Reducing Suicidality Through Insomnia Treatment: Critical Next Steps in Suicide Prevention

Association between sleep duration, suicidal ideation, suicidal attempt and suicidal behavior among Chinese adolescents

BACKGROUND

A relatively small number of studies have researched the relationship between sleep duration and suicidal ideation, attempts, and behavior. This research aims to investigate the link between sleep duration and suicide in Chinese adolescents, and to examine the role of depression as a mediating factor.

METHOD

Data were collected from 3315 students using a multi-stage random cluster sampling method and self-administered questionnaires. The study applied logistic regression to investigate the relationship between sleep duration and various forms of suicidal behavior, and mediation analysis to understand how depression might influence this relationship.

RESULTS

The average sleep duration among the adolescents was 7.25 h (±0.20), with 59.67 % reporting insufficient sleep. The logistic regression analysis showed that longer sleep duration is linked with lower risks of suicidal ideation (OR: 0.753, 95%CI: 0.696 to 0.814), suicidal attempts (OR: 0.830, 95%CI: 0.748 to 0.922), and suicidal behavior (OR: 0.841, 95%CI: 0.713 to 0.992). Analysis using restricted cubic spline plots indicated the connection between sleep duration and these suicidal factors was not linear. The study found that depression plays a partial mediating role between sleep duration and suicidal ideation, with an effect of 52.29 %.

LIMITATIONS

The cross-sectional study design could not prove causation.

CONCLUSIONS

There is a clear non-linear association between sleep duration and suicidal tendencies in adolescents, with depression acting as a mediator. This suggests that future research could focus on sleep and mood management as ways to address suicide risk in this age group.

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

Association between transition patterns of sleep problems and suicidal ideation in Chinese female nurses: A prospective study

OBJECTIVE

Suicidal ideation and sleep problems are both common in nurses. However, few longitudinal studies are available to examine the temporal association between sleep and suicidal ideation in nurses.

METHOD

Data from the Health Longitudinal Survey of Nurses in Shandong Province was analyzed, involving 623 female nurses who had completed data of concern in 2018 (T1) and 2019 (T2). Sleep problem was assessed by the Pittsburgh Sleep Quality Index, in which the transition patterns for global and specific sleep component and the cumulative number of sleep component problems were defined. Suicidal ideation was measured by the ninth item of the Patient Health Questionnaire. Binary logistic regression was used to explore the association between sleep and suicidal ideation.

RESULTS

Chronic and deteriorated global sleep problems is associated with a greater risk of suicidal ideation. For the specific component of sleep, sleep disturbance and short sleep duration are associated with a higher risk of suicidal ideation. The higher number of cumulative sleep component problems is associated with a higher risk of suicidal ideation.

CONCLUSION

Findings indicate sleep disturbance and short sleep duration may be pathways to suicidal ideation. Initiatives that target at sleep problems may be important to reduce suicidal ideation in nurses.

Hope Buffers the Effect of Fear of COVID-19 on Depression among College Students: Insomnia as a Mediator

BACKGROUND

In the period of the global pandemic, psychophysical problems induced by the fear of COVID-19 among college students deserve attention since the dormitory environment in college greatly increases the possibility of COVID-19 infection.

METHODS

A hypothesized mediated moderation model was to be verified using a cross-sectional study among 2453 college students. Fear of COVID-19, insomnia, hope, and depression were assessed by using the relevant scales.

RESULTS

(1) The fear of COVID-19 was positively correlated to depression (β = 0.365, t = 5.553, 95% CI = [0.236, 0.494]); (2) hope moderated the influence of the fear of COVID-19 on depression (β = -0.093, t = -4.066, 95% CI = [-0.137, -0.048]), as well as on insomnia (β = -0.095, t = -4.841, 95% CI = [-0.133, -0.056]); and (3) the mediated moderation model with hope as the moderator and insomnia as the full mediating variable between fear of COVID-19 and depression was verified (β = -0.060, 95% CI = [-0.093, -0.028]).

CONCLUSIONS

The findings suggest that hope is a vital mechanism to explain the relationship between the fear of COVID-19 and depression in early adulthood. In practical application, mental health practitioners should focus on boosting hope and alleviating insomnia when addressing COVID-19-related depression issues among college students.

Cognitive-behavioral therapy for insomnia prevents and alleviates suicidal ideation: insomnia remission is a suicidolytic mechanism

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.

Efficacy of Email-delivered Versus Face-to-face Group Cognitive Behavioral Therapy for Insomnia in Youths: A Randomized Controlled Trial

PURPOSE

The purpose of the study was to compare the efficacy of group-based therapy (GT) and email-delivered self-help (ESH) cognitive behavioral therapy for insomnia (CBT-I) with the wait-list (WL) control group in youths.

METHODS

The study involved an assessor-blind, parallel group randomized controlled trial in youths meeting the diagnostic criteria for insomnia disorder. Participants were randomized to one of the three groups (8-week GT, 8-week ESH, or WL). Participants in all three groups were assessed at baseline and after treatment (week 9 for the WL group). The two treatment groups were additionally assessed at one month and six months after the intervention. Treatment effects were examined using linear mixed models.

RESULTS

A total of 135 youths (mean age: 20.0 ± 2.5 years, female: 67.4%) were recruited. After treatment, both active treatment groups showed significant improvements in insomnia symptoms (GT vs. WL: Cohen's d = -1.03, ESH vs. WL: d = -.63), less presleep arousal (d = -.52 to -1.47), less sleep-related dysfunctional belief (d = -.88 to -1.78), better sleep hygiene practice (d = -.79 to -.84), and improved daytime functioning (d = -.56 to -.96) compared with the WL group. In addition, GT outperformed ESH in improving maladaptive sleep-related beliefs and mood symptoms at post-treatment and 6-month follow-up. A reduction of suicidality with moderate effect size favoring GT emerged at 6-month follow-up.

DISCUSSION

Our findings suggested that both group-based and email-delivered CBT-I were effective in treating youth insomnia, but group-based CBT-I showed superior effects on reducing maladaptive beliefs and mood symptoms.

Zolpidem as a high risk factor for elderly suicide in South Korea

BACKGROUNDS

South Korea, a nation with rapidly aging population, has the highest suicide rates in the world, and the elderly have a suicide rate three times higher than the national average. We classified the drugs ingested for suicide attempts by age groups and compare the clinical outcomes between non-elderly and elderly patients who attempted suicide by ingesting drugs.

MATERIALS AND METHODS

Data were obtained from the nationwide Emergency Department-Based Injury Surveillance of the Korea Centers for Disease Control and Prevention, South Korea between January 2011 and December 2016.

RESULTS

There were 12,104 patients who attempted suicide by ingesting drugs, of whom the elderly (73.5%) ingested more sedatives and hypnotics than the non-elderly (53.9%); of these drugs, zolpidem ingestion was higher in the elderly than the non-elderly. Conversely, the non-elderly ingested more antipsychotics and antidepressants (15.9%) and analgesics (10.8%) than the elderly (7.4% and 2.8%, respectively). The elderly had longer hospital stay, higher intensive care unit (ICU) admission rate, and higher mortality rate than the non-elderly: more elderly patients (30.2%) were admitted to the ICU than the non-elderly (15.7%); the duration of hospital stays was 6.27 ± 11.35 days in the elderly and 8.94 ± 14.85 days in the non-elderly; and the mortality rate was 0.4% in the non-elderly and 3.0% in the elderly.

CONCLUSION

Findings suggest that zolpidem has become the greatest risk factor for the elderly Koreans in suicide attempts. Further prevention efforts are needed to prevent suicide among the elderly.

Association of Genome-Wide Polygenic Scores for Multiple Psychiatric and Common Traits in Preadolescent Youths at Risk of Suicide

IMPORTANCE

Suicide is the second leading cause of death among youths worldwide, but no available means exist to identify the risk of suicide in this population.

OBJECTIVE

To assess whether genome-wide polygenic scores for psychiatric and common traits are associated with the risk of suicide among preadolescent children and to investigate whether and to what extent the interaction between early life stress (a major environmental risk factor) and polygenic factors is associated with suicidal thoughts and behaviors among youths.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed the genotype-phenotype data of 11 869 preadolescent children aged 9 to 10 years from the Adolescent Brain and Cognitive Development study. Data were collected from September 1, 2016, to October 21, 2018, and analyzed from August 1, 2020, to January 3, 2021. Using machine learning approaches, genome-wide polygenic scores of 24 complex traits were estimated to investigate their phenome-wide associations and utility for assessing risk of suicidal thoughts and behaviors (suicidal ideation [active, passive, and overall] and suicide attempt).

MAIN OUTCOMES AND MEASURES

Genome-wide polygenic scores were used to measure 24 traits, including psychiatric disorders, cognitive capacity, and personality and psychological characteristics. The Child Behavior Checklist was used to measure early life stress, and the Family Environment Scale was used to assess family environment. Suicidal ideation and suicide attempts were derived from the computerized version of the Kiddie Schedule for Affective Disorders and Schizophrenia.

RESULTS

Among 11 869 preadolescent children in the US, complete data for phenotypic outcomes, genotypes, and covariates were available for 7140 participants in the multiethnic cohort (mean [SD] age, 9.9 [0.6] years; 3588 girls [50.3%]), including 925 participants with suicidal ideation and 63 participants with suicide attempts. Among those 7140 participants, 729 had African ancestry (self-reported race or ethnicity: 569 Black, 71 Hispanic, and 89 other), 276 had admixed American ancestry (self-reported race or ethnicity: 265 Hispanic, 3 White, and 8 other), 150 had East Asian ancestry (self-reported race or ethnicity: 67 Asian, 18 Hispanic, and 65 other), 5718 had European ancestry (self-reported race or ethnicity: 7 Asian, 39 Black, 1142 Hispanic, 3934 White, and 596 other), and 267 had other ancestries (self-reported race or ethnicity: 70 Asian, 13 Black, 126 Hispanic, 48 White, and 10 other). Three genome-wide polygenic scores were significantly associated (false discovery rate P < .05) with suicidal thoughts and behaviors among all participants: attention-deficit/hyperactivity disorder (odds ratio [OR], 1.12; 95% CI, 1.05-1.21; P = .001), schizophrenia (OR, 1.50; 95% CI, 1.17-1.93; P = .002), and general happiness (OR, 0.89; 95% CI, 0.83-0.96; P = .002). In the analysis including only children with European ancestry, 3 additional genome-wide polygenic scores with false discovery rate significance were associated with suicidal thoughts and behaviors: autism spectrum disorder (OR, 1.18; 95% CI, 1.06-1.31; P = .002), major depressive disorder (OR, 1.12; 95% CI, 1.04-1.21; P = .003), and posttraumatic stress disorder (OR, 1.12; 95% CI, 1.04-1.21; P = .004). A significant interaction between genome-wide polygenic scores and environment was found, with genetic risk factors for autism spectrum disorder and the level of early life stress associated with increases in the risk of overall suicidal ideation and overall suicidal thoughts and behaviors (OR, 1.20; 95% CI, 1.07-1.35; P = .002). A machine learning model using multitrait genome-wide polygenic scores and additional self-reported questionnaire data (Child Behavior Checklist and Family Environment Scale) produced a moderately accurate estimate of overall suicidal thoughts and behaviors (area under the receiver operating characteristic curve [AUROC], 0.77; 95% CI, 0.73-0.81; accuracy, 0.67) and suicidal ideation (AUROC, 0.76; 95% CI, 0.72-0.80; accuracy, 0.66) among children with European ancestry only. Among all children in the multiethnic cohort, the integrated model also outperformed the baseline model in estimating the risk of overall suicidal thoughts and behaviors (AUROC, 0.71; 95% CI, 0.67-0.75; accuracy, 0.68) and suicidal ideation (AUROC, 0.75; 95% CI, 0.71-0.78; accuracy, 0.67).

CONCLUSIONS AND RELEVANCE

In this cohort study of preadolescent youths in the US, higher genome-wide polygenic scores for psychiatric disorders, such as attention-deficit/hyperactivity disorder, autism spectrum disorder, posttraumatic stress disorder, and schizophrenia, were significantly associated with a greater risk of suicidal ideation and suicide attempt. The findings and quantitative models from this study may help to identify children with a high risk of suicide, potentially assisting with early screening, intervention, and prevention.

Sleep Disturbances and the Risk of Incident Suicidality: A Systematic Review and Meta-Analysis of Cohort Studies

OBJECTIVE

The association between sleep disturbances and suicidality is not well understood partly because of the variability in research results. This meta-analysis aimed to investigate the predictive value of sleep disturbances for incident suicidality.

METHODS

A systematic search was conducted in PubMed, EMBASE, PsycINFO, and Web of Science databases for studies examining sleep disturbances and incident suicidality. Cohort studies were screened following a registered protocol, and the eligible ones were meta-analyzed.

RESULTS

Seven studies comprising 1,570,181 individuals at baseline, with 1407 attempting suicide and 1023 completing suicide during follow-up, were included. Individuals with baseline sleep disturbances had a significantly higher incidence of suicidality than did those without (relative risk = 2.17, 95% confidence interval [CI] = 1.45-3.24, I2 = 82.50%, p < .001). The risk of an incident suicide attempt was 3.54-fold higher (95% CI = 3.07-4.09, I2 = 0%, p = .44), whereas the risk of incident completed suicide was 1.80-fold higher (95% CI = 1.32-2.44, I2 = 59.33%, p = .01) in individuals with baseline sleep disturbances.

CONCLUSIONS

Incident suicide attempts and deaths are higher among people with sleep disturbances. Regular screening and preventive measures should be undertaken for people with sleep disturbances to prevent progression into suicide attempts and deaths.Clinical Trial Registration:CRD42019136397.

Specific aspects of sleep disturbance associated with suicidal thoughts and attempts

OBJECTIVE

Previous research suggests that sleep disturbance is associated with suicidal ideation and suicide attempt. However, few studies have accounted for the presence of multiple mental disorders and interpersonal factors associated with suicide risk. Furthermore, limited research has examined which aspects of sleep disturbance are most strongly associated with suicidal thoughts and attempts.

METHOD

A large community-based sample of Australian adults (n = 3,618; 81% female; 37% reporting ideation) completed a comprehensive survey assessing suicidal thoughts and behaviours, sleep disturbance, common mental disorders and interpersonal risk factors. Sleep disturbance was assessed using the 6-item PROMIS sleep disturbance scale and suicidality was measured using the Psychiatric Symptom Frequency Scale. Analyses were adjusted for age, sex, perceived burdensomeness, thwarted belongingness, and clinical caseness for six mental disorders, including major depression.

RESULTS

After accounting for mental health, demographic and interpersonal characteristics, increasing sleep disturbance was significantly associated with higher odds of both suicidal ideation (OR=1.17 for one-SD increase in PROMIS-SD), and suicide attempt (OR=1.33 for one-SD increase in PROMIS-SD). Of the specific indicators of sleep disturbance, only sleep onset (difficulties falling asleep) had a significant independent association with both suicidal ideation (p < 0.001) and suicide attempt (p = 0.047).

CONCLUSIONS

Sleep disturbance is independently associated with greater risk of suicidal thoughts and behaviours. Sleep disturbance is highly modifiable, so sleep interventions for people with suicide risk and sleep problems may provide an effective and efficient approach to suicide prevention in the community.

Role of persistent and worsening sleep disturbance in depression remission and suicidal ideation among older primary care patients: the PROSPECT study

STUDY OBJECTIVES

We analyzed data from a practice-based randomized controlled trial within 20 primary care practices located in greater New York City, Philadelphia, and Pittsburgh to determine whether persistent or worsening sleep disturbance plays a role in the outcomes of depression and suicidal ideation at 1 year in older adults with depression.

METHODS

The study sample consisted of 599 adults aged 60 years and older meeting criteria for major depression or clinically significant minor depression. Longitudinal analysis via growth curve mixture modeling was carried out to classify patients as having worsening, persistent, or improving sleep over 1 year.

RESULTS

At 1-year follow-up, compared with patients with improving sleep, those with worsening sleep were more likely to have a diagnosis of major depression (adjusted odds ratio (aOR) = 28.60, 95% confidence interval (CI) 12.15 to 67.34), a diagnosis of clinically significant minor depression (aOR = 11.88, 95% CI 5.67 to 24.89), and suicidal ideation (aOR = 1.10, 1.005 to 1.199), and were half as likely to achieve remission (aOR = 0.52, 95% CI 0.46 to 0.57). Patients with persistent sleep disturbance showed similar but attenuated results.

CONCLUSIONS

Older primary care patients with depression who exhibit worsening or persistent sleep disturbance were at increased risk for persistent depression and suicidal ideation 1 year later. The pattern of sleep disturbance over time may be an important signal for exploration by primary care physicians of depression and suicidal ideation among older adults with depression.

CLINICAL TRIAL REGISTRATION

NCT00279682.

The clinical problem of the lethality of insomnia: a new empirical exploration from a clinical trial

Moul DE. The clinical problem of the lethality of insomnia: a new empirical exploration from a clinical trial. J Clin Sleep Med. 2020;16(8):1225–1227.