Sleep, depression, and suicide

Associations between multiple sleep dimensions and suicide and non-suicidal self-injury: a cross-sectional study of 3828 Chinese young people

PURPOSE

Suicide and non-suicidal self-injury (NSSI) are preventable concerns in young people. Suicidal ideation (SI), suicidal plans (SP) and suicidal attempt (SA) are closely related to death. Sleep problems are known risk factors for suicide and NSSI. This study aimed to explore the relationship between sleep, suicidality and NSSI.

METHODS

Participants were 3,828 middle school and college students aged 11-23 years from urban and rural areas of Henan Province. Sleep, suicidal phenomena and NSSI were assessed by applying self-reported questionnaires. Chi-squared tests were utilized to demonstrate the demographic data and sleep variables. The correlation between sleep, suicidality and NSSI were explored by using binary logistic regression, while adjusting socio-demographic characteristics with multivariate models.

RESULTS

Sleep variables except mid-sleep time were related to suicidal phenomena (P < 0.05). Greater social jet lag (SJL) [≥ 2 h (h)] was associated with increased risk of SI [Odds ratios (OR) = 1.72, 95% confidence intervals (CI):1.40-2.11], SP (OR = 2.10, 95%CI:1.59-2.79) and SA (OR = 1.50, 95%CI:1.00-2.26). Non-only child participants with SJL (≥ 2 h) had significantly increased odds of SI (OR = 1.75, 95%CI: 1.41-2.18) and SP (OR = 2.25, 95%CI: 1.66-3.05). Eveningness chronotype had the strongest correlation with SI (OR = 3.87, 95%CI:2.78-5.38), SP (OR = 4.72, 95%CI:2.97-7.50), SA (OR = 6.69, 95%CI:3.08-14.52) and NSSI (OR = 1.39, 95%CI:1.02-1.90).

CONCLUSION

Overlong or short sleep duration, SJL, eveningness chronotype and other sleep abnormalities (e.g., daytime dysfunction, low sleep efficiency) were associated with a higher prevalence of SI, SP and SA. Additionally, eveningness was significantly correlated with NSSI among young people. These findings suggested the importance of assessing and intervening in sleep habits to prevent suicide and NSSI in young people.

Sleep duration has a limited impact on the prevalence of menstrual irregularities in athletes: a cross-sectional study

Background

This study aimed to investigate the relationship between the prevalence of menstrual irregularities, energy intake, and sleep deprivation among female athletes.

Methods

A total of 128 female athletes, with an average age of 19.2 ± 1.2 years, participated in the study and tracked their food intake over a three-day period. Menstrual status and sleep duration were assessed using a questionnaire, and psychological anxiety was evaluated using the State and Trait Anxiety Inventory (STAI). These were measured once during the investigation. The impact of sleep status on state anxiety and daily energy intake was examined using the T-test. A generalized linear model (GLM) with a log link function was employed to investigate the effects of sleep deprivation on the presence of menstrual irregularities.

Results

As the results of the present study, sleep deprivation significant increased both state and trait anxiety (p < 0.05), as well as affecting energy intake (p < 0.05), particularly protein and carbohydrate intakes (p < 0.05). However, GLM analysis indicated that while sleep deprivation did not directly influence the prevalence of menstrual irregularities (p > 0.05), state anxiety emerged as a significant factor impacting the prevalence of menstrual irregularities (p < 0.05).

Conclusions

The results of the present study suggest a potential pathway wherein sleep deprivation might elevate state anxiety levels, consequently indirectly contributing to an increase the probability of menstrual irregularities. In conclusion, the results of the presents study provide novels insights suggesting that sleep deprivation might directly increase state anxiety and indirectly affect the prevalence of menstrual irregularities. Hence, decreased sleep duration might be related to mental health issues and the prevalence of menstrual irregularities both significant concerns among female athletes. Future studies will play a crucial role in further elucidating how sleep patterns impact the health and well-being of female athletes.

Sleepy and grumpy go hand in hand for US Navy Sailors

Study Objectives

The study explores how sleep, sleep-related practices, and behaviors, in addition to various demographic and occupational characteristics, are related to overall mood of US Navy sailors when they are underway.

Methods

Longitudinal assessment of US Navy sailors performing their underway duties (N = 873, 79.2% males, median age 25 years). Participants completed standardized questionnaires, wore wrist-worn actigraphs, and completed daily activity logs.

Results

Sailors who reported worse profile of mood states (POMS) total mood disturbance scores had shorter sleep duration, worse sleep quality, and more episodes of split sleep. The group with worse mood also reported more symptoms of excessive daytime sleepiness as well as more symptoms of insomnia. In addition to sleep results, sailors with worse mood also tended to be younger, more likely to use nicotine and tobacco products, and less likely to have an exercise routine when compared to sailors with better POMS scores. Finally, the group with worse POMS scores included more enlisted personnel, tended to work more hours per day, and were more likely to stand watch-especially on rotating watch schedules.

Conclusions

The results found significant associations between the sleep practices and mood of sailors aboard US Navy ships. Numerous other demographic and occupational factors were also strongly associated with mood. This paper is part of the Sleep and Circadian Rhythms: Management of Fatigue in Occupational Settings Collection.

Objective sleep markers of suicidal behaviors in patients with psychiatric disorders: A systematic review and meta-analysis

Close relationships have been reported between sleep alterations and suicidal behaviors, nevertheless few studies used objective measures of sleep. Such objective markers would be interesting in clinical practice to better screen and prevent suicide. We conducted a systematic review and meta-analysis of published studies examining the relationship between sleep markers and suicidal behaviors using PubMed, Cochrane Library, and Web of Science databases. Actigraphy, polysomnography, and nocturnal EEG were considered. The qualitative analysis retained 15 original studies, including 1179 participants (939 with a psychiatric disorder), and 11 studies were included for the meta-analysis. Current suicidal behaviors were associated with a decreased total sleep time (TST) (SMD = -0.35, [95% CI: -0.66 to -0.04], p = 0.026, I² = 39.8%). The evaluation of possible moderators shows that age, gender, and depression scores had no effects on the random effect model. No significant differences were observed regarding sleep efficiency, REM latency, or percentage of REM sleep. In conclusion, among candidate objective markers, decreased total sleep time seems associated with suicidal behaviors and could be easily used to assess suicide risk. Alterations of regular sleep duration should invite healthcare professionals to screen the cause and propose sleep interventions to prevent suicide.

Sleep disturbance and suicide risk among sexual and gender minority people

Sleep disturbance has emerged as an independent, mechanistic, and modifiable risk factor for suicide. Sexual and gender minority (SGM) people disproportionately experience sleep disturbance and are at higher risk of death by suicide relative to cisgender and/or heterosexual individuals. The present narrative review evaluates nascent research related to sleep disturbance and suicide-related thoughts and behaviors (STBs) among SGM populations, and discusses how experiences of minority stress may explain heightened risk among SGM people. Although there is a growing understanding of the link between sleep disturbance and STBs, most research has not been conducted in SGM populations or has not examined suicide as an outcome. Research is needed to examine whether and how aspects of sleep disturbances relate to STBs among SGM people in order to better tailor sleep treatments for SGM populations.

Patterns of sleep disturbances and associations with depressive symptoms in autistic young adults

Autistic individuals are at an increased risk for both sleep disturbances and depression. While studies in the general population and in autistic adults have drawn general links between sleep disturbances and mental health, few studies have examined the extent to which specific sleep problems may be implicated in the extremely high rates of depression among autistic adults. This study aimed to describe the patterns of sleep disturbances in autistic young adults, and their associations with depressive symptoms while controlling for relevant demographic factors. A sample of 304 legally independent adults (age 18-35 years old) with a childhood diagnosis of autism spectrum disorder self-reported on their average sleep behaviors during the past week and depressive symptoms on the Beck Depressive Inventory-II. A significant proportion (86.01%) of autistic young adults experienced at least one of the primary sleep disturbances of interest, including short total sleep time (39.59%), poor sleep efficiency (60.07%), and delayed sleep phase (36.18%). Additionally, lower sleep efficiency and delayed sleep phase were both associated with higher depressive symptoms. The associations between sleep and depressive symptoms identified in our study suggest that sleep treatments may hold potential for ameliorating depressive symptoms in autistic adults who also experience sleep problems. Further research using daily sleep diaries and objective measures of sleep behaviors, as well as longitudinal studies, are needed to understand how changes in sleep may relate to changes in depressive symptoms in autistic adults.

Self-reported sleep and exercise patterns in patients admitted with suicidal attempts: a cross-sectional comparative study

BACKGROUND

There is evidence that sleep disturbances and exercise are risk factors for suicide attempts; however, whether sleep disturbances are independently associated with suicide attempts is debatable. We compared the sleep and exercise patterns of individuals who attempted suicide to those of the general population and investigated whether sleep disturbances were independently associated with suicide attempts.

METHODS

Over a year, individuals presented to the emergency department at Hamad General Hospital and Mental Health Services in Doha with suicide attempts (n = 127) filled out questionnaires on sleep and exercise, demographics, and clinical measures. A control group (n = 126) from two primary care centers filled out the same questionnaires during the same period.

RESULTS

Subjects in the suicide group were significantly younger, single, had a lower level of education, and showed considerably more early insomnia, daytime tiredness, interrupted sleep, and no regular exercise. The most common diagnoses seen with suicidality were adjustment disorder and major depression, and the most common method used to attempt suicide was an overdose. After multiple regression analysis, being Arab, belonging to the category "other nationalities," unemployment, and early insomnia were significantly associated with an increased risk of suicide attempts.

CONCLUSION

This is the first comparative study on suicide in the Arabian Gulf. Individuals in Qatar with acute stress, depressive symptoms, sleep disturbances, and lack of exercise are at increased risk of attempting suicide. Thus, clinicians need to routinely screen for sleep and physical activity because of their significant contribution to physical and mental well-being.

Sleep in Young People With Features of Borderline Personality Disorder: A Scoping Review

Sleep disturbance is commonly reported in young people with features of borderline personality disorder (BPD). Examining sleep quality and sleep-wake patterns in young people with features of BPD is essential to inform the development of sleep-improvement interventions. A scoping review was conducted according to the Joanna Briggs Institute methodology. The objectives were to map the literature regarding sleep in young people with features of BPD, highlight areas for further investigation, and provide methodological recommendations for future research. Seven data sets were included in the review. Young people with features of BPD had poorer objective and subjective sleep quality, disturbed sleep architecture (particularly rapid-eye-movement sleep), an increased vulnerability to delayed sleep phase syndrome, and more nightmares and dream anxiety, compared with healthy individuals. Future research should use both objective and subjective sleep measures, include clinical comparison groups, and focus specifically on young people with BPD.

Polysomnographic markers of suicidal ideation in untreated unipolar major depressed individuals

Given the major role played by sleep in the particular relationship between suicidality and major depression, the aim of this study was to empirically identify polysomnographic markers specific to suicidal ideation in major depressed individuals in order to allow better suicide prevention in this high-risk subpopulation. Demographic and polysomnographic data from 190 individuals (34 healthy controls and 156 untreated unipolar major depressed individuals) recruited from the sleep laboratory database were analysed. Suicidal ideation were considered present if the score in item G of the Beck Depression Inventory was ≥1 and/or if they were highlighted during the systematic psychiatric assessment conducted on admission to the sleep laboratory. Independently of depression severity, major depressed individuals with suicidal ideation present a decrease in deep NREM sleep (slow-wave sleep) and an increase in light NREM sleep (stage 1 + stage 2) compared to those without suicidal ideation. There are no significant differences for the other polysomnographic parameters. In our study, we highlighted the existence of potential polysomnographic markers of suicidal ideation in untreated unipolar major depressed individuals, which seems to open up new perspectives for the identification and management of individuals at high-risk of suicide in this particular subpopulation.

Assessing the impacts of ALAN and noise proxies on sleep duration and quality: evidence from a nation-wide survey in Israel

Sleep is a reversible state that sustains physiological and psychological processes in humans. As well established, individual-level factors, such as stress, smoking, drugs, and caffeine intake, reduce sleep duration and quality. However, studies of the effect of environmental risk factors, such as artificial light at night (ALAN) and noise, on sleep have been infrequent. Using records obtained from the 2017 Social Survey of Israel and combined with ALAN satellite data and various proxies for traffic noise, the present study aimed to determine how the combination of ALAN and traffic noise impact sleep duration and quality in urban areas. The increase of road density at the place of residence reduces average sleep duration by ~4.5% (~18 min.) and increases the frequency of reported sleep difficulties by ~3.5%, all other factors held equal. Similarly, an increase in ALAN exposure reduces average sleep duration by ~3% (~12 min) and increases the frequency of reported sleep difficulties by ~11%. The study also reveals a significant interaction between the two environmental risk factors in question, with the adverse impact of ALAN on sleep quality especially pronounced in high noise exposure areas.

Depression and suicidal thoughts in untreated and treated narcolepsy: Systematic analysis

OBJECTIVES

To assess the frequency and determinants of depressive symptoms and suicidal thoughts in adults with narcolepsy type 1 (NT1) and controls, as well as the changes after NT1 management and the risk factors of major depressive episode (MDE) and suicide risk (SR) in NT1.

METHODS

Two hundred ninety-seven patients with NT1 (age 39 ± 17 years, 172 drug-free) and 346 controls (age 38 ± 16 years) underwent a comprehensive clinical evaluation including the Beck Depression Inventory-II (BDI-II) self-questionnaire, with 1 item on suicidal thoughts. One hundred one drug-free patients with NT1 completed the BDI-II a second time during treatment. In 162 patients with NT1, the face-to-face Mini International Neuropsychiatric Interview was performed to formally diagnose current MDE and SR.

RESULTS

BDI-II total scores were higher in patients with NT1 than controls and in untreated than treated patients. Patients with moderate to severe BDI-II scores (24.9%) were less educated, were more frequently obese, and had more severe narcolepsy symptoms, more autonomic dysfunctions, and poorer quality of life. Results were unchanged in models adjusted for NT1 medication intake. Suicidal thoughts were more frequent in untreated patients than controls (22.7% vs 12.4%). Patients with suicidal thoughts were more likely to be men and to have more severe narcolepsy symptoms. After narcolepsy management, BDI-II total score and suicidal thoughts decreased. MDE was diagnosed in 29 (18.1%) and SR in 27 (16.9%) patients.

CONCLUSIONS

Depression, depressive symptoms, suicidal thoughts, and SR were frequent in patients with NT1, especially those without treatment, and were associated with NT1 severity. Depressive symptoms and suicidal thoughts improved after NT1 management.

Clarifying the role of sleep in depression: A narrative review

It has been established that 4.4 to 20% of the general population suffers from a major depressive disorder (MDD), which is frequently associated with a dysregulation of normal sleep-wake mechanisms. Disturbances of circadian rhythms are a cardinal feature of psychiatric dysfunctions, including MDD, which tends to indicate that biological clocks may play a role in their pathophysiology. Thus, episodes of depression and mania or hypomania can arise as a consequence of the disruption of zeitgebers (time cues). In addition, the habit of sleeping at a time that is out of phase with the body's other biological rhythms is a common finding in depressed patients. In this review, we have covered a vast area, emerging from human and animal studies, which supports the link between sleep and depression. In doing so, this paper covers a broad range of distinct mechanisms that may underlie the link between sleep and depression. This review further highlights the mechanisms that may underlie such link (e.g. circadian rhythm alterations, melatonin, and neuroinflammatory dysregulation), as well as evidence for a link between sleep and depression (e.g. objective findings of sleep during depressive episodes, effects of pharmacotherapy, chronotherapy, comorbidity of obstructive sleep apnea and depression), are presented.

Objective measurement of sleep, heart rate, heart rate variability, and physical activity in suicidality: A systematic review

BACKGROUND

Emerging literature suggests that the arousal and regulatory systems as measured by sleep-wakefulness, heart rate (HR) and heart rate variability (HRV) may be powerful objective warning signs of suicidality. However, there is no systematic literature review examining the association between objective measurements of these variables with suicide and suicidal behavior.

METHODS

A web-based, systematic literature search using PubMed and EMBASE was conducted for articles that measured sleep-wakefulness and HR/HRV quantitatively in association with suicide. Search results were limited to human subjects and articles published in peer-reviewed journals in English. There were no restrictions for age, sex, settings and durations of measurements, types of mental illnesses, or comorbidity.

RESULTS

Twenty-three studies were included in the current systematic review. Across the studies, consistent patterns of disturbed sleep-wakefulness such as greater sleep onset latency and lower sleep efficiency were related to suicide. In addition, higher HR and lower variance of R-R intervals was an indicator of risk of suicide.

LIMITATIONS

Studies that used different equipment for sleep studies (i.e., polysomnography, electroencephalogram, actigraphy) were combined, and potential differences in their findings due to the different equipment were not considered.

CONCLUSIONS

Findings provide initial evidence for consistent patterns of sleep-wakefulness and HR/HRV possibly associated with suicidality; however, more studies are needed in order to identify the precise objective variables (e.g., sleep onset latency, high-frequency HRV), as well as time-varying patterns in these variables, that are related to acute suicide risk.

Current and future strategies for insomnia management

Different forms of insomnia are present as symptoms of many psychiatric and other disorders. The first step for a treatment strategy is therefore a correct diagnosis. As insomnia is more common in patients with psychiatric disorders than in the general population, a careful consideration should be given, depressive and anxiety disorders should especially be carefully investigated. There are reasons to believe that even in so-called insomnia not obviously related to psychiatric disorders, stressful life situations may play a role. Therefore a co-morbidity with emotional disorders which may follow these events is worth considering. Insomnia should always be considered as pan of a sleep-wake schedule disturbance and this has an impact on the importance of the pharmacological properties of the drugs used to treat insomnia. The recent trend for more specific agents both on receptor sub-populations and on relevant sites of the GABA receptor complex will help very much in selecting the most appropriate drug for treating patients.

Integrating sleep, neuroimaging, and computational approaches for precision psychiatry

In advancing precision psychiatry, we focus on what imaging technology and computational approaches offer for the future of diagnostic subtyping and personalized tailoring of interventions for sleep impairment in mood and anxiety disorders. Current diagnostic criteria for mood and anxiety tend to lump different forms of sleep disturbance together. Parsing the biological features of sleep impairment and brain circuit dysfunction is one approach to identifying subtypes within these disorders that are mechanistically coherent and offer targets for intervention. We focus on two large-scale neural circuits implicated in sleep impairment and in mood and anxiety disorders: the default mode network and negative affective network. Through a synthesis of existing knowledge about these networks, we pose a testable framework for understanding how hyper- versus hypo-engagement of these networks may underlie distinct features of mood and sleep impairment. Within this framework we consider whether poor sleep quality may have an explanatory role in previously observed associations between network dysfunction and mood symptoms. We expand this framework to future directions including the potential for connecting circuit-defined subtypes to more distal features derived from digital phenotyping and wearable technologies, and how new discovery may be advanced through machine learning approaches.

Comparing primary insomnia to the insomnia occurring in major depression and general anxiety disorder

Apart from possibly distinguishing the different clinical causes of insomnia, this article explores the subjective and objective sleep differences amongst primary insomnia, major depression with insomnia and general anxiety disorder with insomnia. Subjective sleep and objective sleep of the participants were evaluated by using the Pittsburgh sleep quality index and polysomnography, respectively. We found that major depression with insomnia exhibited higher daytime dysfunction than primary insomnia; showed significantly higher values of rapid eye movement (REM) periods, time of REM sleep and percentage of REM stage; and presented lower percentage of non-rapid eye movement stage compared with primary insomnia and general anxiety disorder with insomnia (p < 0.05). General anxiety disorder with insomnia showed lower awakening number (AN) than primary insomnia, and other objective and subjective sleep values of general anxiety disorder with insomnia and primary insomnia showed no significant difference (p > 0.05). Our findings showed that major depression with insomnia increased active REM sleep and severe daytime function, which could alert clinicians to the risk of depression. Major depression with insomnia and primary insomnia may be categorically different. However, general anxiety disorder with insomnia and primary insomnia might be a continuum of a disease rather than be categorically distinct.

Sleep Patterns and Anxiety in Children Interact to Predict Later Suicidal Ideation

Elevated levels of childhood anxiety pose risk for suicide; however, factors that accentuate this risk are unknown. Seventy-one children participated in a longitudinal study investigating anxiety and sleep in childhood (between 7-11 years) and later suicidal ideation (SI; M = 3.3 years later). Sleep was assessed via subjective reports and objective measures (actigraphy and polysomnography). Children with greater anxiety symptoms were at greater risk for later SI when sleep disturbances were present in childhood. Results suggest that sleep disruption may amplify SI risk in anxious children.

The Relationship between Sleep Duration and Perceived Stress: Findings from the 2017 Community Health Survey in Korea

Sleep is exceedingly important for our physical, physiological, psychological, and social health. Currently, few Koreans get the recommended daily amount of sleep. Stress can also have a major impact on our physiological, neurological, and mental health. In this study, we explored the correlation between sleep duration and perceived stress. The study used data from the Community Health Survey (CHS), 2017, which included 133,444 responses from Koreans. Sleeping time and stress were measured by self-diagnosis. The relationship between sleeping time and stress was analyzed using the chi-square test and multivariable regression. Both men and women felt the most stress when they slept for an average of 6 h a day. The results of the subgroup analysis showed that even when they sleep for the same time, younger people felt more stressed than older people. In the group that slept for an average of 6 h a day, women were the most stressed. We observed a correlation between sleeping time and stress in Korean adults. We found that about 16.7% of Koreans were sleeping for less than 5 h. This is less than the 7–9 h of sleep recommended by the National Sleep Foundation (NSF). In addition, stress was found to increase when sleep was insufficient. In particular, it was also observed that young people who slept for less than 8 h felt stressed more easily.

Sleep Quality and Sleepiness Among Veterinary Medical Students Over an Academic Year

Good sleep health is a key component to good personal well-being. It has been postulated that veterinary students have poor sleep health, but few measurements have been undertaken. This study measured Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale values at multiple points throughout an academic year for students in a veterinary medical curriculum. Students were found to have overall poor sleep quality and above average to excessive daytime sleepiness. Further investigation is necessary to determine specific causes as well as what action can be taken to improve student sleep health.

Short sleep duration and poor sleep quality predict next-day suicidal ideation: an ecological momentary assessment study

BACKGROUND

Sleep problems are a modifiable risk factor for suicidal thoughts and behaviors. Yet, sparse research has examined temporal relationships between sleep disturbance, suicidal ideation, and psychological factors implicated in suicide, such as entrapment. This is the first in-the-moment investigation of relationships between suicidal ideation, objective and subjective sleep parameters, and perceptions of entrapment.

METHODS

Fifty-one participants with current suicidal ideation completed week-long ecological momentary assessments. An actigraph watch was worn for the duration of the study, which monitored total sleep time, sleep efficiency, and sleep latency. Daily sleep diaries captured subjective ratings of the same sleep parameters, with the addition of sleep quality. Suicidal ideation and entrapment were measured at six quasi-random time points each day. Multi-level random intercept models and moderation analyses were conducted to examine the links between sleep, entrapment, and suicidal ideation, adjusting for anxiety and depression severity.

RESULTS

Analyses revealed a unidirectional relationship whereby short sleep duration (both objective and subjective measures), and poor sleep quality, predicted the higher severity of next-day suicidal ideation. However, there was no significant association between daytime suicidal ideation and sleep the following night. Sleep quality moderated the relationship between pre-sleep entrapment and awakening levels of suicidal ideation.

CONCLUSIONS

This is the first study to report night-to-day relationships between sleep disturbance, suicidal ideation, and entrapment. Findings suggest that sleep quality may alter the strength of the relationship between pre-sleep entrapment and awakening suicidal ideation. Clinically, results underscore the importance of assessing and treating sleep disturbance when working with those experiencing suicidal ideation.

Sleep architecture in adolescents hospitalized during a suicidal crisis

OBJECTIVE/BACKGROUND

Rates of suicide attempts in Canadian youths are concerning. Adolescence is a sensitive period for the emergence of both sleep and mood problems, two major risk factors for suicidality. This naturalistic study aimed to define the sleep profile of adolescents under the combined influence of suicidality, depression and pharmacotherapy during hospitalization for a suicidal crisis.

PATIENTS/METHODS

Seventeen suicidal adolescents (15.0 + 1.2years, 82% females) with major depression were recruited from a Canadian pedopsychiatric inpatient unit. Seventeen non-depressed adolescents were retrospectively collated from another database (15.0 + 1.1years, 83% females). None of the participants had a history of sleep disorders or significant medical conditions.

RESULTS

Compared to controls, suicidal adolescents had a longer sleep onset latency (Z = -4.5, p < 0.001), longer REM latency (Z = -3.2, p = 0.001), higher percentage of NREM1 sleep t(33) = -2.6, p = 0.020), and higher REM density (Z = -2.8, p = 0.004) than controls. Higher REM density correlated with higher CDI-II scores (r = 0.55, p = 0.27) A significant interaction indicated that the two groups had similar NREM3 percentages in the first two-thirds of the night, but that the suicidal group had significantly lower NREM3 percentage than the controls in the last third of the night (F(2,66) = 3.4, p = 0.041).

CONCLUSIONS

Significant sleep abnormalities were observed during hospitalization for a suicidal crisis in a sample of depressed and mostly medicated adolescents. This included sleep initiation and REM sleep latency abnormalities, shallower sleep and high REM density. Future studies should decipher the relative effects of depression, suicidality and medication on sleep. These findings stress the need to address sleep disturbances in the management of suicidality in adolescents.

Risk profile of young people admitted to hospital for suicidal behaviour in Melbourne, Australia

AIM

Self-harm and suicidal behaviour is most prevalent during adolescence, but little is known about the risk profile of adolescents admitted to hospital for suicidal behaviour. Young people who self-harm are at an increased risk of mortality compared to those who do not self-harm; adolescents admitted to hospital for suicidal behaviour are particularly at risk. The aim of this study was to generate a risk profile of adolescents admitted to hospital with suicidal behaviour.

METHODS

We conducted a 12-month retrospective audit of adolescent admissions to the mental health inpatient unit at a tertiary children's hospital in Melbourne, Australia. Routinely collected data were used to generate a risk profile.

RESULTS

We found that 212 of 271 (78.2%) admissions were due to suicidal behaviour. Of these, 107 (51%) adolescents were diagnosed with one or more mental disorders at discharge, most commonly major depressive disorder. Beyond known distal determinants of health risk, the proximal risk profile of these adolescents included factors relating to gender, substance use, prior mental health diagnoses and prior admission to hospital. Poor sleep was also a risk factor, with 159 (75%) reporting a recent history of sleeping problems.

CONCLUSIONS

The very high proportion of admissions to the mental health inpatient unit due to suicidal behaviour reinforces the importance of finding effective methods of identification of the risk processes underpinning suicidal behaviours to reduce the unnecessary waste of young lives by suicide.

Associations among daytime sleepiness, depression and suicidal ideation in Korean adolescents

The aim of this study was to examine the effects of daytime sleepiness on depression and suicidal ideation in adolescent high-school students. A survey of 538 high school students aged 16-17 years attending two academic schools was conducted. The Epworth Sleepiness Scale (ESS), the Beck Depression Inventory and the Scale for Suicide Ideation were used to assess subjects' daytime sleepiness, depression and suicidal ideation. The mean score for daytime sleepiness was 8.52, which indicates a sleep deficit. Significant positive correlations were found between daytime sleepiness and depression, between daytime sleepiness and suicidal ideation and between depression and suicidal ideation. Gender and depression were significant predictors of suicidal ideation, accounting for 48% of the variance in this measure. Depression acts as a mediator of the relationship between daytime sleepiness and suicidal ideation. High school students in Korea generally have insufficient sleep time and feel sleepy during the day; insufficient sleep during adolescence may be associated with depression and suicidal ideation.

Objectively Assessed Sleep Variability as an Acute Warning Sign of Suicidal Ideation in a Longitudinal Evaluation of Young Adults at High Suicide Risk

OBJECTIVE

Young adults attempt suicide at disproportionately high rates relative to other groups and demonstrate high rates of sleep disturbance. No study has yet prospectively evaluated disturbed sleep as an acute indicator of risk using an objective index of sleep. We investigated objective and subjective parameters of disturbed sleep as a warning sign of suicidal ideation among young adults over an acute period.

METHODS

A longitudinal study across a 21-day observation period and 3 time points. Fifty of 4,847 participants (aged 18-23 years) were prescreened from a university undergraduate research pool (February 2007-June 2008) on the basis of suicide attempt history and recent suicidal ideation. Actigraphic and subjective sleep parameters were evaluated as acute predictors of suicidal ideation (Beck Scale for Suicide Ideation), with adjustment for baseline symptoms. Hierarchical regression analyses were employed to predict residual change scores.

RESULTS

Ninety-six percent of participants (n = 48) endorsed a suicide attempt history. Mean actigraphy values revealed objectively disturbed sleep parameters; 78% (n = 39) and 36% (n = 18) endorsed clinically significant insomnia and nightmares, respectively. When results were controlled for baseline suicidal and depressive symptoms, actigraphic and subjective sleep parameters predicted suicidal ideation residual change scores at 7- and 21-day follow-ups (P < .001). Specifically, actigraphy-defined variability in sleep timing, insomnia, and nightmares predicted increases in suicidal ideation (P < .05). In a test of competing risk factors, sleep variability outperformed depressive symptoms in the longitudinal prediction of suicidal ideation across time points (P < .05).

CONCLUSIONS

Objectively and subjectively measured sleep disturbances predicted acute suicidal ideation increases in this population, independent of depressed mood. Self-reported insomnia and nightmares and actigraphically assessed sleep variability emerged as acute warning signs of suicidal ideation. These findings highlight the potential utility of sleep as a proposed biomarker of suicide risk and a therapeutic target.

Life-time history of insomnia and hypersomnia symptoms as correlates of alcohol, cocaine and heroin use and relapse among adults seeking substance use treatment in the United States from 1991 to 1994

AIMS

To examine the association between a life-time history of insomnia and hypersomnia compared with no sleep disturbance and substance use patterns and amounts before and after a substance use treatment episode.

DESIGN

Secondary analysis of data from the Drug Abuse Treatment Outcome Studies conducted from 1991 to 1994.

SETTING

Data were collected at 96 substance use treatment programs in 11 United States cities, including short-term in-patient, long-term residential, methadone maintenance and out-patient drug-free treatment modalities.

PARTICIPANTS

Study samples included 7168 adults at treatment entry and 2965 at 12 months post-treatment entry whose primary substance use at entry was alcohol (14.7%), cocaine (62.7%) or heroin (22.6%).

MEASUREMENTS

Life-time history of insomnia and hypersomnia was assessed via self-report. Type and frequency of substance use were assessed at treatment entry. Substance use was also assessed 12 months following treatment completion. Associations were examined using linear and logistic regression with age, sex, race, education level, depression history, treatment modality and in-treatment substance use as covariates.

FINDINGS

Life-time history of insomnia, hypersomnia, both or neither was reported by 26.3, 9.5, 28.0 and 36.2% of participants, respectively. Compared with no sleep disturbance, life-time insomnia and hypersomnia were associated at treatment entry with unique substance use patterns and a higher frequency of any substance use (P < 0.001). All types of sleep disturbance were associated with higher rates of cocaine use at 12-month post-entry (odds ratios: 1.30-1.57).

CONCLUSIONS

There is evidence of an adverse association between substance use and sleep disturbance including higher frequency of all substance use before substance abuse treatment and higher rates of cocaine use after a treatment episode.

Understanding Suicide Risk within the Research Domain Criteria (RDoC) Framework: Insights, Challenges, and Future Research Considerations

Suicide is a leading cause of death worldwide. Prior research has focused primarily on sociodemographic and psychiatric risk factors with little improvement in the prediction or prevention of suicidal behavior over time. The Research Domain Criteria (RDoC) may be an especially useful framework for advancing research in this area. This paper provides a brief and broad overview of research on suicidal behavior relating to each of the RDoC domains-highlighting the RDoC construct(s) where research has focused, construct(s) where research is lacking, and suggestions for future research directions. We also discuss major challenges for suicide research within the RDoC framework, including the intersection of RDoC domains, interaction of domains with the environment, incorporation of developmental stage, integration of distal and proximal processes, and inclusion of suicide-specific constructs. We conclude by underscoring important considerations for future research aimed at using the RDoC framework to study suicidal behavior and other forms of psychopathology.

Neurophysiological correlates of suicidal ideation in major depressive disorder: Hyperarousal during sleep

BACKGROUND

Suicide is a major public health concern, and a barrier to reducing the suicide rate is the lack of objective predictors of risk. The present study considers whether quantitative sleep electroencephalography (EEG) may be a neurobiological correlate of suicidal ideation.

METHODS

Participants included 84 (45 female, mean age=26.6) adults diagnosed with major depressive disorder (MDD). The item that measures thoughts of death or suicide on the Quick Inventory of Depressive Symptomatology (QIDS) was used to classify 47 participants as low suicidal ideation (24 females, mean age=26.1) and 37 as high suicidal ideation (21 females, mean age=27.3). Data were obtained from archival samples collected at the University of Michigan and University of Texas Southwestern Medical Center between 2004 and 2012. Sleep EEG was quantified using power spectral analysis, and focused on alpha, beta, and delta frequencies.

RESULTS

Results indicated that participants with high compared to low suicidal ideation experienced 1) increased fast frequency activity, 2) decreased delta activity, and 3) increased alpha-delta sleep after adjusting for age, sex, depression, and insomnia symptoms.

LIMITATIONS

Limitations include the exclusion of imminent suicidal intent, a single suicidal ideation item, and cross-sectional archival data.

CONCLUSIONS

This is one of the first studies to provide preliminary support that electrophysiological brain activity during sleep is associated with increased suicidal ideation in MDD, and may point toward central nervous system (CNS) hyperarousal during sleep as a neurobiological correlate of suicidal ideation.

Examining the role of psychological factors in the relationship between sleep problems and suicide

We sought to conduct the first systematic review of empirical evidence investigating the role of psychological factors in the relationship between sleep problems and suicidal thoughts and behaviours. Twelve studies were identified which examined psychological factors grouped into four categories of cognitive appraisals, psychosocial factors, emotion regulation strategies, and risk behaviours. Although there was substantial heterogeneity across studies with respect to measurement, sampling, and analysis, preliminary evidence indicated that negative cognitive appraisals, perceived social isolation, and unhelpful emotion regulation strategies may contribute to the association between sleep problems and suicidal thoughts and behaviours. Given that findings in this area are currently restricted to studies with cross-sectional designs, the directionality of the interrelationships between these psychological factors, sleep problems and suicidality, remains unclear. We integrate the findings of our review with contemporary psychological models of suicidal behaviour to develop a clear research agenda. Identified pathways should now be tested with longitudinal and experimental designs. In addition, a more thorough investigation of the complexities of sleep, psychological factors, and suicidal thoughts and behaviours is crucial for the development of targeted psychological interventions.

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Systematic review of the role of psychological factors in sleep/suicide relationships

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Review findings integrated with suicide theory to define a clear research agenda.

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Reliance on cross-sectional designs limits interpretation of directionality of pathways.

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Identified pathways should be investigated with longitudinal and experimental designs.

Sleep architecture parameters as a putative biomarker of suicidal ideation in treatment-resistant depression

BACKGROUND

Disturbed sleep may confer risk for suicidal behaviors. Polysomnographic (PSG) sleep parameters have not been systematically evaluated in association with suicidal ideation (SI) among individuals with treatment-resistant depression (TRD).

METHODS

This secondary data analysis included 54 TRD individuals (N=30 with major depressive disorder (MDD) and N=24 with bipolar depression (BD)). PSG sleep parameters included Sleep Efficiency (SE), Total Sleep Time (TST), Wakefulness After Sleep Onset (WASO), REM percent/latency, and non-REM (NREM) Sleep Stages 1-4. The Hamilton Depression Rating Scale (HAM-D) was used to group participants according to presence or absence of SI. Sleep abnormalities were hypothesized among those with current SI. ANOVA analyses were conducted before (Model 1) and after adjusting for depression (Model 2) and diagnostic variables (Model 3).

RESULTS

Significant differences in PSG parameters were observed in Model 1; those with SI had less NREM Stage 4 sleep (p<.05). After adjusting for central covariates, Models 2 and 3 revealed significantly less NREM Stage 4 sleep, lower SE (P<.05), and higher WASO (P<.05) among those with SI. BD participants with SI also had less NREM Stage 4 and more NREM Stage 1 sleep.

LIMITATIONS

1) a predominantly white sample; 2) exclusion of imminent suicide risk; 3) concomitant mood stabilizer use among BD patients; and 4) single-item SI assessment.

CONCLUSIONS

Independent of depression severity, SI was associated with less NREM Stage 4 sleep, and higher nocturnal wakefulness across diagnostic groups. Sleep may warrant further investigation in the pathogenesis of suicide risk, particularly in TRD, where risk may be heightened.

Ketamine-Induced Glutamatergic Mechanisms of Sleep and Wakefulness: Insights for Developing Novel Treatments for Disturbed Sleep and Mood

Ketamine, a drug with rapid antidepressant effects and well-described effects on slow wave sleep (SWS), is a useful intervention for investigating sleep-wake mechanisms involved in novel therapeutics. The drug rapidly (within minutes to hours) reduces depressive symptoms in individuals with major depressive disorder (MDD) or bipolar disorder (BD), including those with treatment-resistant depression. Ketamine treatment elevates extracellular glutamate in the prefrontal cortex. Glutamate, in turn, plays a critical role as a proximal element in a ketamine-initiated molecular cascade that increases synaptic strength and plasticity, which ultimately results in rapidly improved mood. In MDD, rapid antidepressant response to ketamine is related to decreased waking as well as increased total sleep, SWS, slow wave activity (SWA), and rapid eye movement (REM) sleep. Ketamine also increases brain-derived neurotrophic factor (BDNF) levels. In individuals with MDD, clinical response to ketamine is predicted by low baseline delta sleep ratio, a measure of deficient early night production of SWS. Notably, there are important differences between MDD and BD that may be related to the effects of diagnosis or of mood stabilizers. Consistent with its effects on clock-associated molecules, ketamine alters the timing and amplitude of circadian activity patterns in rapid responders versus non-responders with MDD, suggesting that it affects mood-dependent central neural circuits. Molecular interactions between sleep homeostasis and clock genes may mediate the rapid and durable elements of clinical response to ketamine and its active metabolite.

[Seasons, circadian rhythms, sleep and suicidal behaviors vulnerability]

INTRODUCTION

Suicidal behaviors are common in the general population and are so a major public health problem. In order to improve suicide prevention and to reduce the mortality by suicide, it appears essential to better identify suicide risk factors. Seasonality, circadian rhythms and sleep abnormalities have been already associated with numerous psychiatric disorders. This review aimed to characterize the associations between seasonality, circadian rhythms, sleep and suicidal behaviors including suicide attempts and completed suicides.

METHODS

We conducted a literature search between 1973 and 2015 in PubMed databases using the following terms: ("suicide" OR "suicidality" OR "suicide attempts" OR "suicidal behavior") AND ("circadian rhythms" OR "seasons" OR "sleep").

RESULTS

Many studies confirm a specific seasonality for suicide with a higher peak of suicides in spring for both sex and a lower peak in autumn especially for women. This distribution seems to correlate with depressive symptoms (especially for the autumn peak), gender and different types of suicide. Regarding gender and type of suicide differences, males more commonly commit violent suicide with a higher rate of suicides in spring. Suicide behaviors appear to be influenced by climatic and biological factors like sunshine, daylight cycles, temperature, air pollutants, viruses, parasites and aeroallergens. Circadian variations exist in suicide rates depending on age with a morning peak for elder and an evening peak for youth. In addition, completed suicide peak in early morning whereas suicide attempts peak rather in later afternoon. Several biomarkers dysregulation like melatonin, serotonin and cortisol may be implicated in suicide circadian variations. Furthermore, specific sleep disorders like insomnia, nightmares and sleep deprivation are common risk factors of suicide and possibly independently of the presence of depressive symptoms. Finally, the efficacy of chronotherapeutics (such as luminotherapy, dark therapy, sleep deprivation and melatonin drugs) has been suggested in the reduction of suicidal behaviors.

CONCLUSION

The suicide seasonality is very well documented showing a main peak in spring and another one in autumn. A suicide circadian distribution also exists depending of the suicidal behavior intensity and of the age. Numerous sleep disorders are also suicide risk factors and can be treated with chronotherapeutics. A better identification of seasonality, circadian rhythms and sleep abnormalities in suicidal behaviors could allow a better prevention in suicidal attempts and a reduction in death by suicide.

Sleep and mental disorders: A meta-analysis of polysomnographic research

Investigating sleep in mental disorders has the potential to reveal both disorder-specific and transdiagnostic psychophysiological mechanisms. This meta-analysis aimed at determining the polysomnographic (PSG) characteristics of several mental disorders. Relevant studies were searched through standard strategies. Controlled PSG studies evaluating sleep in affective, anxiety, eating, pervasive developmental, borderline and antisocial personality disorders, attention-deficit-hyperactivity disorder (ADHD), and schizophrenia were included. PSG variables of sleep continuity, depth, and architecture, as well as rapid-eye movement (REM) sleep were considered. Calculations were performed with the "Comprehensive Meta-Analysis" and "R" software. Using random effects modeling, for each disorder and each variable, a separate meta-analysis was conducted if at least 3 studies were available for calculation of effect sizes as standardized means (Hedges' g). Sources of variability, that is, sex, age, and mental disorders comorbidity, were evaluated in subgroup analyses. Sleep alterations were evidenced in all disorders, with the exception of ADHD and seasonal affective disorders. Sleep continuity problems were observed in most mental disorders. Sleep depth and REM pressure alterations were associated with affective, anxiety, autism and schizophrenia disorders. Comorbidity was associated with enhanced REM sleep pressure and more inhibition of sleep depth. No sleep parameter was exclusively altered in 1 condition; however, no 2 conditions shared the same PSG profile. Sleep continuity disturbances imply a transdiagnostic imbalance in the arousal system likely representing a basic dimension of mental health. Sleep depth and REM variables might play a key role in psychiatric comorbidity processes. Constellations of sleep alterations may define distinct disorders better than alterations in 1 single variable. (PsycINFO Database Record

Insomnia, dreams, and suicide: Connecting links

INTRODUCTION

A growing empirical literature has examined insomnia symptoms as a possible risk factor for a range of suicidal behavior. Not much literature is available in normal adolescent population.

AIMS

The aim is to find insomnia prevalence, studying various dream factors, and suicidality prevalence among students of various courses. To check if there is a relation between insomnia and suicidal behavior and dreams, particularly nightmares and suicide.

MATERIALS AND METHODS

A total of 400 students of various courses were assessed using Insomnia Severity Index and The Mannheim Dream Questionnaire and Suicide Behaviour Questionnaire.

RESULTS

Insomnia was present in 11%, 23%, 19%, and 19% and suicide behavior in 16%, 17%, 12%, and 22%, respectively, in medical, commerce, engineering, and arts students. Statistically significant correlation was found between suicide and insomnia severity and various dream factors.

CONCLUSIONS

Insomnia and dreams had relation with suicidality in normal adolescent population.

Nocturnal Wakefulness Is Associated With Next-Day Suicidal Ideation in Major Depressive Disorder and Bipolar Disorder

OBJECTIVE

Self-reported sleep disturbances may confer elevated risk for suicidal ideation, suicide attempts, and death. However, limited research has evaluated polysomnographically determined sleep disturbance as an acute physiologic risk factor for suicidal thoughts. This study sought to investigate the relationship between nocturnal wakefulness in association with next-day suicidal ideation using overnight polysomnography assessment from data collected between 2006 and 2013.

METHODS

Sixty-five participants with DSM-IV-diagnosed major depressive disorder or bipolar depression underwent overnight polysomnography monitoring in a sleep laboratory. The Hamilton Depression Rating Scale (HDRS) was administered the morning after polysomnography recording to assess next-day suicidal ideation, severity of depressive symptoms, and subjective sleep disturbances.

RESULTS

Using a generalized linear mixed model, a significant time-by-ideation interaction was found indicating greater nocturnal wakefulness at 4:00 am among participants with suicidal ideation (F4,136 = 3.65, P = .007). Increased time awake during the 4:00 am hour (4:00 to 4:59) was significantly associated with elevated suicidal thoughts the next day (standardized β = 0.31, P = .008). This relationship persisted after controlling for age, gender, diagnosis, and severity of depressive symptoms.

CONCLUSIONS

Greater nocturnal wakefulness, particularly in the early morning hours, was significantly associated with next-day suicidal thoughts. Polysomnographically documented sleep disruption at specific times of night may represent an acute risk factor of suicidal ideation that warrants additional research.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00024635.

The Impact of Sleep Timing, Sleep Duration, and Sleep Quality on Depressive Symptoms and Suicidal Ideation amongst Japanese Freshmen: The EQUSITE Study

Aim. The aim of this study was to identify the impact of bedtime, wake time, sleep duration, sleep-onset latency, and sleep quality on depressive symptoms and suicidal ideation amongst Japanese freshmen. Methods. This cross-sectional data was derived from the baseline survey of the Enhancement of Q-University Students Intelligence (EQUSITE) study conducted from May to June, 2010. A total of 2,631 participants were recruited and completed the following self-reported questionnaires: the Pittsburgh Sleep Quality Index (PSQI), the Center for Epidemiologic Studies Depression Scale (CES-D), and the original Health Support Questionnaires developed by the EQUSITE study research team. Results. Of 1,992 participants eligible for analysis, 25.5% (n = 507) reported depressive symptoms (CES-D total score ≥ 16), and 5.8% (n = 115) reported suicidal ideation. The present study showed that late bedtime (later than 01:30), sleep-onset latency (≥30 minutes), and poor sleep quality showed a marginally significant association with depressive symptoms. Poor sleep quality was seen to predict suicidal ideation even after adjusting for depressive symptoms. Conclusion. The current study has important implications for the role of bedtime in the prevention of depressive symptoms. Improving sleep quality may prevent the development of depressive symptoms and reduce the likelihood of suicidal ideation.

Sleep disturbances as an evidence-based suicide risk factor

Increasing research indicates that sleep disturbances may confer increased risk for suicidal behaviors, including suicidal ideation, suicide attempts, and death by suicide. Despite increased investigation, a number of methodological problems present important limitations to the validity and generalizability of findings in this area, which warrant additional focus. To evaluate and delineate sleep disturbances as an evidence-based suicide risk factor, a systematic review of the extant literature was conducted with methodological considerations as a central focus. The following methodologic criteria were required for inclusion: the report (1) evaluated an index of sleep disturbance; (2) examined an outcome measure for suicidal behavior; (3) adjusted for presence of a depression diagnosis or depression severity, as a covariate; and (4) represented an original investigation as opposed to a chart review. Reports meeting inclusion criteria were further classified and reviewed according to: study design and timeframe; sample type and size; sleep disturbance, suicide risk, and depression covariate assessment measure(s); and presence of positive versus negative findings. Based on keyword search, the following search engines were used: PubMed and PsycINFO. Search criteria generated N = 82 articles representing original investigations focused on sleep disturbances and suicide outcomes. Of these, N = 18 met inclusion criteria for review based on systematic analysis. Of the reports identified, N = 18 evaluated insomnia or poor sleep quality symptoms, whereas N = 8 assessed nightmares in association with suicide risk. Despite considerable differences in study designs, samples, and assessment techniques, the comparison of such reports indicates preliminary, converging evidence for sleep disturbances as an empirical risk factor for suicidal behaviors, while highlighting important, future directions for increased investigation.

The Effect of Sleep Problems on Suicidal Risk among Young Adults in the Presence of Depressive Symptoms and Cognitive Processes

We aimed to investigate the effect of sleep problems, depression, and cognitive processes on suicidal risk among 460 young adults. They completed self-report questionnaires assessing suicidal behavior, sleep quality, depressive symptoms, emotion regulation, rumination, and impulsivity. Suicidal participants exhibited higher rates of depressive symptoms, sleep problems, expressive suppression, rumination, and impulsivity. A confirmatory factor analysis model revealed pathways to suicidal risk that showed no direct pathways between sleep problems and suicidal risk. Instead, sleep was related to suicidal risk via depression and rumination, which in turn increased suicidal risk. These results suggest that addressing sleep problems will be useful in either the treatment or prevention of depressive and rumination symptoms and reduction in suicidal risk.

The timing of deliberate self harm behaviour

Objectives: To critically review the scientific literature relating to the timing of deliberate self harm behaviour and completed suicide.

Method: A literature search of the Medline and CINAHL databases from 1970-2002 was performed, using deliberate self harm, overdose, self poisoning, suicide, parasuicide, and time, timing, day, week, month and season as key words. Relevant secondary references were retrieved and hand searching of important journals was done.

Results: The time of day of non-fatal self harm shows a marked diurnal variation, with an evening peak that is related to non-violent episodes, concomitant alcohol use, and a younger age. It is not conclusively linked to the degree of suicidal intent or particular psychiatric diagnoses. Completed suicides more commonly occur earlier in the day, at the beginning of the week and during springtime, but show no overall increase during many national events and holidays.

Conclusions: Circadian biological mechanisms involving the serotonin-melatonin axis, Cortisol secretion and sleep abnormalities appear to be implicated. Psychosocial explanations for these epidemiological findings include alcohol use, a sense of personal isolation and the ‘broken promise’ effect.

Linkages between insomnia and suicidality: prospective associations, high-risk subgroups and possible psychological mechanisms

Insomnia can be lethal, increasing the risk of suicide and accidental death by overdose. In this review we present a synthesis of the literature investigating the insomnia-suicide link and the psychological mechanisms underpinning the association. Specifically, we review the findings of prospective epidemiological studies demonstrating the insomnia-suicide link in adult and adolescent community populations. Robust associations between insomnia and suicide are observed in clinically depressed and anxious populations, and there are indications across a number of cross-sectional and longitudinal studies that these linkages are attributable to a disrupted sleep pattern, dysfunctional beliefs about sleep and nightmares, independent of depression and anxiety symptoms. Borderline personality disorder (BPD) and chronic pain (CP) are highlighted as high-risk subgroups given the elevated rates of insomnia and suicidality in both conditions. Aside from the influence of comorbid depression and anxiety symptoms, emerging evidence has identified impulsivity and emotional dysregulation as possible mechanisms driving the insomnia-suicide link in BPD, and catastrophizing and the sense of defeat/entrapment as potential cognitive pathways through which insomnia aggravates suicidality in CP. Screening for, and interventions that tackle, insomnia and these associated psychological mechanisms, offer a novel avenue for reducing suicidality across a range of clinical and non-clinical populations.

Subjective and objective sleep and self-harm behaviors in young children: a general population study

Significant association between sleep disturbances and suicidal ideation and/or attempts is reported in adults and adolescents. However, there is paucity of studies exploring the association between sleep and self-harm behaviors (SHB) in young children and are limited to only subjective sleep measures. We examined the association between SHB and both subjective and objective sleep in a population-based sample of 5-12 yr old. Parents of every student in 3 local school (K-5) districts (n=7312) was sent a screening questionnaire. Randomly selected children from this sample underwent a comprehensive history, physical examination, a 9-h overnight polysomnogram and completed several questionnaires. Among the final sample (n=693), 27 children had SHB with adjusted prevalence of 3%. There was no difference in age, gender, obesity, or socioeconomic status in subjects with or without SHB. Significantly more children with SHB had subjective sleep difficulty and depression. Difficulty maintaining sleep and frequent nightmares were associated with SHB independent of depression or demographics. Polysomnographic %REM-sleep was significantly higher in the SHB group after adjusting for demographics and depression. These data indicate that parent reported sleep disturbances are independently associated with SHB. It is possible that higher REM-sleep is a non-invasive biomarker for risk of self-harm behaviors in young children.

Risk factors for suicidal ideation of the general population

The aim of this study was to investigate risk factors of suicide ideation in general population. A total of 1,116 adults were sampled with randomization in an urban area. After excluding 116 participants due to incomplete answer, 1,000 participants (500 males; mean age 39.6 ± 11.6) completed self-report questionnaire including the Center for Epidemiologic Study Depression Scale (CES-D), the Beck Scale for Suicide Ideation (BSI), the Spielberger State-Trait Anger Expression Inventory (STAXI), the Barratt Impulsiveness Scale (BIS), and questions on weekday sleep duration. Results showed higher scores on the BSI were related with higher scores on the STAXI, CES-D, a family history of psychiatric illness, and short or long sleep duration (≤ 5 or ≥ 10 hr) (adjusted R (2) = 0.151, P < 0.001, P < 0.001, P = 0.001, and P = 0.008, respectively). The predictive power of the STAXI scores, the presence of psychiatric family history and short or long sleep duration was stronger in the high CES-D group with scores of 16 or higher (adjusted R (2) = 0.275, P < 0.001, P < 0.001, and P < 0.001, respectively). These findings suggest that suicide idea in general population may be related with the presence of family history for psychiatric illness, depressive mood, high anger and short or long sleep duration.

Gender differences in factors associated with suicidal ideation and depressive symptoms among middle-aged workers in Japan

The purpose of this study was to assess middle-aged Japanese workers for possible gender differences in the risk factors associated with depressive symptoms and suicidal ideation. 5,878 workers (40-60 yr of age) (3,631 males and 2,247 females) were recruited from randomly selected companies in northern Japan. Demographic and lifestyle factors, suicidal ideation rate, and the data for the Brief Job Stress Questionnaire (BJSQ) and the Center for Epidemiologic Studies for Depression scale (CES-D) were obtained from the self-report questionnaires. After adjusting for possible confounding variables, marital status, absent of stress reduction technique and low job compatibility were significant independent risk factors for suicidal ideation among males. In females, marital status, feeling of insufficient sleep and absence of stress reduction techniques were significant independent risk factors after adjusting for all variables. Under the same adjustments, temporary employment also showed a protective effect against female suicidal ideation. In conclusion, our results suggest that factors related to suicidal ideation differed by gender. Different approaches for each gender might be useful in the development of suicide prevention programs. However, interpretation of work-related effects, such as temporary employment, interpersonal conflict and transportation industry, was hampered by lack of data concerning personal income, working hours and organizational commitment. Additional studies are needed to examine the longitudinal relationships between the risk factors associated with suicidal ideation and depressive symptoms.

Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military

BACKGROUND

Sleep problems appear to represent an underappreciated and important warning sign and risk factor for suicidal behaviors. Given past research indicating that disturbed sleep may confer such risk independent of depressed mood, in the present report we compared self-reported insomnia symptoms to several more traditional, well-established suicide risk factors: depression severity, hopelessness, PTSD diagnosis, as well as anxiety, drug abuse, and alcohol abuse symptoms.

METHODS

Using multiple regression, we examined the cross-sectional and longitudinal relationships between insomnia symptoms and suicidal ideation and behavior, controlling for depressive symptom severity, hopelessness, PTSD diagnosis, anxiety symptoms, and drug and alcohol abuse symptoms in a sample of military personnel (N=311).

RESULTS

In support of a priori hypotheses, self-reported insomnia symptoms were cross-sectionally associated with suicidal ideation, even after accounting for symptoms of depression, hopelessness, PTSD diagnosis, anxiety symptoms and drug and alcohol abuse. Self-reported insomnia symptoms also predicted suicide attempts prospectively at one-month follow up at the level of a non-significant trend, when controlling for baseline self-reported insomnia symptoms, depression, hopelessness, PTSD diagnosis and anxiety, drug and alcohol abuse symptoms. Insomnia symptoms were unique predictors of suicide attempt longitudinally when only baseline self-reported insomnia symptoms, depressive symptoms and hopelessness were controlled.

LIMITATIONS

The assessment of insomnia symptoms consisted of only three self-report items. Findings may not generalize outside of populations at severe suicide risk.

CONCLUSIONS

These findings suggest that insomnia symptoms may be an important target for suicide risk assessment and the treatment development of interventions to prevent suicide.

Teen sleep and suicidality: results from the youth risk behavior surveys of 2007 and 2009

STUDY OBJECTIVES

Suicide in the adolescent population is a tragic and preventable cause of death. Previous studies have confirmed both long and short total sleep times (TSTs) are associated with suicidal ideation in the adult population. We hypothesized that both long and short TSTs are risk factors for serious suicide attempt in the adolescent population as well.

METHODS

We tested this hypothesis using the Youth Risk Behavior Surveys from 2007 and 2009, which consist of school-based, nationally representative samples (N = 12,154 for 2007, N = 14,782 for 2009). Logistic regression models were used to assess the relationship between suicidality and sleep after adjusting for confounders including age, sex, race/ethnicity, feelings of sadness, and substance abuse.

RESULTS

Of the total sample, roughly 15% reported suicidal ideation, 10% planned suicide, 5% attempted and 2% reported an attempt requiring treatment. Teens who reported sleeping ≤ 5 or ≥ 10 h had a significantly higher risk for suicidality compared to those with a TST of 8 h. The largest odds ratios were found among the most severe forms of suicidality (attempt requiring treatment) with an odds ratio of 5.9 for a TST ≤ 4 h and 4.7 for a TST ≥ 10 h.

CONCLUSION

Both short and long TSTs are risk factors for suicidality among teens and extremes in TST may indicate more serious suicidality. Self-reported sleep duration may be a useful screening question for suicide risk. Future studies should examine whether sleep duration is a causal and/or modifiable risk factor for suicidality in teens.

Short self-reported sleep duration and suicidal behavior: a cross-sectional study

BACKGROUND

Prior studies on the association between sleep disturbances and suicidal behavior did not explore whether or not short sleep is a marker of suicide intent, lethality or risk.

DESIGN

Cross-sectional.

PARTICIPANTS

Suicide attempters (SAs) (n=434). Controls included 83 psychiatric inpatients who have never been SAs, and 509 healthy controls.

MEASUREMENTS

Short sleep was defined by self-assessment as ≤ 5 h per day. The MINI and the DSM-IV version of the International Personality Disorder Examination Screening Questionnaire were used to diagnose Axis I and Axis II diagnoses, respectively. Suicide intent and lethality were evaluated through the Beck's Suicidal Intent Scale (SIS) and the Risk-Rescue Rating Scale (RRRS), respectively. Beck's Medical Lethality Scale (BMLS) was administered to assess the degree of medical injury, and the SAD PERSONS mnemonic scale was used to evaluate suicide risk.

STATISTICAL ANALYSES

Chi-square tests and logistic regression analyses explored frequencies of short sleep in 3 samples. Chi-square tests explored whether or not suicide intent, lethality and risk were greater in SAs with short-sleep versus those without short-sleep.

RESULTS

Short sleep was more prevalent in SAs than in psychiatric controls only in males. In female SAs, short sleep was significantly associated with several SIS items and high scores in the SAD PERSONS.

LIMITATIONS

Sleep duration was assessed only by self-report.

CONCLUSIONS

The association between short sleep and suicidal behavior may be partly explained by confounders. Short sleep may be a marker of severity of suicidal behavior among female SAs.

Sleep disturbances and suicidality: a common association to look for in clinical practise and preventive care

Suicidality and suicide has been associated with many risk factors, while recent clinical and epidemiological studies increasingly point to a potential link between sleep loss or sleep disturbances and suicidality. This review on studies of sleep disturbances associated with suicidality, i.e., suicidal ideation, suicide attempt and completed suicide suggests a frequent association especially with insomnia and nightmares but also hypersomnia and sleep panic attacks. In suicidal insomniacs with comorbid psychiatric disorders, there is some evidence for an even independent predictive nature of sleep problems for suicidality. Considerations on the shared neurobiology, risk assessment and treatment options complement the overview. Thus, sleep disturbances may qualify as an individual treatable target of personalised medicine in the clinical routine as well as in suicide prevention programmes. A more detailed assessment of sleep problems and identification of specific risk domains in primary or secondary prevention of suicidality seem to be a future area of high importance.