The influence of reported ADHD and substance abuse on suicidal ideation in a non-clinical sample of young men
The influence of reported ADHD and substance abuse on suicidal ideation in a non-clinical sample of young men
Julia Huemer 0 1 2
Anita Riegler 0 1 2
Sabine Völkl-Kernstock 0 1 2
Alexander Wascher 0 1 2
Otto M. Lesch 0 1 2
Henriette Walter 0 1 2
Katrin Skala 0 1 2
0 A. Wascher Yeshiva University , New York , USA
1 Dr. A. Riegler · Prof. O. M. Lesch · Prof. H. Walter Dept. of Psychiatry, University of Vienna , Vienna , Austria
2 Prof. J. Huemer · Dr. S. Völkl-Kernstock · Dr. K. Skala ( ) Dept. of Child and Adolescent Psychiatry, University of Vienna , Waehringer Guertel 18-20, 1090 Vienna , Austria
ADHD; Suicidal Ideation; Substance Abuse; Adolescents
Summary This study intended to determine whether
former and current ADHD symptomatology is
associated with suicidal ideation in a non-clinical sample
of 18 year old males. We performed a cross sectional
descriptive study of 3280 men during the
examination for military service. The investigation included
a screening for substance abuse, past (WURS) and
current (ADHD symptom checklist) ADHD
symptomatology and an interview about suicidal ideations.
We found a correlation of suicidal ideations with
a history of ADHD symptomatology. ADHD
symptoms were strongly consistent over time. These results
indicate that a history of (diagnosed or undiagnosed)
ADHD could be a predictor for suicidal ideations.
Surveying a history of ADHD in primary care might
help identify subjects at risk for suicidal tendencies.
Authors’ contributions: JH and KS were the principal
investigators. They contributed substantially to the study
design, literature search, collection and assembly of data,
data analyses, and data interpretation. OL, AR, and SVK
contributed to the conception and design of the study, the
collection and assembly of data, data analyses, and data
interpretation. JH, AW and HW wrote all drafts and the final
version of the report. All authors had full access to all the
data in the study and take responsibility for the integrity of
the data and the accuracy of the data analysis. All authors
contributed to preparation of the report and approved the
Der Einfluss von geschildertem ADHD und
Substanzmissbrauch auf Suizidgedanken bei
jungen, unbehandelten Männern
Zusammenfassung Im Rahmen dieser
Untersuchung sollten in einer Gruppe 18-jähriger Männer
untersucht werden, ob und inwiefern
anamnestische und gegenwärtige ADHD Symptomatik mit
Suizidgedanken assoziiert sind. In einem deskriptiven
Querschnittsdesign wurden bei 3280 Männern
während ihrer Stellungsuntersuchung ein Screening für
Substanzmissbrauch und ein Interview bezüglich
Suizidgedanken durchgeführt sowie anamnestische
(WURS) und gegenwärtige (ADHD symptom
checklist) erhoben. Es zeigte sich ein Zusammenhang
zwischen Suizidgedanken und dem Vorhandensein von
ADHD-Symptomatik, weiters eine zeitliche Stabilität
von ADHD-Symptomatik. Diese Ergebnisse deuten
darauf hin, dass die Präsenz von (diagnostiziertem
oder undiagnostiziertem) ADHD ein Prädiktor für
Suizidgedanken sein könnte. Die Erhebung einer
ADHD-Anamnese könnte bei der Identifizierung von
Personen mit Suizidimpulsen hilfreich sein.
Schlüsselwörter ADHD · Suizidgedanken ·
Substanzmissbrauch · Jugendliche
Attention Deficit-Hyperactivity Disorder (ADHD) is
a chronic developmental psychiatric disorder
affecting 3–12 % of all children and around 1–6 % of adults
[7, 15, 49]. With core symptoms of inattention,
impulsivity and hyperactivity the condition often leads
to severe social and academic problems [12, 42] thus
The influence of reported ADHD and substance abuse on suicidal ideation in a non-clinical sample of. . .
seriously impairing the lives of those concerned.
A growing body of evidence suggests that ADHD is
a risk factor for premature death caused by accidents,
violence, substance misuse and poor health habits [6,
14, 23]. While factors like a personal or family history
of mental illness or suicide, a personal history of
sexual, physical or verbal abuse or a history of recent loss
are still considered the most important risk factors
for suicidal behavior in youth , ADHD has been
shown to play an important role in the risk of
selfharm or suicide [4, 22, 38, 47]. An increased
prevalence of ideas of death and suicidal ideation  as
well as attempted and completed suicide  in
subjects affected by ADHD has been reported by several
studies. Although it is meanwhile known that ADHD
often persists even in elderly adults , studies on
the association between ADHD and suicidal behavior
among the general adult population have been rare
and inconclusive . While several investigations of
the association between ADHD and suicide suggested
that the relation was at best modest, and primarily
due to ADHD exacerbating the effects of other
comorbid conditions [1, 23], recent studies found that
there was a strong relation between ADHD and
suicide attempts or deaths independent of psychiatric
comorbidity [29, 44].
Suicide is among the leading causes of death
worldwide but the need for diagnosis and treatment of
suicidal behavior is still unmet [19, 36]. Completed
suicide, especially in young people is one of the most
tragic events to be encountered by a person’s
environment. In such cases the question of whether or how
such a deed could have been prevented always arises
but very often remains unanswered. In young adults,
suicidal ideation are obviously a very common event
occurring in up to 44 % of high school students [9, 28,
39]. Although suicide is still most frequent in elderly
people, an increase in suicide rates among younger
people has been observed . A study investigating
suicidal behavior of high school students in Vienna,
Austria, found suicidal ideation at some point in their
lives in as many as 37.9 % of all subjects investigated.
A value matching data of other studies performed on
suicidality in youth [9, 28, 39]. An investigation of
completed suicide in Austrian children and
adolescents between 1946 and 2002 showed a mean suicide
rate of 6.2 per 100,000  with as many as 1.4 per
100,000 suicides in the group of 10 to 14-year-olds
Very little is known about the interaction of ADHD
symptoms and suicidal behavior in young adults. This
group however has to be considered at special risk, as
only about 15 % of young people with attention deficit
hyperactivity disorder (ADHD) make a transition into
an adult psychiatric treatment setting . Also, adult
psychiatrists have only recently directed their
attention to the field of ADHD and adult ADHD services
are sparse or non-existent. Many professionals are
skeptical about the existence of ADHD in adulthood,
and adult psychiatrists most likely do not screen for
ADHD in their patients as child and youth
psychiatrists do in minors . Another reason that puts
young adults with ADHD at special risk is the fact
that young adults are, due to neurobiological
maturation processes, certainly more prone to act
impulsively and are thus more likely to execute suicidal
tendencies than older subjects with a comparable
psychiatric condition .
This investigation set out to examine the
association of ADHD with suicidal ideation in a non-clinical
sample of 18-year-old males. Additionally, we
examined the added effect of comorbid substance use
disorder on rates of suicidal ideation in individuals with
Overview, sample, procedures
In Austria military service is mandatory for all
18year-old males. Conscription of military servicemen is
based on a preliminary psychological and medical
examination of all males who turn 18 in the respectable
year. This investigation includes blood and urine
testing as well as a psychological examination in order to
assess the subject’s fitness and capability to perform
National Service. In order to obtain an unbiased and
representative sample we chose 11 districts including
urban and rural areas, agricultural and industrial
regions, as well as lower and higher income areas.
Data collection has been performed from January
2010 to December 2010 at two of a total of six
recruitment centers for military service in Austria. One of
these centers was located in the province of Tyrol, the
other one in the province of Lower Austria. All male
residents of the selected districts born in 1992, who
were liable to enlistment to the Military Service were
included in the study. Participation in the study was
declined by 60 out of 3340 persons (22 (1.70 %) of 1297
young men from the districts in Tyrol and 38 (1.86 %)
of 2043 subjects in Lower Austria). With a response
rate of 98.20 %, a total 3280 subjects have thus been
enrolled in the investigation. Data were collected
in addition to the standard procedure performed by
Military Service authorities. Our examination was
performed anonymously after the examination for
the Military Service, subjects were aware that no
information they gave would be communicated to the
examiner of the Armed Forces.
Life time prevalence of ADHD was examined using
the Wender Utah Rating Scale (WURS-K) [41, 50], an
instrument designed for the retrospective diagnosis of
attention deficit/hyperactivity disorder in adults.
Current symptoms of ADHD were investigated by means
of the ADHD checklist for adults based on DSM IV .
The frequency of alcohol consumption was reported
according to the question: “Do you drink alcohol?”
(0) I do not drink, (1) less than once a week, (2) once
a week, (3) several times a week, (4) every day. In
addition, the CAGE questionnaire (Cutting down,
Annoyance by criticism, Guilty feeling and Eye-openers)
was used to rate alcohol related behavior. The CAGE
questionnaire  has good sensitivity and specificity
for alcohol dependence . Both alcohol
consumption measures were correlated with r = 0.41, p < 0.001.
Smoking was assessed with the question: “Do you
smoke?” (“Yes” or “No”) followed by the Heavy
Smoking Index (HSI), which consists of two questions:
“How many cigarettes do you smoke per day?”
(“Nonsmoker”, “10 or less”, “11–20”, “21–30” and “31 or
more”) and “When do you smoke your first cigarette
in the morning?” (“Within 5 minutes” “6–30 minutes”
“31–60 minutes” and “After more than 60 minutes”).
Both questions were scored between 0 and 3 and an
HSI-sum score ranging between 0 and 6 was built.
The HSI has been previously validated by plasma and
saliva cotinine, as well as carbon monoxide levels [20,
Illicit drug use
To assess experiences with illicit drugs, the subjects
were asked, “Have you ever consumed one of the
following drugs?” The response options for each
substance (THC, Benzodiazepines, Cocaine, Opiates,
Ecstasy, and other drugs) were: (0) never, (1) once, (2)
several times (3) regularly. Based on these reports,
a dummy variable “drug experience” was build,
representing at least one drug experience during lifetime.
Suicidal ideation was assessed by the question “Have
you ever considered to commit suicide?” with the
response options: (0) never, (1) at some earlier point
in life, (2) last month, (3) last week. A positive
answer (being any answer from 1 to 3) was considered
as lifetime suicidal ideation in further analyses.
To verify reports, GGT, MCV, ALT, AST, were
determined in serum samples as were illicit drugs in urine
samples Carbon monoxide (CO) levels in exhaled air
were determined using a “smokerlyser” (EC50
Smokerlyser; Bedfont Instruments; Kent, UK).
Differences in characteristics between subjects with
and without ADHD symptoms were assessed by
T-tests and Mann–Whitney-U tests for not normally
Regression analyses (adjusted for abuse of
nicotine, alcohol illicit substances and former ADHD) were
used to investigate whether suicidal ideations were
associated with prevalence of ADHD. P-values at the
level of p < 0.05 were considered significant.
Log-linear analysis was performed to determine a possible
synergistic effect of ADHD and drug abuse on
suicidal ideations. Data Analysis was conducted using IBM
SPSS Statistics 21.0 software (SPSS Inc., Chicago, IL).
The sample included 3340 18-year-old males of which
3280 consented to participate in the investigation.
Out of the total sample 2.7 % stated that they have
been treated for ADHD and 1.5 % reported that they
had at one point received pharmacological treatment
for the condition. Concerning WURS, 10.1 % had
a score above the cut-off of >36 indicating past ADHD
symptoms. There was a strong association of former
(WURS) and current (ADHD checklist) symptoms (r =
0,648, p = < 0.001). Alcohol consumption at any rate
was very common (91.4 %) with 19.3 % meeting the
CAGE cut-off score of 2 or higher, indicating an
alcohol problem. Regular smoking was reported by
43.9 %, life time use of cannabis was stated by 19 %.
The prevalence of Cocaine abuse was 2.6 % that of
benzodiazepine abuse was 2.1 %. Unspecific
psychoactive substances have at least once been used
by 1.8 % and opiates by 0.2 % of all participants. For
details also see Table 1.
Suicidal ideation at any time was found in 6.8 % of
all subjects. Former ADHD symptoms (p < 0.001) and
drug abuse (p < 0.001) significantly predicted suicidal
ideations in the subjects investigated. Odds for
suicidal behavior increased with the number of
symptoms. The log-linear analysis determining the
influence of both ADHD an drug abuse on suicidality
produced a model with significant two-way-interactions
between ADHD and suicidal ideas (χ² (1) = 60.54, p <
0.01), between ADHD and drug abuse (χ² (1) = 4.67,
p = 0.03) and between drug abuse and suicidal ideas
(χ² (1) = 20.37, p < 0.01), but no significant
three-wayinteraction (χ² (1) = 0.02, p = 0.89). Alcohol and
Nicotine abuse did not have any significant influence on
suicidality both in subjects with and without ADHD
symptoms (Table 2).
This study examined the association between ADHD
symptoms and suicide ideation in 18-year-old males
during their routing investigation for military service.
Table 1 Sample characteristics
Failed to complete 9th grade
Financial status of family
In this sample we found a proportion of 6.8 %
reporting lifetime suicidal ideations.
An earlier investigation performed in high school
students in the same country  and other studies
performed in youth in Europe found rates of
suicidality between 31 and 44 % [8, 18, 48]. All investigations
mentioned above were using self-administered
interviews completed anonymously so these differences
cannot be explained by different levels of openness.
Subjects investigated had also been informed that
military authorities would not gain insight in any of the
results of the questionnaires completed in the
framework of our investigation, so preoccupation about the
outcome of their investigation by the armed forces
is not likely to impair openness either. A possible
explanation however is that subjects in our sample
were older than in the above mentioned studies and
probably approaching lower values, which are
usually found in adults . This idea is supported by
the fact that an investigation in a comparable group
of non-clinical young adults found a rate of lifetime
suicidal ideations of 12.5 % . This generally
observable decline of lifetime suicidal ideation with age
can probably be explained by a recall bias or a neglect
Table 2 Influence of different factors on suicidal ideations
during 12 months prior to examination
Prevalence of suicidal ideation
95 % CI for Odds Ratio
*p < 0.05; **p < 0.01; ***p < 0.001, R2 = 0.11 (Cox & Snell), 0.27
(Nagelkerke), Model χ2(5) = 113.61, p < 0.01
of suicidal thoughts that might have occurred earlier
Clinically relevant former ADHD symptoms were
found in 10 %, which can be considered comparable
to the percentage estimated for the general population
. About one third of the subjects that seemingly
fulfilled ADHD criteria has actually been diagnosed
with ADHD and received treatment for the condition
and roughly half of those who had undergone
treatment had been prescribed medication. Lifetime use of
alcohol (91.4 %) as well as problem drinking (19.3 %)
was consistent with the prevalence in the general
population as was the use of illicit substances.
Regular smoking was, however, more frequent than
expected (43.9 %). Logistic regression analysis showed
that there was a positive and statistically significant
relation between lifetime suicide ideation and former
ADHD symptoms as well as between suicide ideation
and abuse of illicit drugs.
Concerning substance abuse, we were surprised
not to find an association of smoking or alcohol
consumption and suicidal ideation. Abuse of these
substances has been identified as independent risk
factors for the development of suicidal behavior [9,
52]. While the strong association of drug abuse with
suicidal thoughts found in our sample is consistent
with other findings , we do not have an
explanation for the missing influence of nicotine and alcohol
on suicidal tendencies.
It has recently been suggested that ADHD is
associated with a small but definite increase in the risk of
suicide [1, 35]. Mortality rates significantly depended
on age at first ADHD diagnosis. People diagnosed with
ADHD in adulthood had a greater risk of premature
death than those diagnosed in childhood and
adolescence . This finding could be caused by the fact that
persistent ADHD represents a more severe form of the
disorder. An elevated risk for suicidal tendencies
during early adulthood could also be explained by a
reduction or weaning of stimulant medication, which
is also common during adolescence . As
adolescence and early adulthood can be considered times of
great risk for the development of suicidality especially
during psychosocial stress , this obviously
concerns individuals affected by ADHD to an even greater
extent. Some studies, however, that were examining
the association between ADHD and suicidal behavior
among the general adult population have found an
association with suicidal tendencies that was only weak
to moderate and also considered comorbid mental
disorders to play an important role in the
development of suicidal behavior . While methodological
differences between investigations on suicidality and
ADHD render comparability of many studies difficult,
two recent investigations examining the connection
of ADHD and suicidal ideations in large samples of
the general population both found that adults with
more ADHD symptoms had significantly higher odds
for suicidal behavior, the risk remaining substantial
even after adjusting for comorbid disorders [29, 44].
In our sample, former, but not current ADHD
syndrome correlated with an increased risk of suicidal
thoughts. This might be explained by the fact that
subjects scoring positive for childhood ADHD might
suffer from a more pronounced form of the disease. It
is also important to bear in mind that of all subjects
scoring positive for childhood ADHD, only less than
one third has been diagnosed with the disease.
Therefore, fulfilling the diagnostic criteria in this sample is
not equivalent with ever having been diagnosed with
In consideration of possible reasons for the
connection of ADHD and suicidal thoughts in young
adults, the trait of impulsiveness  might be
crucial. Impulsiveness is the tendency to act quickly
without prior thought and with little regard for the
consequences. It is one of the central components
in ADHD [3, 33] but has also been described to be
associated with an increased risk for suicidal behavior
. Cyclothymic temperament as another possible
link is highly prevalent in adults with ADHD  and
has also been shown to correlate with suicidal
tendencies . Self-directedness, reward dependence,
persistence and cooperativeness as features
commonly associated with a resilient profile negatively
correlate with ADHD .
Currently, a trend towards the revision of nosologic
criteria and deconstruction of global assessments of
ADHD into component subtypes can be observed
 by elaborating subgroups and focusing on
specific traits, identification of subjects at risk for suicidal
tendencies amongst those affected by ADHD might
cide prevention in subjects suffering from ADHD is
limited. The finding that young adults in the general
population with a history of ADHD have an increased
risk for suicide ideation has several implications. On
the one hand prospective studies on the interaction
of ADHD and suicidal behavior in order to better
understand the relationship between ADHD and suicidal
behavior in this age group are needed. On the other
hand, preventive strategies focusing on young adults
with a history of ADHD ought to be established.
Limitations and strengths
As always, the results of this study must be interpreted
in the context of several limitations. Firstly, the
sample consists of men only. Secondly, as subjects had to
be fit enough to perform military service, men with
severe mental or physical disorders were excluded, thus
generating a possible bias towards the inclusion of
subjects healthier than in the general population.
Finally, the cross-sectional study design does not allow
making conclusions about the temporal relationships
between ADHD symptoms and suicidality.
In terms of strengths our sample is highly
representative including 6.8 % of all males born in
Austria in 1992 all 18-year-old males of the respective
areas fit enough to be enlisted for military service.
Districts of investigation were carefully chosen in
order to obtain an unbiased and representative
sample. All subjects were rated by one single person,
who was very experienced in all questionnaires
applied. We have employed widely used questionnaire
instruments with recognized reliability and validity.
Reports on substance use were verified by
examination of blood, urine and breath.
Compliance with ethical guidelines
Conflict of interest J. Huemer, A. Riegler, S. Völkl-Kernstock,
A. Wascher, O. M. Lesch, H. Walter, and K. Skala declare that
they have no competing interests.
Ethical standards Ethical approval was obtained from the
Ethics Committee of the Medical University of Vienna as well
as the Ethics Committee of the Austrian Armed Forces.
Informed consent was obtained from each participant.
Open Access This article is distributed under the terms of
the Creative Commons Attribution 4.0 International License
permits unrestricted use, distribution, and reproduction in any
medium, provided you give appropriate credit to the
original author(s) and the source, provide a link to the Creative
Commons license, and indicate if changes were made.
Although suicide prevention programs and research
on factors contributing to suicidal behavior have been
extensive for many decades, current research on
1. Agosti V , Chen Y , Levin FR . Does attention deficit hyperactivity disorder increase the risk of suicide attempts ? J Affect Disord . 2011 ; 133 : 595 - 9 .
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders , 4th ed. Arlington: American Psychiatric Publishing; 2000 .
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders , 5th ed. Arlington: American Psychiatric Publishing; 2013 .
4. Balazs J , Miklosi M , Kereszteny A , Dallos G , Gadoros J. Attention-deficit hyperactivity disorder and suicidality in a treatment naïve sample of children and adolescents . J Affect Disord . 2014 ; 152 - 154 : 282 - 7 .
5. Bradley KA , Kivlahan DR , Bush KR , McDonell MB , Fihn SD . Variations on the CAGE alcohol screening questionnaire: strengths and limitations in VA general medical patients . Alcohol Clin Exp Res . 2001 ; 25 ( 10 ): 1472 - 8 .
6. Dalsgaard S , Østergaard SD , Leckman JF , Mortensen PB , Pedersen MG . Mortality in children, adolescents, andadults with attention deficit hyperactivity disorder: a nationwide cohort study . Lancet , 2015 ; S0140 - 6736 ( 14 ): 61684 - 6 .
7. Das D , Cherbuin N , Easteal S , Anstey KJ. Attention Deficit/ Hyperactivity Disorder symptoms and cognitive abilities in the late-life cohort of the PATH Through life study . PLoSOne , 2014 ; 9 ( 1 ) :28; e .vol 86552.
8. Dervic K , Akkaya-Kalayci T , Friedrich MH , Csorba J , Tringer L , Rozsa S , Lenz G. Attitudes toward suicide and helpseeking in Hungarian adolescents . J Am Acad Child Adolesc Psychiatry . 2005 ; 44 ( 7 ): 628 - 9 .
9. Dervic K , Akkaya-Kalayci T , Kapusta DN , Kaya M , Merl E , Vogel E , Pellegrini E , FriedrichMH. Suicidal ideation among Viennese high school students . Wien Klin Wochenschr . 2007 ; 119 ( 5-6 ): 174 - 80 .
10. Dervic K , Friedrich E , Oquendo MA , Voracek M , Friedrich MH , Sonneck G . Suicide in Austrian children and young adolescents aged 14 and younger . Eur Child Adolesc Psychiatry . 2006 ; 15 ( 7 ): 427 - 34 .
11. Dervic K , Friedrich E , Prosquill D , Kapusta ND , Lenz G , Sonneck G , Friedrich MH . Suicide among Viennese minors , 1946 - 2002 . Wien Klin Wochenschr . 2006 ; 118 ( 5-6 ): 152 - 9 .
12. Ekinci S , Oncu B , Canat S. Adult Attention deficit hyperactivity disorders: comorbidity and functioning . Anatolian J Psychiatry . 2011 ; 12 : 185 - 91 .
13. Ewing JA . Detecting alcoholism . The CAGE questionnaire. J Am Med Assoc . 1984 ; 252 : 1905 - 7 .
14. Faraone SV . Attention deficit hyperactivity disorder and premature death . Lancet . 2015 ; 385 ( 9983 ): 2132 - 3 .
15. Faraone SV , Sergeant J , Gillberg C , Biederman J. The worldwide prevalence of ADHD: is it an American condition? World Psychiatry . 2003 ; 2 ( 2 ): 104 - 13 .
16. Furczyk K , Thome J. Adult ADHD and suicide. Atten Defic Hyperact Disord 2014 ; 6 ( 3 ): 153 - 8 .
17. Galvan A , Rahdar A. The neurobiological effects of stress on adolescent decision making . Neuroscience . 2013 ; 26 ( 249 ): 223 - 31 .
18. Gmitrowicz A , Szymczak W , Kropiwnicki P , Rabe-Jabłon ´ ska J. Gender influence in suicidal behaviour of Polish adolescents . Eur Child Adolesc Psychiatry 2003 ; 12 ( 5 ): 205 - 13
19. Hawton K , Van Heeringen K. Suicide . Lancet. 2009 ; 373 ( 9672 ): 1372 - 81 .
20. Heatherton TF , Kozlowski LT , Frecker RC , Rickert W , Robinson J. Measuring theheavinessof smoking: using selfreported time to the first cigarette of the day and number of cigarettes smoked per day . Br J Addict . 1989 ; 84 : 791 - 9 .
21. Heatherton TF , Kozlowski LT , Frecker RC , Fagerstrom KO . The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire . Br J Addict . 1991 ; 86 : 1119 - 27 .
22. Impey M , Heun R. Completed suicide, ideation and attempt in attention deficit hyperactivity disorder . Acta Psychiatr Scand . 2012 ; 125 ( 2 ): 93 - 102 .
23. James A , Lai FH , Dahl C. Attention deficit hyperactivity disorder and suicide: a review of possible associations . Acta Psychiatr Scand . 2004 ; 110 ( 6 ): 408 - 15 .
24. Kapusta ND , Pietschnig J , Plener PL , Blüml V , Lesch OM , Walter H. Does breath carbon monoxide measure nicotine dependence ? J Addict Dis . 2010 ; 29 ( 4 ): 493 - 9 .
25. Karalunas SL , Fair D , Musser ED , Aykes K , Iyer SP , Nigg JT . Subtyping attention-deficit/hyperactivity disorder using temperament dimensions: toward biologically based nosologic criteria . JAMA Psychiatry . 2014 ; 71 ( 9 ): 1015 - 24 .
26. Kessler RC , Borges G , Walters EE . Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey . Arch Gen Psychiatry . 1999 ; 56 ( 7 ): 617 - 26 .
27. Landaas ET , Halmoy A , Oedegaard KJ , Fasmer OB , Haavik J. The impact of cyclothymic temperament in adult ADHD . J Affect Disord . 2012 ; 142 ( 1-3 ): 241 - 7 .
28. Liu X , Tein JY , Zhao Z , Sandler IN. Suicidality and correlates among rural adolescents of China . J Adolesc Health . 2005 ; 37 ( 6 ): 443 - 51 .
29. Ljung T , Chen Q , Lichtenstein P , Larsson H. Common etiological factors of attention-deficit/hyperactivity disorder andsuicidalbehavior: apopulation-basedstudyinSweden . JAMA Psychiatry . 2014 ; 71 : 958 - 64 .
30. Mann J , Oquendo M , Underwood M , Arango V. The neurobiology of suicide risk: a review for the clinician . J Clin Psychiatry . 1999 ; 60 (Suppl2): 7 - S11 .
31. Melegari MG , Nanni V , Luicidi F , Russo PM , Donfrancesco R , Cloninger CR . Temperamental and character profiles of preschool children with ODD, ADHD, and anxiety disorders . Compr Psychiatry . 2015 ; 58 : 94 - 101 .
32. Michielsen M , Semeijn E , ComijsHC, van deVen P , Beekman AT , Deeg DJ , Kooij JJ . Prevalence of attention-deficit hyperactivity disorder in older adults inTheNetherlands . Br J Psychiatry . 2012 ; 201 : 298 - 305 .
33. Moeller F , Barratt E , Dougherty D , Schmitz J , Swann A. Psychiatric aspects of impulsivity . Am J Psychiatry , 2001 ; 158 : 1783 - 93 .
34. National Collaborating Centre for Mental Health . Attention deficit hyperacitivty disorder - the guideline on diagnosis and management of ADHD in children, young people and adults . Great Britain: The British Psychological Society and The Royal College of Psychiatrists: NICE ; 2009 .
35. Nigg JT . Attention deficits and hyperactivity-impulsivity: what have we learned , what next? Dev Psychopathol 2013 ; 25 : 1489 - 503 .
36. Nock MK , Borges G , Bromet EJ , Cha CB , Kessler RC , Lee S. Suicide and suicidal behavior . Epidemiol Rev . 2008 ; 30 : 133 - 54 .
37. Ogundele MO , Omenaka IL. An audit of transitional care for adolescents with ADHD in a North West England district . Arch Dis Child . 97 (Suppl. 1): A129 - A129 .
38. Patros CH , Hudec KL , Alderson RM , Kasper LJ , Davidson C , Wingate LR . Symptoms of attention-deficit/hyperactivity disorder (ADHD) moderate suicidal behaviors in college students with depressed mood . J Clin Psychol . 2013 ; 69 ( 9 ): 980 - 93 .
39. Payci SO , Ergin A , Saatci E , Bozdemir N , Akpinar E , Ergun G. Suicidal thought and behavior in high school students in Adana . Turkey Coll Antropologicum . 2005 ; 29 ( 2 ): 527 - 31 .
40. Poorolajal J , Haghtalab T , Farhadi M , Darvishi N. Substance use disorder and risk of suicidal ideation, suicide attempt and suicide death: a meta-analysis . J Public Health . 2015 . [Epub ahead of print] doi:10.1093/pubmed/fdv148.
41. Retz-Junginger P , Retz W , Blocher D , Stieglitz RD , Georg T , Supprian T , et al. Reliability and validity of the WenderUtah-Rating-Scale short form. Retrospective assessment of symptoms for attention deficit/hyperactivity disorder . Nervenarzt . 2003 ; 11 : 987 - 93 .
42. Seidman LJ , Biederman J , Weber W , Hatch M , Faraone SV . Neuropsychological function in adults with attention-deficit hyperactivity disorder . Biol Psychiatry . 1998 ; 44 : 260 - 8 .
43. Skala K , Kapusta ND , Schlaff G , Unseld M , Erfurth A , Lesch OM . et al. Suicidal ideation and temperament: an investigation among college students . J Aff Disord . 2012 ; 141 ( 2-3 ): 399 - 405 .
44. Stickley A , Koyanagi A , Ruchkin V , Kamio Y. Attentiondeficit/hyperactivity disorder symptoms and suicide ideation and attempts: Findings from the Adult Psychiatric Morbidity Survey 2007 . J Affect Disord . 2016 ; 189 : 321 - 8 .
45. Center SPR . Promoting Mental Health and Preventing Suicide in College and University Settings . Education Development Center. Inc Newton Ma . 2004 ; 1 : 5 - 27 .
46. Swift KD , Sayal K , Hollis C. ADHD and transitions to adult mental health services: a scoping review . Child Care Health Dev . 2014 ; 40 : 775 - 86 .
47. Taylor MR , Boden JM , Rucklidge JJ . The relationship between ADHD symptomatology and self-harm, suicidal ideation, and suicidal behaviours in adults: a pilot study . Atten Defic Hyperact Disord . 2014 ; 6 ( 4 ): 303 - 12 .
48. Tomori M , Zalar B , Kores Plesnicar B , Ziherl S , Stergar E. Smoking in relation to psychosocial risk factors in adolescents . Eur Child Adolesc Psychiatry 2001 ; 10 ( 2 ): 143 - 50 .
49. Turkyilmaz E , Yavuz BG , Karamustafalioglu O , Ozer OA , Bakim B. Prevalence of adult attention deficit hyperactivity disorder in therelatives of patients withbipolar disorder . Int J Psychiat Clin . 2012 ; 16 : 223 - 8 .
50. Ward MF , Wender PH , Reimherr FW . The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder . Am J Psychiatry . 1993 ; 150 ( 6 ): 885 - 90 .
51. Wasserman D , Cheng Q , Jiang GX . Global suicide rates among young people aged 15-19 . World Psychiatry . 2005 ; 4 ( 2 ): 114 - 20 .
52. Yoshimasu K , Kiyohara C , Miyashita K. Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies . Environ Health Prev Med 2008 ; 13 ( 5 ): 243 - 56 .