Two Cases of Suicide Attempt by Patients With Down's Syndrome

Individuals with mental retardation suffer from the full range of psychiatric disorders at a rate higher than that of the general population (1). The presentation of the psychiatric illness may differ somewhat from that of persons of normal intelligence, making assessment difficult. Although significant rates of mental illness have been identified in the mentally retarded population, reports of suicide are extremely rare and rarer still among persons with Down's syndrome (2). This low rate of suicide may be due to several factors linked to cognitive impairment, such as lack of ability to make cognitive connections between the feelings of depression and thoughts to end one's life, poor planning ability, and lack of opportunity because of supervision by family or staff. Due to lack of recognition of the seriousness of such behavior in persons with mental retardation, underreporting of these cases may also occur (1,3).

Cases of suicide attempts among persons with mental retardation have been reported, and four studies of suicide among persons with mental retardation were located. The first study, conducted at a state institution, found a rate of nine suicide attempts per 1,000 patients (4). The second study examined 90 consecutive admissions to an inpatient service for children and adolescents with mental retardation. It found ten patients who showed suicidal behavior, and 60 percent of those acts were potentially lethal (3).

The third study, in a large clinic for persons with mental retardation, identified 12 patients who had made suicide attempts and ten who had suicidal ideation (5). In that study, ingestion of medication, cutting with sharp instruments, suffocation, and ingestion of toxic liquids were the most frequently used methods (5). Last, a study of 204 sudden deaths among patients with mental retardation over a 50-year period in institutions found one suicide, which resulted from jumping off a bridge (6).

Persons with Down's syndrome generally make a good adjustment to community living. However, a wide range of psychiatric disorders has been reported in this population, including anorexia nervosa, phobias, obsessive-compulsive disorder, mood disorders, autism, Tourette's syndrome, and schizophrenia (7,8). A review of case reports of major depressive episodes among persons with Down's syndrome found 15 cases, a high frequency of associated psychotic symptoms, and one patient with suicidal ideation (9). In an outpatient study of 164 adults and 261 children with Down's syndrome, Myers and Pueschel (10) found nine cases of depression; one of these patients had suicidal ideation.

This report describes two cases of potentially lethal suicide attempt by persons with Down's syndrome. Each attempt occurred during a major depressive episode. The two cases were identified in a sample of 19 individuals with Down's syndrome who were evaluated for psychiatric disorder between 1985 and 1995. Both patients lived with their families, received vocational and case management services from a state agency, and experienced a distressing situation as the result of their disability.

Case 1

Mr. A was a 26-year-old man with Down's syndrome whose functioning indicated intelligence in the range of mild mental retardation. He lived with his supportive family and attended a vocational program. Beginning in adolescence, he approached nondisabled young women for dates and was continually rejected. In response, he made suicidal statements and gestures, such as burning himself with a cigarette lighter. At age 26, after a rejection, he jumped from a second-story window but was not seriously injured. His family reported that he had appeared agitated and sad for several months before the attempt and had trouble getting to sleep, and staff of the vocational program reported that he had appeared agitated and unproductive at work.

Mr. A was referred for a psychological evaluation. His full-scale IQ was measured at 62. On the Thematic Apperception Test, he described protagonists as sad, tired, and frustrated, with feelings of hopelessness and thoughts of suicide. He was referred for a psychiatric evaluation, but he declined pharmacotherapy. Subsequently, Mr. A engaged in psychotherapy, where he was able to articulate his belief that a relationship with a woman of his choosing was hopeless due to his having Down's syndrome. He enrolled in social programs for persons with mental retardation, and he made no further suicide attempts while in psychotherapy over the next year.

Case 2

Ms. B was a 25-year-old woman with mild mental retardation. She lived with her mother and attended a vocational program for adults with mental retardation. Ms. B's mother refused to allow her to attend social programs and occasionally kept her from attending the vocational program. Ms. B had many aspirations for a full life and wanted to have a relationship with a man, which her mother thwarted.

Ms. B's depressive illness began at approximately age 22, and her work production was dramatically affected by her increasing agitation and inability to stay focused on her tasks. She cried and appeared sad and sent notes to the staff of the vocational program, stating, for example, "I'm gong to kill myself." Ms. B was assigned a psychotherapist, who referred her for a full psychological evaluation.

Ms. B's full-scale IQ was measured at 56. On the Thematic Apperception Test, she described protagonists who were sad and depressed and considered killing themselves. She articulated her belief that her future was hopeless and that she would never experience a full life, and she reported disturbed sleep during the night. One week after the evaluation, Ms. B ran away from home, went to the town square, and attempted to throw herself in front of a car. The car missed her, the police came to the scene, and returned Ms. B to her home. She was referred for a psychiatric evaluation, and the state disability agency was enlisted to provide her with extensive support services.

Discussion and conclusions

These two patients presented with a major depressive episode and suicide attempts that were potentially lethal. Common themes in the two cases are striking. First, both individuals had Down's syndrome, which is characterized by mental retardation and obvious physical stigmata. Both had a need for adult relationships, which were thwarted by their disability. Mr. A was continually rejected by women of normal intelligence when he approached them for a social relationship. Ms. B was dependent on her mother and was prohibited from attending social programs and at times from attending her vocational program.

Previous reports of depression among persons with Down's syndrome found few reports of suicidal ideation and no reported attempts. This lack of suicidal behavior may be due to limited verbal expression or poor planning ability. In the two cases described here, the patients were articulate about their feelings and carried out suicidal acts.

It is vitally important that mental health practitioners recognize psychiatric disorders among persons with mental retardation and appreciate that patients may experience suicidal ideation and act on these thoughts. Although impaired intellectual ability and poor planning skills may limit the success of plans for suicide, many suicidal acts are impulsive and do not require extensive planning ability.

^{Dr. Hurley} is associate clinical professor of psychiatry at Tufts University School of Medicine. Address correspondence to her at the Department of Psychiatry, No. 1007, Tufts-New England Medical Center, 750 Washington Street, Boston, Massachusetts 02111 (e-mail, [email protected]).