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Shepard CA, Rufino KA, Lee J, Tran T, Paddock K, Wu C, Oldham JM, Mathew SJ, Patriquin MA. Nighttime Sleep Quality and Daytime Sleepiness Predicts Suicide Risk in Adults Admitted to an Inpatient Psychiatric Hospital. Behav Sleep Med 2023; 21:129-141. [PMID: 35296204 DOI: 10.1080/15402002.2022.2050724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
As sleep problems have been identified as an important, yet understudied, predictor of suicide risk, the present study analyzed the relationship between daytime sleepiness and nighttime sleep disturbance in a high-risk population of adults admitted to an inpatient psychiatric hospital. Objectives were to (1) examine the time course of subjective daytime sleepiness, nighttime sleep disturbance, and suicide risk throughout inpatient psychiatric treatment, (2) examine pre- to post-treatment changes in sleep disturbance with treatment as usual in an inpatient psychiatric setting, and (3) investigate whether daytime sleepiness and nighttime sleep disturbance predicted suicide risk above and beyond anxiety and depression. Participants were 500 consecutively admitted adults admitted to an intermediate length of stay (4-6 weeks) inpatient psychiatric hospital (47% female; 18-87 years of age). Measures of sleep, suicide risk, depression, and anxiety were completed at admission, weeks 1 through 4, and at discharge. Latent growth curve modeling (LGM) and hierarchal linear modeling (HLM) were conducted. The LGM analysis demonstrated that daytime sleepiness, nighttime sleep disturbance, and suicide risk all improved throughout inpatient treatment. Further, HLM showed that daytime sleepiness predicted suicide risk above and beyond symptoms of anxiety, depression, major sleep medications, and prior suicidal ideation and attempts, while nighttime sleep disturbance predicted suicide risk above and beyond symptoms of anxiety, major sleep medications, and prior suicidal ideation and attempts. Findings indicate the need to reevaluate safety protocols that may impact sleep, particularly that may increase daytime sleepiness, and to develop evidence-based sleep interventions for individuals admitted to inpatient psychiatric hospitals.
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Affiliation(s)
| | - Katrina A Rufino
- The Menninger Clinic, Houston, TX, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,University of Houston-Downtown, Houston, TX, USA
| | - Jaehoon Lee
- Department of Educational Psychology & Leadership, Texas Tech University, Lubbock, TX, USA
| | | | | | - Chester Wu
- The Menninger Clinic, Houston, TX, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - John M Oldham
- The Menninger Clinic, Houston, TX, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Sanjay J Mathew
- The Menninger Clinic, Houston, TX, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - Michelle A Patriquin
- The Menninger Clinic, Houston, TX, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
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Kalmbach DA, Cheng P, Ahmedani BK, Peterson EL, Reffi AN, Sagong C, Seymour GM, Ruprich MK, Drake CL. Cognitive-behavioral therapy for insomnia prevents and alleviates suicidal ideation: insomnia remission is a suicidolytic mechanism. Sleep 2022; 45:zsac251. [PMID: 36242607 PMCID: PMC9742891 DOI: 10.1093/sleep/zsac251] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/21/2022] [Indexed: 11/11/2022] Open
Abstract
STUDY OBJECTIVES Insomnia is associated with elevated levels of suicidal thoughts and behaviors. Emerging evidence suggests that cognitive-behavioral therapy for insomnia (CBTI) may reduce suicidal ideation (SI). However, the role of digital therapeutics in both the alleviation and prevention of SI remains unclear, and treatment mechanisms facilitating SI reductions have not been clearly identified. METHODS A total of 658 adults with Diagnostic and Statistical Manual of Mental Disorders, 5th Edition insomnia disorder enrolled in a single-site randomized controlled trial evaluating the efficacy of digital CBTI relative to attention control. Outcomes were measured at pretreatment, posttreatment, and 1-year follow-up. RESULTS Before treatment, 126 patients endorsed SI (19.1% prevalence). Among those with baseline SI, CBTI patients reported lower SI rates at posttreatment (30.0% vs 54.5%, p = .005) and 1-year follow-up (29.6% vs 46.8%, p = .042) relative to control. PRODCLIN analysis estimated that half of suicidolytic effects of CBTI were mediated through insomnia remission. Among those without baseline SI, CBTI did not directly prevent new onset SI. However, insomnia remitters reported lower rates of new-onset SI at posttreatment relative to non-remitters (1.5% vs 6.5%, p = .009). Mediation analysis supported a significant indirect effect wherein CBTI increased the likelihood of insomnia remission, which was associated with SI prevention (αβ = -3.20, 95% CI = -5.74 to -0.87). CONCLUSION Digital CBTI reduces insomnia symptoms, which promotes SI alleviation and prevention. For nonsuicidal patients, digital CBTI may serve as a highly accessible monotherapy for improving sleep, thereby reducing the risk for SI. For suicidal patients, digital CBTI may be appropriately administered as an adjunct treatment to support mainline intervention more directly targeting suicidogenic thoughts.
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Affiliation(s)
- David A Kalmbach
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
| | - Philip Cheng
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Edward L Peterson
- Department of Public Health Services, Henry Ford Health System, Detroit, MI, USA
- Department of Epidemiology, Henry Ford Health System, Detroit, MI, USA
| | - Anthony N Reffi
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
| | - Chaewon Sagong
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
| | - Grace M Seymour
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
| | - Melissa K Ruprich
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
| | - Christopher L Drake
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
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Sleep duration trajectory during the transition to adolescence and subsequent risk of non-suicidal self-harm. Eur Child Adolesc Psychiatry 2022; 31:1-9. [PMID: 33825948 DOI: 10.1007/s00787-021-01768-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 03/29/2021] [Indexed: 02/01/2023]
Abstract
Non-suicidal self-harm (NSSH) and chronic insufficient sleep are both major health problems during the transition from childhood to adolescence. We examined to identify sleep duration trajectories from childhood to adolescence and their associations with subsequent risk of NSSH. A cohort of children around the period of pubertal onset (7-9 years old) were followed from 2013 over 6 years. Group-based trajectory modeling was recruited to identify sleep duration trajectories derived from 5 repeated measures. Association between sleep duration trajectories with the risk of NSSH was examined using multivariate logistic regression model. Nonlinear dose-response associations between sleep duration and NSSH risk were also assessed using restricted cubic spline models. Of the 1973 participants included in the study (mean ± SD, 8.1 ± 0.9 years age at baseline, 41.1% female). Three sleep duration trajectories were identified: persistent sleeping ≥ 8 h/day (27.7%), moderately decreasing (60.8%) and rapidly decreasing (11.5%) sleep duration groups. After multivariable adjustment for covariates, compared with the persistent sleeping ≥ 8 h/day group, the odds ratio of NSSH was 2.58 (95% CI 1.92, 3.45) for the moderately decreasing group, and 4.16 (2.86, 6.04) for rapidly decreasing group. In dose-response analysis, sleep duration was associated with NSSH risk in a non-linear fashion (χ2 = 25.16, Pnonlinearity < 0.001). When compared with the reference (sleep duration = 8 h), the ORs (95% CI) for NSSH risks were 3.20 (1.93, 5.29), 2.37 (1.64, 3.41), 1.75 (1.39, 2.20) and 1.30 (1.18, 1.44) for sleep duration at 4 to 7 h, respectively. Also, we found sleep duration at 9 h [0.82 (0.75, 0.89)] and at 10 h [0.72 (0.57, 0.91)] significantly associated with decreased risk of NSSH. Longitudinal sleep duration patterns may assist in identification of adolescents at greatest risk of NSSH in the future, which could lead to improved targeting of prevention and intervention strategies. The findings also highlight a non-linear relationship between sleep duration and NSSH during the transition to adolescence.
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Bradford DRR, Biello SM, Russell K. Defeat and Entrapment Mediate the Relationship Between Insomnia Symptoms and Suicidal Ideation in Young Adults. Arch Suicide Res 2022; 26:1632-1643. [PMID: 33616024 DOI: 10.1080/13811118.2021.1885537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM In recent years, there has been a growing interest in understanding the relationship between sleep disturbance and suicide. The current study aimed to advance understanding of the psychological processes driving these relationships by examining whether insomnia symptoms are related to suicidal ideation via perceptions of defeat and entrapment. METHODS Young adults (n = 259; 202 students [78.0%], 45 employed [17.4%], 12 unemployed [4.6%]) completed an anonymous self-report survey that was advertised via social media, university participant pools, and fliers. The survey was described as being related to sleep and mood/mental health. Validated measures were used to assess insomnia symptoms, chronotype, defeat, entrapment, suicidal ideation, and affective covariates. RESULTS Bivariate associations found insomnia severity to be related to poorer affective outcomes including severity of suicidal ideation. Insomnia and depression were significant independent variables in multiple linear regression with suidical ideation as the dependent variable. The relationship between insomnia and suicidal ideation was mediated by perceptions of defeat and entrapment. CONCLUSION Taken together, these findings shed light on the psychological mechanisms linking sleep disturbance and suicidal ideation by highlighting the role of defeat and entrapment. These findings have the potential to improve suicide risk assessment and prevention in young adults experiencing difficulties initiating or maintaining sleep.HighlightsDefeat and entrapment mediate relationship between insomnia and suicidal ideationEvidence for Integrated Motivational-Volitional Model of Suicidal Behavior in community sampleUses validated multi-item suicide measure.
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Bradford DRR, Biello SM, Russell K. Insomnia symptoms mediate the association between eveningness and suicidal ideation, defeat, entrapment, and psychological distress in students. Chronobiol Int 2021; 38:1397-1408. [PMID: 34100311 DOI: 10.1080/07420528.2021.1931274] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Chronotype describes a person's general preference for mornings, evenings, or neither. It is typically conceptualized as a continuous unidimensional spectrum from morningness to eveningness. Eveningness is associated with poorer outcomes across a myriad of physical and mental health outcomes. This preference for later sleep and wake times is associated with increased risk of depression, anxiety, and suicidal ideation in both clinical and community samples. However, the mechanisms underlying the negative consequences of this preference for evenings are not fully understood. Previous research has found that sleep disturbances may act as a mediator of this relationship. The present study aimed to explore the associations between chronotype and affective outcomes in a sample of students. Additionally, it aimed to investigate the potential role of insomnia as a mediator within these relationships. Participants (n = 190) completed an anonymous self-report survey of validated measures online which assessed chronotype, insomnia symptoms, and a range of affective outcomes (defeat, entrapment, suicide risk, stress, and depressive and anxious symptomology). Eveningness was associated with more severe or frequent experiences of these outcomes, with participants that demonstrated a preference for eveningness more likely to report poorer affective functioning and increased psychological distress. Mediation analysis found the relationship between chronotype and these outcome measures was completely or partially mediated by insomnia symptom severity measured by the validated Sleep Condition Indicator insomnia scale. Taken together, these findings add further evidence for the negative consequences of increased eveningness. Additionally, our results show that chronotype and sleep disturbances should be considered when assessing mental well-being. Implementing appropriate sleep-related behavior change or schedule alterations can offer a tool for mitigation or prevention of psychological distress in students that report a preference for later sleep and wake times.
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Tubbs AS, Fernandez FX, Perlis ML, Hale L, Branas CC, Barrett M, Chakravorty S, Khader W, Grandner MA. Suicidal ideation is associated with nighttime wakefulness in a community sample. Sleep 2021; 44:5866613. [PMID: 32614967 DOI: 10.1093/sleep/zsaa128] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 06/19/2020] [Indexed: 12/20/2022] Open
Abstract
STUDY OBJECTIVES Nocturnal wakefulness is a risk factor for suicide and suicidal ideation in clinical populations. However, these results have not been demonstrated in general community samples or compared to sleep duration or sleep quality. The present study explored how the timing of wakefulness was associated with suicidal ideation for weekdays and weekends. METHODS Data were collected from 888 adults aged 22-60 as part of the Sleep and Healthy Activity, Diet, Environment, and Socialization study. Suicidal ideation was measured by the Patient Health Questionnaire-9, while timing of wakefulness was estimated from the Sleep Timing Questionnaire. Binomial logistic regressions estimated the association between nocturnal (11 pm-5 am) and morning (5 am-11 am) wakefulness and suicidal ideation. RESULTS Nocturnal wakefulness was positively associated with suicidal ideation on weekdays (OR: 1.44 [1.28-1.64] per hour awake between 11:00 pm and 05:00 am, p < 0.0001) and weekends (OR: 1.22 [1.08-1.39], p = 0.0018). Morning wakefulness was negatively associated with suicidal ideation on weekdays (OR: 0.82 [0.72-0.92] per hour awake between 05:00 am and 11:00 am, p = 0.0008) and weekends (OR: 0.84 [0.75-0.94], p = 0.0035). These associations remained significant when adjusting for sociodemographic factors. Additionally, nocturnal wakefulness on weekdays was associated with suicidal ideation when accounting for insomnia, sleep duration, sleep quality, and chronotype (OR 1.25 [1.09-1.44] per hour awake, p = 0.002). CONCLUSION Wakefulness at night was consistently associated with suicidal ideation. Additionally, morning wakefulness was negatively associated with suicidal ideation in some models. Although these findings are drawn from a non-clinical sample, larger longitudinal studies in the general population are needed to confirm these results.
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Affiliation(s)
- Andrew S Tubbs
- Sleep and Health Research Program, Department of Psychiatry, University of Arizona, Tucson, AZ
| | - Fabian-Xosé Fernandez
- Department of Psychology, BIO5 and McKnight Brain Research Institutes, University of Arizona, Tucson, AZ
| | - Michael L Perlis
- Behavioral Sleep Medicine Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Lauren Hale
- Program in Public Health, Department of Family, Population, and Preventative Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY
| | | | - Marna Barrett
- Mood and Anxiety Disorders Treatment Research Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Subhajit Chakravorty
- Behavioral Sleep Medicine Program, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Waliuddin Khader
- Sleep and Health Research Program, Department of Psychiatry, University of Arizona, Tucson, AZ
| | - Michael A Grandner
- Sleep and Health Research Program, Department of Psychiatry, University of Arizona, Tucson, AZ
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Tubbs AS, Perlis ML, Basner M, Chakravorty S, Khader W, Fernandez F, Grandner MA. Relationship of Nocturnal Wakefulness to Suicide Risk Across Months and Methods of Suicide. J Clin Psychiatry 2020; 81:19m12964. [PMID: 32097547 PMCID: PMC8121668 DOI: 10.4088/jcp.19m12964] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/11/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Insomnia is a risk factor for suicide, and the risk of suicide after accounting for population wakefulness is disproportionately highest at night. This study investigated whether this risk varied across months and/or methods of suicide. METHODS Time, date, method (eg, firearm, poisoning), and demographic information for 35,338 suicides were collected from the National Violent Death Reporting System for the years 2003-2010. Time of fatal injury was grouped into 1-hour bins and compared to the estimated hourly proportion of the population awake from the American Time Use Survey for 2003-2010. Negative binomial modeling then generated hourly incidence risk ratios (IRRs) of suicide. Risks were then aggregated into 4 categories: morning (6:00 am to 11:59 am), afternoon (noon to 5:59 pm), evening (6:00 pm to 11:59 pm), and night (midnight to 5:59 am). RESULTS The risk of suicide was higher at night across all months (P < .001) and methods (P < .001). The mean nocturnal IRR across months was 3.18 (SD = 0.314), with the highest IRR in May (3.90) and the lowest in November (2.74). The mean (SD) nocturnal IRR across methods was 3.09 (0.472), with the highest IRR for fire (3.75) and the lowest for drowning (2.44). Additionally, nocturnal risk was elevated within all demographics (all P < .001). However, there were no month-by-time or method-by-time interactions across demographics (all P > .05). CONCLUSIONS Regardless of month or method, the incidence risk of suicide at night is higher than at any other time of day. Additionally, demographic subgroups did not differentially experience higher risks across months or mechanisms at night.
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Affiliation(s)
- Andrew S Tubbs
- Department of Psychiatry, University of Arizona, College of Medicine, PO Box 245002, Tucson, AZ 85724-5002. .,Sleep and Health Research Program, Department of Psychiatry, University of Arizona, Tucson, Arizona, USA
| | - Michael L Perlis
- University of Pennsylvania, Department of Psychiatry, Philadelphia, Pennsylvania, USA
| | - Mathias Basner
- University of Pennsylvania, Department of Psychiatry, Philadelphia, Pennsylvania, USA
| | - Subhajit Chakravorty
- University of Pennsylvania, Department of Psychiatry, Philadelphia, Pennsylvania, USA
| | - Waliuddin Khader
- Sleep and Health Research Program, Department of Psychiatry, University of Arizona, Tucson, Arizona, USA,Department of Psychology, University of Arizona, Tucson, Arizona, USA
| | - Fabian Fernandez
- Department of Psychology, University of Arizona, Tucson, Arizona, USA
| | - Michael A Grandner
- Sleep and Health Research Program, Department of Psychiatry, University of Arizona, Tucson, Arizona, USA
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