodemographic and clinical features associated with increased risk of suicidality in these patients.\u003c/p\u003e"},{"header":"2. Material and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design and sample\u003c/h2\u003e \u003cp\u003eThis is a cross-sectional observational study.\u003c/p\u003e \u003cp\u003eThe sample consisted of 74 adults (\u0026ge;\u0026thinsp;18 years of age) outpatients with a diagnosis of ADHD according to DSM-5-TR criteria [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], who were referred to the regional reference center for ADHD in the Psychiatry Unit of San Luigi Gonzaga University Hospital, Orbassano (Turin).\u003c/p\u003e \u003cp\u003ePotential participants were thoroughly explained aims and study procedures and had to give their written consent before participation; exclusion criteria included age\u0026thinsp;\u0026lt;\u0026thinsp;18 and refusal to consent participating in the study. The protocol was approved by the local Ethical Committees.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Assessment\u003c/h2\u003e \u003cp\u003eData were obtained through a semi-structured interview, which format covered the following areas:\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e1) Sociodemographic data: age, sex, marital status, education level and occupational status.\u003c/h3\u003e\n\u003cp\u003e2) Clinical features of ADHD: ADHD subtype; severity of symptoms in childhood and in adulthood (according to the \u0026ldquo;Diagnostic Interview for ADHD in adults\u0026rdquo; - DIVA) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]; current occurrence of symptoms (measured through ADHD rating scale IV \u0026ndash; ADHD-RS IV) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]; impulsiveness (measured through \u0026ldquo;Barratt Impulsiveness Scale\u0026rdquo; \u0026ndash; BIS-11) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]; ADHD related symptoms (such as mood swings, anger outbursts, low self-esteem, low tolerance for frustrations, sleep onset insomnia); areas of functional impairment; age at ADHD diagnosis; age at first ADHD treatment; family history of psychiatric disorders.\u003c/p\u003e \u003cp\u003e3) Psychiatric comorbidities: psychiatric comorbidities were determined according to the Italian version of the Structured Clinical Interview for DSM-5 Axis I Disorders (SCID-5) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Personality status was assessed using the Millon Clinical Multiaxial Inventory (MCMI-III) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Diagnoses made with DSM-IV-TR criteria were updated to meet the DSM-5-TR criteria [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e4) Suicidality: all the patients were assessed using the Italian version of the Columbia-Suicide Severity Rating Scale (C-SSRS) Lifetime/Recent version [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], a semi-structured clinical interview that rates SI and SB through four subscales (ideation severity, ideation intensity, behavior and lethality). The first subscale measures the SI severity with a 5-point ordinal scale ranging from 1 (wish to be dead) to 5 (active suicidal ideation with specific plan and intent). Patients with no SI receive a 0. The second subscale, completed only by the patients with a severity scale\u0026thinsp;\u0026ge;\u0026thinsp;1, investigates the intensity of ideation and consists of five items: frequency, duration, controllability, deterrents and reasons for ideation. Each of these items is rated on an ordinal scale (with total scores ranging from 2 to 25). The third subscale assesses SB (actual, interrupted and aborted suicide attempts, preparatory behaviors for a suicide attempt) and NSSIB. The fourth subscale, lethality, assesses actual attempts: actual lethality is rated on a 6-point scale; if actual lethality is 0, the potential lethality of attempts is rated on a 3-point scale. For the purpose of this study, suicidality was assessed regarding SI and SB. Lifetime SI was considered a score\u0026thinsp;\u0026ge;\u0026thinsp;1 in the severity subscale, while lifetime SSI was considered a severity score\u0026thinsp;\u0026ge;\u0026thinsp;4. This dichotomization has been used previously [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and allows the identification of high-risk patients, relying on the assumption that the intent to act (the extent to which one is ready to act on thoughts of killing oneself) could be a predictive factor for future SB [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Lifetime SB was considered a score\u0026thinsp;\u0026ge;\u0026thinsp;1 in the behavior subscale, as other studies previously did [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This dichotomy was based on the fact that engaging in suicidal acts is associated with an increased risk of subsequent suicide attempts [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. NSSIB was assessed with a specific item in the behavior subscale.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003eThe sociodemographic and clinical features of the patients were summarized as mean and SD for continuous variables and as frequency and percentage for categorical variables. We tested the distribution of continuous variables with the Kolmogorov-Smirnov test.\u003c/p\u003e \u003cp\u003eThe sample was divided, one at a time, in the following subgroups:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eADHD with SI (score\u0026thinsp;\u0026ge;\u0026thinsp;1 on the suicidal severity subscale) vs. ADHD without SI (score\u0026thinsp;=\u0026thinsp;0);\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eADHD with SSI (score\u0026thinsp;\u0026ge;\u0026thinsp;4 on the suicidal severity subscale) vs. ADHD without SSI (score\u0026thinsp;\u0026lt;\u0026thinsp;4);\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eADHD with SB (preparatory acts or aborted/interrupted/actual attempts) vs. ADHD without SB;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eADHD with NSSIB vs. ADHD without NSSIB.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eBecause the distribution was not normal (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), comparisons were performed using χ\u003csup\u003e2\u003c/sup\u003e tests for categorical variables and Kruskal-Wallis test for continuous variables.\u003c/p\u003e \u003cp\u003eBinary logistic regression was used to identify explanatory variables associated with lifetime SI/SSI/SB/NSSIB, considering the presence of lifetime SI/SSI/SB/NSSIB as the dependent variable. Significant variables were selected using a forward stepwise procedure. A probability of 0.05 was required for inclusion in the equation. The group comparison results were presented as two-sided p-values rounded to three decimal places. The criterion for statistical significance in all comparison was a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eAll statistical analyses were performed by SPSS software version 29.0.1.0.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 74 adult patients with a diagnosis of ADHD were enrolled in the study. The sample\u0026rsquo;s demographic and clinical features are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and clinical characteristics of the total sample (n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (67,6)\u003c/p\u003e \u003cp\u003e24 (32,4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30,05 (10,8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status, n (%)\u003c/p\u003e \u003cp\u003eSingle\u003c/p\u003e \u003cp\u003eMarried\u003c/p\u003e \u003cp\u003eSeparated\u003c/p\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (82,4)\u003c/p\u003e \u003cp\u003e11 (14,9)\u003c/p\u003e \u003cp\u003e2 (2,7)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (years), mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12,8 (3,4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaid employment, n (%)\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (75,7)\u003c/p\u003e \u003cp\u003e18 (24,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily history of ADHD, n (%)\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (12,2)\u003c/p\u003e \u003cp\u003e65 (87,8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult ADHD subtype, n (%)\u003c/p\u003e \u003cp\u003eInattentive subtype\u003c/p\u003e \u003cp\u003eCombined subtype\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (43,2)\u003c/p\u003e \u003cp\u003e42 (56,8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at diagnosis (years), mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25,9 (11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at first ADHD treatment (years), mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26,1 (10,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDIVA 2.0, mean (SD)\u003c/p\u003e \u003cp\u003eInattentive symptoms in childhood\u003c/p\u003e \u003cp\u003eHyperactivity symptoms in childhood\u003c/p\u003e \u003cp\u003eInattentive symptoms in adulthood\u003c/p\u003e \u003cp\u003eHyperactivity symptoms in adulthood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7,4 (1,1)\u003c/p\u003e \u003cp\u003e5,2 (2,9)\u003c/p\u003e \u003cp\u003e7,4 (1,2)\u003c/p\u003e \u003cp\u003e5,54 (2,5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADHD-RS, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (8,6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBIS-11, mean (SD)\u003c/p\u003e \u003cp\u003eAttentional impulsiveness\u003c/p\u003e \u003cp\u003eMotor impulsiveness\u003c/p\u003e \u003cp\u003eNon-planning impulsiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70,4 (11,6)\u003c/p\u003e \u003cp\u003e20,3 (4)\u003c/p\u003e \u003cp\u003e22,5 (4,7)\u003c/p\u003e \u003cp\u003e27,6 (5,2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLifetime psychiatric comorbidities, n (%)\u003c/p\u003e \u003cp\u003eAny comorbid disorder\u003c/p\u003e \u003cp\u003eMajor depressive disorder\u003c/p\u003e \u003cp\u003eBipolar disorders\u003c/p\u003e \u003cp\u003eSubstance use disorders\u003c/p\u003e \u003cp\u003ePersonality disorders\u003c/p\u003e \u003cp\u003eAnxiety disorders\u003c/p\u003e \u003cp\u003eAutism spectrum disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (68,9)\u003c/p\u003e \u003cp\u003e27 (36,5)\u003c/p\u003e \u003cp\u003e3 (4,1)\u003c/p\u003e \u003cp\u003e19 (25,7)\u003c/p\u003e \u003cp\u003e8 (10,8)\u003c/p\u003e \u003cp\u003e6 (8,1)\u003c/p\u003e \u003cp\u003e5 (6,7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAreas of functional impairment, n (%)\u003c/p\u003e \u003cp\u003eSocial functioning\u003c/p\u003e \u003cp\u003eRelational functioning\u003c/p\u003e \u003cp\u003eAcademic functioning\u003c/p\u003e \u003cp\u003eOccupational functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (60,8)\u003c/p\u003e \u003cp\u003e53 (71,6)\u003c/p\u003e \u003cp\u003e69 (93,2)\u003c/p\u003e \u003cp\u003e53 (71,6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelated symptoms, n (%)\u003c/p\u003e \u003cp\u003eMood swings\u003c/p\u003e \u003cp\u003eAnger outbursts\u003c/p\u003e \u003cp\u003eLow self-esteem\u003c/p\u003e \u003cp\u003eLow tolerance for frustractions\u003c/p\u003e \u003cp\u003eSleep onset insomnia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (70,3)\u003c/p\u003e \u003cp\u003e35 (47,3)\u003c/p\u003e \u003cp\u003e55 (74,3)\u003c/p\u003e \u003cp\u003e51 (68,9)\u003c/p\u003e \u003cp\u003e51 (68,9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe lifetime prevalence of SI and SSI were 59,5% (n\u0026thinsp;=\u0026thinsp;44) and 16,2% (n\u0026thinsp;=\u0026thinsp;12), respectively. The 9,5% of patients (n\u0026thinsp;=\u0026thinsp;7) showed lifetime SB, while NSSIB was found in 10,8% of the subjects (n\u0026thinsp;=\u0026thinsp;8).\u003c/p\u003e \u003cp\u003eFigures \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e show the severity of lifetime SI and the different types of lifetime SB in the sample.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe results of the binary logistic regression models are described in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe relationship between potential explanatory variables and lifetime suicidal ideation: results from the binary logistic regression analysis (n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeverity of inattentive symptoms in adulthood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0,829\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5,317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2,291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,164-2,884\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow self-esteem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1,374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,614\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5,013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3,953\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,104-3,283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpairment in social functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1,075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,548\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3,856\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2,931\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,037\u0026thinsp;\u0026minus;\u0026thinsp;2,672\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2,405\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,680\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12,512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11,080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eTotal number of variables initially entered in the model: n\u0026thinsp;=\u0026thinsp;5\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe relationship between potential explanatory variables and lifetime severe suicidal ideation: results from the binary logistic regression analysis (n\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeverity of inattentive symptoms in childhood\u003c/p\u003e \u003cp\u003eAttentional impulsiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,772\u003c/p\u003e \u003cp\u003e0,845\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,815\u003c/p\u003e \u003cp\u003e0,406\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4,725\u003c/p\u003e \u003cp\u003e4,327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,030\u003c/p\u003e \u003cp\u003e0,038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5,880\u003c/p\u003e \u003cp\u003e2,327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,291\u0026thinsp;\u0026minus;\u0026thinsp;65,893\u003c/p\u003e \u003cp\u003e0,039\u0026thinsp;\u0026minus;\u0026thinsp;2,176\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of hospitalizations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0,587\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0,261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5,050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1,799\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,030\u0026ndash;38,569\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2,641\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6,104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-80,768- -0,594\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-14,133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4,646\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9,254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0,002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eTotal number of variables initially entered in the model: n\u0026thinsp;=\u0026thinsp;6\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe incidence of lifetime SI appeared related to severity of inattentive symptoms during adulthood (p\u0026thinsp;=\u0026thinsp;0,021, OR 2,291, 95%CI 0,164-2,884), low self-esteem (p\u0026thinsp;=\u0026thinsp;0,025, OR 3,953, 95%CI 0,104-3,283) and impairment in social functioning (p\u0026thinsp;=\u0026thinsp;0,049, OR 2,931, 95%CI 0,037\u0026thinsp;\u0026minus;\u0026thinsp;2,672).\u003c/p\u003e \u003cp\u003eLifetime SSI was significantly associated to the severity of inattentive symptoms during childhood (p\u0026thinsp;=\u0026thinsp;0,030, OR 5,880, 95%CI 0,291\u0026thinsp;\u0026minus;\u0026thinsp;65,893), attentional impulsiveness (p\u0026thinsp;=\u0026thinsp;0,038, OR 2,327, 95%CI 0,039\u0026thinsp;\u0026minus;\u0026thinsp;2,176) and number of hospitalizations (p\u0026thinsp;=\u0026thinsp;0,025, OR 1,799, 95%CI 0,030\u0026ndash;38,569). Physical exercise showed to be related with a significant lower lifetime prevalence of SSI (p\u0026thinsp;=\u0026thinsp;0,013, OR 0,071, 95%CI \u0026minus;\u0026thinsp;80,768- -0,594).\u003c/p\u003e \u003cp\u003eNo socio-demographic features resulted significantly associated to the occurrence of SI and SSI.\u003c/p\u003e \u003cp\u003eThe prevalence of lifetime SB didn\u0026rsquo;t appear significantly related to any socio-demographic or clinical feature (including any psychiatric comorbidity), also when stratified in the different types of SB. Similarly, no factor significantly linked with higher prevalence of NSSIB emerged.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis observational study aimed to evaluate the prevalence of suicidality in adult patients with ADHD using a dimensional approach and a validated instrument; we also analyzed socio-demographic and clinical factors potentially related to occurrence of SI or SB in these patients.\u003c/p\u003e \u003cp\u003eThe Columbia-Suicide Severity Rating Scale (C-SSRS) has allowed us to better define and quantify a complex phenomenon such as suicidality, which can\u0026rsquo;t be resumed in a single question. As highlighted by Posner and colleagues in the original validation results of this scale, a generic wish to be dead does not present a comparable risk factor to SB when compared to active suicidal ideation. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Furthermore, considering the high levels of impulsiveness in ADHD patients and the resulting risk of acting-out, identify those with active SI could play an important role in preventing suicide.\u003c/p\u003e \u003cp\u003eWe identified a high prevalence of suicidality in adult patients with ADHD. Specifically, 59,5% of our sample reported wishing to be dead at least once in their life; moreover, 9,5% of the participants reported at least one lifetime SB. A considerable proportion of individuals with ADHD can be considered at high risk for suicide: 16,2% of our sample scored\u0026thinsp;\u0026ge;\u0026thinsp;4 on the severity scale of the C-SSRS, presenting lifetime active SI with a specific plan and intent (6,8%) or active SI with some intent to act but no plan (9,4%). Concerning SB, only a minority of our patients had actually attempted suicide (6,8%); many others, however, engaged in some SB, such as interrupted attempts (1,4%), aborted or self-interrupted attempts (2,7%), or in preparatory acts or behaviors (5,4%). Moreover, a considerable part of our sample (10,8%) engaged in NSSIB. Our results are reasonably in line with findings from a recent meta-analysis which evidenced a lifetime SI and SB prevalences of 40% and 18,9%, respectively [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe identification of a high suicidality risk among adults with ADHD underscores the necessity for focused assessment and careful monitoring within clinical practice. Regular clinical assessments and implementation of psychoeducational interventions, not only for patients but also for their familial and caregiving networks, can be crucial tools in addressing this complex clinical concern.\u003c/p\u003e \u003cp\u003eThe severity of inattentive symptoms in adulthood appeared significantly associated with lifetime SI, while the severity of hyperactivity/impulsivity symptoms didn\u0026rsquo;t result to have an impact on suicidality (both SI, SSI, SB and NSSIB). This evidence suggests that the association between ADHD and suicidality could be mediated by inattention, which represents the core symptom of ADHD.\u003c/p\u003e \u003cp\u003eIn accordance with this hypothesis, the only type of impulsiveness (measured through BIS-11) which resulted associated with suicidality (specifically with SSI) in our sample was attentional impulsiveness. This has been defined as an inability to focus attention or concentrate, and it assesses task-focus, intrusive thoughts, and racing thoughts. Instead, motor impulsiveness (acting without thinking) and non-planning impulsiveness (lack of futuring or forethought) didn\u0026rsquo;t result to affect both SI and SB, confirming that the risk of suicide in ADHD patients could depend on inattention rather than impulsivity itself.\u003c/p\u003e \u003cp\u003eFurthermore, while lifetime SI appeared related to the severity of inattentive symptoms in adulthood, we found that lifetime SSI was associated with the severity of inattentive symptoms during childhood. This result endorses the potential impact in adulthood of the symptoms during childhood, suggesting they may be prognostic factors. Prior research findings highlighted some predictive factors for suicidality in ADHD such early externalizing behaviors, adverse child experiences and negative father\u0026ndash;daughter interactions, without focusing on inattentive symptomatology [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Therefore, considering SSI as the proper risk factor for suicide, exploring symptoms of attention deficit in childhood should be a target in ADHD patients. However, in clinical practice, identifying this cluster in childhood can be challenging due to the occasional unavailability of caregivers and the less overt presentation of inattention, which is not always the predominant feature of ADHD, particularly in children.\u003c/p\u003e \u003cp\u003eIt is important to underline that in our sample SI, SSI, SB and NSSIB didn\u0026rsquo;t appear associated with any psychiatric comorbidity, in line with prior research findings from Septier\u0026rsquo;s meta-analysis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, we did not find any clinical or socio-demographic factors significantly associated with SB and NSSIB in adult patients with ADHD, indicating a direct correlation between these phenomena.\u003c/p\u003e \u003cp\u003eUnlike SB and NSSIB, other clinical factors were found to be associated with SI and SSI in addition to the previously mentioned inattentive symptoms and attentional impulsiveness. Patients with SI exhibited significantly more frequent impairments in social functioning, though not in other areas. This finding, consistent with existing literature, supports the notion of a causal link between social isolation and suicide, as well as the protective influence of social support against suicide [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Physical activity appeared to be associated with a lower lifetime prevalence of SSI, suggesting that being physically active could reduce suicidal risk. This evidence, in line with a recent meta-analysis ran on psychiatric patients [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], is relevant given that there are only few interventions which proved to be effective against suicide and they aren\u0026rsquo;t always available in public health system.\u003c/p\u003e \u003cp\u003eLow self-esteem is a known risk factor for suicide, especially in emerging adulthood [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. It appeared significantly related with lifetime SI (it was found in 84,1% of the patients with suicidality history), but it is important to underline how frequently it occurs also in patients without an history of suicidality (60%), being one of the most associated symptoms in ADHD.\u003c/p\u003e \u003cp\u003eNo gender differences arised regarding both SI, SSI, SB and NSSIB in our sample.\u003c/p\u003e \u003cp\u003eOur study has several strengths, including a well characterized clinical sample, the use of standardized validated assessments and a dimensional approach. However, our study should be considered in light of some limitations. First, the cross-sectional design does not allow causal relationships to be inferred or etiological factors to be assessed. Moreover, the sample did not include completed suicides, meaning that we are unable to test whether the results are generalizable to suicide deaths. Another study limitation is represented by the small number of participants: thus, the results about potential predictors of SB/NSSIB should be considered as preliminary.\u003c/p\u003e \u003cp\u003eDespite these limitations, our findings are noteworthy since they highlight that a significant proportion of patients with ADHD have lifetime SI/SB. Moreover, this association appeared not to be affected by psychiatric comorbidities. Instead, our findings suggest that the risk of suicide in ADHD patients could depend on inattention itself.\u003c/p\u003e \u003cp\u003eIn conclusion, adult patients with ADHD are to be considered at risk of suicide and it is important to determine which patients should be considered at higher risk, in order to guide preventive pharmacological or psychological treatments and psychoeducational interventions. Therefore, for adult ADHD patients, alongside pharmacological therapy, the utilization of psychotherapeutic interventions, particularly cognitive-behavioral and psychoeducational approaches, is crucial. These interventions aid patients in gaining a deeper understanding of their condition, enhancing self-esteem, and guiding them towards adopting healthy and protective lifestyles, such as regular physical activity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors confirm that this manuscript has not been previously published nor is it currently under consideration by any other journal. This research did not received any specific grants from funding agencies in the publica, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Gianluca Rosso has been a speaker and/or consultant from Angelini, Lundbeck, Janssen and Otsuka outside of the current work. Giuseppe Maina has been a consultant/speaker and/or has received research grants from Angelini, Boheringer, Innovapharma, Janssen, Fb Health, Otsuka, Lundbeck, Italfarmaco and Sanofi. Gabriele Di Salvo has been a speaker for Lundbeck and Angelini. Nevertheless, all authors report that this did not result in conflicts of interest for the present study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final version submitted and take public responsibility for all aspects of the work. Gabriele Di Salvo, Giuseppe Maina and Gianluca Rosso designed the study. Gabriele Di Salvo, Camilla Perotti, Lorenzo Filippo and Camilla Garrone collected the patients\u0026rsquo; data. Gabriele Di Salvo and Camilla Perotti managed literature search and Gabriele Di Salvo and Camilla Perotti analyzed the data. Gabriele Di Salvo wrote the draft. Giuseppe Maina and Gianluca Rosso provided substantial comments and helped drafting the manuscript in its final form.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLeffa DT, Caye A, Rohde LA. ADHD in Children and Adults: Diagnosis and Prognosis. Curr Top Behav Neurosci. 2022;57:1-18.\u003c/li\u003e\n\u003cli\u003eWeibel S, Menard O, Ionita A, Boumendjel M, Cabelguen C, Kraemer C, et al. Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults. Encephale. 2020;46(1):30-40. doi: 10.1016/j.encep.2019.06.005.\u003c/li\u003e\n\u003cli\u003eKatzman MA, Bilkey TS, Chokka PR, Fallu A, Klassen LJ. Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC Psychiatry. 2017;17(1):302. doi: 10.1186/s12888-017-1463-3.\u003c/li\u003e\n\u003cli\u003ePosner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168:1266-77. doi: 10.1176/appi.ajp.2011.10111704.\u003c/li\u003e\n\u003cli\u003eGiupponi G, Innamorati M, Rogante E, Sarubbi S, Erbuto D, Maniscalco I, et al. The Characteristics of Mood Polarity, Temperament, and Suicide Risk in Adult ADHD. Int J Environ Res Public Health. 2020;17(8):2871. doi: 10.3390/ijerph17082871.\u003c/li\u003e\n\u003cli\u003eOlsson P, Wiktorsson S, Str\u0026ouml;msten LMJ, Salander Renberg E, Runeson B, et al. Attention deficit hyperactivity disorder in adults who present with self-harm: a comparative 6-month follow-up study. BMC Psychiatry. 2022;22(1):428. doi: 10.1186/s12888-022-04057-0.\u003c/li\u003e\n\u003cli\u003eFuller-Thomson E, Rivi\u0026egrave;re RN, Carrique L, Agbeyaka S. The Dark Side of ADHD: Factors Associated With Suicide Attempts Among Those With ADHD in a National Representative Canadian Sample. Arch Suicide Res. 2022;26(3):1122-1140. doi: 10.1080/13811118.2020.1856258.\u003c/li\u003e\n\u003cli\u003eStickley A, Koyanagi A, Ruchkin V, Kamio Y. Attention-deficit/hyperactivity disorder symptoms and suicide ideation and attempts: Findings from the Adult Psychiatric Morbidity Survey 2007. J Affect Disord. 2016;189:321-8. doi: 10.1016/j.jad.2015.09.061.\u003c/li\u003e\n\u003cli\u003eRuchkin V, Koposov RA, Koyanagi A, Stickley A. Suicidal Behavior in Juvenile Delinquents: The Role of ADHD and Other Comorbid Psychiatric Disorders. Child Psychiatry Hum Dev. 2017;48(5):691-698. doi: 10.1007/s10578-016-0693-9.\u003c/li\u003e\n\u003cli\u003eArias AJ, Gelernter J, Chan G, Weiss RD, Brady KT, Farrer L, et al. Correlates of co-occurring ADHD in drug-dependent subjects: prevalence and features of substance dependence and psychiatric disorders. Addict Behav. 2008;33(9):1199-207. doi: 10.1016/j.addbeh.2008.05.003.\u003c/li\u003e\n\u003cli\u003eBrook U, Boaz M. Attention deficit and hyperactivity disorder/learning disabilities (ADHD/LD): parental characterization and perception. Patient Educ Couns. 2005;57(1):96-100. doi: 10.1016/j.pec.2004.03.018.\u003c/li\u003e\n\u003cli\u003eWestmoreland P, Gunter T, Loveless P, Allen J, Sieleni B, Black DW. Attention deficit hyperactivity disorder in men and women newly committed to prison: clinical characteristics, psychiatric comorbidity, and quality of life. Int J Offender Ther Comp Criminol. 2010;54(3):361-77. doi: 10.1177/0306624X09332313.\u003c/li\u003e\n\u003cli\u003eHaavisto A, Sourander A, Multim\u0026auml;ki P, Parkkola K, Santalahti P, Helenius H, et al. Factors associated with ideation and acts of deliberate self-harm among 18-year-old boys. A prospective 10-year follow-up study. Soc Psychiatry Psychiatr Epidemiol. 2005;40(11):912-21. doi: 10.1007/s00127-005-0966-2.\u003c/li\u003e\n\u003cli\u003eAustgulen A, Skram NKG, Haavik J, Lundervold AJ. Risk factors of suicidal spectrum behaviors in adults and adolescents with attention-deficit / hyperactivity disorder - a systematic review. BMC Psychiatry. 2023;23(1):612. doi: 10.1186/s12888-023-05099-8.\u003c/li\u003e\n\u003cli\u003eKakuszi B, Bitter I, Czobor P. Suicidal ideation in adult ADHD: gender difference with a specific psychopathological profile. \u003cem\u003eCompr Psychiatry. \u003c/em\u003e2018;85:23\u0026ndash;29. doi: 10.1016/j.comppsych.2018.06.003.\u003c/li\u003e\n\u003cli\u003eBabinski DE, Neely KA, Ba DM, Liu G. Depression and suicidal behavior in young adult men and women with ADHD: evidence from claims data. \u003cem\u003eJ Clin Psychiatry. \u003c/em\u003e2020;81(6):22578. doi: 10.4088/JCP.19m13130.\u003c/li\u003e\n\u003cli\u003eLjung T, Chen Q, Lichtenstein P, Larsson H. Common etiological factors of attention-deficit/hyperactivity disorder and suicidal behavior. JAMA Psychiat. 2014;71(8):958. doi: 10.1001/jamapsychiatry.2014.363.\u003c/li\u003e\n\u003cli\u003eMayes SD, Calhoun SL, Baweja R, Feldman L, Syed E, Gorman AA, et al. Suicide ideation and attempts are associated with co-occurring oppositional defiant disorder and sadness in children and adolescents with ADHD. Journal of Psychopathology and Behavioral Assessment, 2015;37(2), 274\u0026ndash;282. https://doi.org/10.1007/s10862-014-9451-0. \u003c/li\u003e\n\u003cli\u003eBalazs J, Mikl\u0026oacute;si M, Kereszt\u0026eacute;ny A, Dallos G, G\u0026aacute;doros J. Attention-deficit hyperactivity disorder and suicidality in a treatment na\u0026iuml;ve sample of children and adolescents. J Affect Disord. 2014;152-154:282-7. doi: 10.1016/j.jad.2013.09.026.\u003c/li\u003e\n\u003cli\u003eSeptier M, Stordeur C, Zhang J, Delorme R, Cortese S. Association between suicidal spectrum behaviors and Attention-Deficit/Hyperactivity Disorder: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2019;103:109-118. doi: 10.1016/j.neubiorev.2019.05.022.\u003c/li\u003e\n\u003cli\u003ePark S, Cho MJ, Chang SM, Jeon HJ, Cho SJ, Kim BS, et al. Prevalence, correlates, and comorbidities of adult ADHD symptoms in Korea: results of the Korean epidemiologic catchment area study. Psychiatry Res. 2011;186(2-3):378-83. doi: 10.1016/j.psychres.2010.07.047.\u003c/li\u003e\n\u003cli\u003eAmerican Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).\u003c/li\u003e\n\u003cli\u003eKooij JJS, Francken MH. (2010) DIVA 2.0. Diagnostic Interview Voor ADHD in Adults bij volwassenen [DIVA 2.0 Diagnostic Interview ADHD in Adults]. DIVA Foundation.\u003c/li\u003e\n\u003cli\u003eDuPaul, Power, Anastopoulos, Reid (1998) ADHD Rating Scale-IV. \u003c/li\u003e\n\u003cli\u003ePatton JH, Stanford MS, Barratt ES (1995). Barratt Impulsiveness Scale-11 (BIS-11)\u003c/li\u003e\n\u003cli\u003eFirst MB, Williams JBW, Karg RS, Spitzer RL. Structured Clinical Interview for DSM-5 Disorders, Clinician Version (SCID-5-CV). Arlington, VA, American Psychiatric Association, 2016. \u003c/li\u003e\n\u003cli\u003eMillon T: Clinical Multiaxial Inventory (MCMI-III), 1997.\u003c/li\u003e\n\u003cli\u003eConway PM, Erlangsen A, Teasdale TW, Jakobsen IS, Larsen KJ. Predictive validity of the Columbia-Suicide Severity Rating Scale for short-term suicidal behavior: a Danish study of adolescents at a high risk of suicide. Arch Suicide Res. 2017;21:455-69. doi: 10.1080/13811118.2016.1222318.\u003c/li\u003e\n\u003cli\u003eBramante S, Maina G, Borgogno R, Pellegrini L, Rigardetto S, Albert U. Assessing suicide risk in patients with obsessive-compulsive disorder: a dimensional approach. Braz J Psychiatry. 2023;45(1):28-37. doi: 10.47626/1516-4446-2022-2632.\u003c/li\u003e\n\u003cli\u003eGreist JH, Mundt JC, Gwaltney CJ, Jefferson JW, Posner K. Predictive Value of Baseline Electronic Columbia-Suicide Severity Rating Scale (eC-SSRS) Assessments for Identifying Risk of Prospective Reports of Suicidal Behavior During Research Participation. Innov Clin Neurosci. 2014;11(9-10):23-31.\u003c/li\u003e\n\u003cli\u003eMeza JI, Owens EB, Hinshaw SP. Childhood predictors and moderators of lifetime risk of self-harm in girls with and without attention-deficit/hyperactivity disorder. Dev Psychopathol. 2021;33(4):1351-1367. doi: 10.1017/S0954579420000553.\u003c/li\u003e\n\u003cli\u003eMotillon-Toudic C, Walter M, S\u0026eacute;guin M, Carrier JD, Berrouiguet S, Lemey C. Social isolation and suicide risk: Literature review and perspectives. Eur Psychiatry. 2022;65(1):e65. doi: 10.1192/j.eurpsy.2022.2320.\u003c/li\u003e\n\u003cli\u003eVancampfort D, Hallgren M, Firth J, Rosenbaum S, Schuch FB, Mugisha J, et al.. Physical activity and suicidal ideation: A systematic review and meta-analysis. J Affect Disord. 2018;225:438-448. doi: 10.1016/j.jad.2017.08.070.\u003c/li\u003e\n\u003cli\u003ePereira AS, Willhelm AR, Koller SH, Almeida RMM. Risk and protective factors for suicide attempt in emerging adulthood. Cien Saude Colet. 2018;23(11):3767-3777. doi: 10.1590/1413-812320182311.29112016.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"annals-of-general-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"agps","sideBox":"Learn more about [Annals of General Psychiatry](http://annals-general-psychiatry.biomedcentral.com/)","snPcode":"12991","submissionUrl":"https://submission.nature.com/new-submission/12991/3","title":"Annals of General Psychiatry","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Attention-deficit hyperactivity disorder, suicidal ideation, suicidal behavior, suicide attempts, risk factors.","lastPublishedDoi":"10.21203/rs.3.rs-4634231/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4634231/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The association between Attention-deficit hyperactivity disorder (ADHD) and suicidality has been subject of growing interest for research in the latest years. However, suicidality was generally assessed categorically and without validated instruments, which have led to heterogeneous or even conflicting evidence: the prevalence of both suicidal ideation and attempts vary considerably, and risk factors are not clear. Our study investigated suicidality in ADHD using a dimensional approach and a validated and internationally recognized instrument. Our primary aim was to evaluate the prevalence of suicidal ideation (SI), severe suicidal ideation (SSI), suicidal behavior (SB) and non suicidal self-injury behavior (NSSIB) in a sample of adult patients with ADHD. The second objective was to identify sociodemographic and clinical features associated with increased risk of suicidality in these patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The sample included 74 adult patients with clinical diagnosis of ADHD. Suicidality was assessed by administering the Columbia-Suicide Severity Rating Scale. Logistic regressions were used to examine predictors of SI, SSI, SB and NSSIB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe lifetime prevalence of SI and SSI were 59,5% and 16,2%, respectively. The 9,5% of patients showed lifetime SB, while NSSIB was found in 10,8% of the subjects. Lifetime SI was associated with severity of inattentive symptoms during adulthood, low self-esteem and impairment in social functioning. Lifetime SSI appeared related to severity of inattentive symptoms during childhood, attentional impulsiveness and number of hospitalizations, while physical activity appeared to be protective. The prevalence of lifetime SB and NSSIB didn’t appear significantly related to any socio-demographic or clinical feature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eAdults with ADHD are to be considered at risk of suicide and it is important to determine which patients are at higher risk, in order to guide preventive interventions. The association between ADHD and suicidal ideation didn’t appear to be influenced by psychiatric comorbidities, but rather by inattention itself, which represents the core symptom of ADHD.\u003c/p\u003e","manuscriptTitle":"Assessing Suicidality in Adult ADHD Patients: Prevalence and Related Factors ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-19 00:41:51","doi":"10.21203/rs.3.rs-4634231/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-23T15:09:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-25T12:37:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-25T12:34:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"Annals of General Psychiatry","date":"2024-06-25T07:09:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"annals-of-general-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"agps","sideBox":"Learn more about [Annals of General Psychiatry](http://annals-general-psychiatry.biomedcentral.com/)","snPcode":"12991","submissionUrl":"https://submission.nature.com/new-submission/12991/3","title":"Annals of General Psychiatry","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50f6ae87-d89d-4bcc-9032-797cb9948cf9","owner":[],"postedDate":"July 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-04T16:30:29+00:00","versionOfRecord":{"articleIdentity":"rs-4634231","link":"https://doi.org/10.1186/s12991-024-00528-8","journal":{"identity":"annals-of-general-psychiatry","isVorOnly":false,"title":"Annals of General Psychiatry"},"publishedOn":"2024-11-01 16:13:06","publishedOnDateReadable":"November 1st, 2024"},"versionCreatedAt":"2024-07-19 00:41:51","video":"","vorDoi":"10.1186/s12991-024-00528-8","vorDoiUrl":"https://doi.org/10.1186/s12991-024-00528-8","workflowStages":[]},"version":"v1","identity":"rs-4634231","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4634231","identity":"rs-4634231","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}