Suicidality in sleep disorders: prevalence, impact, and management strategies

Suicidal ideation, suicide attempt, and self-injury among American Indian, Alaskan Native, and Native Hawaiian college students in the United States from 2015 to 2019

Background

Suicide is a major driver of mortality among college students and is the leading cause of death among American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) young adults.

Methods

Data on suicidal ideation, suicide attempt, and self-injury among AI/AN/NH college students (n = 8103) were analyzed via multivariable logistic regressions employing the American College Health Association National College Health Assessment survey from 2015 to 2019. Adjusted odds ratios (aORs) were used to assess how opioid misuse may act as a risk or protective factor for suicidality and self-injury.

Results

Between 2015 and 2019, suicidal ideation was the most prevalent dimension of suicidality affecting AI/AN/NH college students (ranges from 12.69% to 18.35%), followed by self-injury (7.83%-11.41%) and suicide attempt (2.40%-4.10%). AI/AN/NH college students who reported opioid misuse were significantly more likely to experience suicidal ideation (aOR: 1.417; 95% confidence interval [CI]: 1.154-1.740) and self-injury (aOR: 1.684; 95% CI: 1.341-2.116) than those who did not engage in such behavior.

Conclusions

We identified opioid misuse as a potential risk factor for suicidal ideation and intentional self-injury among populations of AI/AN/NH college students. Programs seeking to reduce suicide prevalence among Indigenous college students may benefit from the inclusion of evidence-based interventions that prevent and treat issues related to opioid use.

The Inter-Relationships Between Depressive Symptoms and Suicidality Among Macau Residents After the "Relatively Static Management" COVID-19 Strategy: A Perspective of Network Analysis

Background

Suicidality is a global public health problem which has increased considerably during the coronavirus disease 2019 (COVID-19) pandemic. This study examined the inter-relationships between depressive symptoms and suicidality using network analysis among Macau residents after the "relatively static management" COVID-19 strategy.

Methods

An assessment of suicidal ideation (SI), suicide plan (SP), suicide attempt (SA) and depressive symptoms was conducted with the use of individual binary response items (yes/no) and Patient Health Questionnaire (PHQ-9). In the network analysis, central and bridge symptoms were identified in the network through "Expected Influence" and "Bridge Expected Influence", and specific symptoms that were directly associated with suicidality were identified via the flow function. Network Comparison Tests (NCT) were conducted to examine the gender differences in network characteristics.

Results

The study sample included a total of 1008 Macau residents. The prevalence of depressive symptoms and suicidality were 62.50% (95% CI = 59.4-65.5%) and 8.9% (95% CI = 7.2-10.9%), respectively. A network analysis of the sample identified SI ("Suicidal ideation") as the most central symptom, followed by SP ("Suicide plan") and PHQ4 ("Fatigue"). SI ("Suicidal ideation") and PHQ6 ("Guilt") were bridge nodes connecting depressive symptoms and suicidality. A flow network revealed that the strongest connection was between S ("Suicidality") and PHQ6 ("Guilt"), followed by S ("Suicidality") and PHQ 7 ("Concentration"), and S ("Suicidality") and PHQ3 ("Sleep").

Conclusion

The findings indicated that reduction of specific depressive symptoms and suicidal thoughts may be relevant in decreasing suicidality among adults. Further, suicide assessment and prevention measures should address the central and bridge symptoms identified in this study.

The influence of childhood trauma and chronotype on suicide attempts in Chinese emerging adults with severe depressive symptoms

BACKGROUND

Studies have investigated how adults with severe depressive symptoms are more likely to attempt suicide, and these adults often have traumatic experiences and chaotic sleep/wake rhythms. Thus, this study using Latent class analysis aimed to investigate the relationship between childhood trauma class, chronotype, and suicide attempts among emerging adults with severe depressive symptoms.

METHODS

This study was conducted among emerging adults with severe depressive symptoms covering 63 Universities in Jilin Province, China. A total of 1,225 emerging adults (mean age = 19.6 ± 1.78) constructed the final sample. In addition to measuring socio-demographic characteristics, the Childhood Trauma Questionnaire-Short Form, the Single-Item Chronotyping, and a single item for suicide attempts were used to evaluate childhood trauma, chronotype, and suicide attempts, respectively. Latent class analysis was applied to identify the classes of childhood trauma within emerging adults who had severe depressive symptoms. Hierarchical logistic regression models were run to investigate the effects of socio-demographic characteristics, chronotype, and childhood trauma class on suicide attempts.

RESULTS

Three latent classes were identified: the Low-risk for childhood trauma class, the Neglect class, and the High-risk for childhood abuse class. Those who suffered sexual, emotional, and physical abuse at the same time were divided into the High-risk for childhood abuse class, and were significantly more likely to experience suicide attempts than those in the Neglect class (OR = 1.97, 95%CI = 1.34-2.89, p < 0.001) and the Low-risk for childhood trauma class (OR = 2.28, 95% CI = 1.50-3.46, p < 0.001). In terms of chronotype, the results showed that the chaotic type was a risk factor for suicide attempts when compared with the evening type (OR = 0.46, 95%CI = 0.27-0.78, p < 0.01), the moderately active type (OR = 0.53, 95%CI = 0.31-0.89, p < 0.05), and the daytime type (OR = 0.42, 95%CI = 0.21-0.86, p < 0.05). Overall, the significant risk factors for suicide attempts included being female, living in an urban area, having experienced sexual, emotional, and physical abuse simultaneously, and having a chaotic chronotype.

CONCLUSION

Emerging adults suffering sexual, emotional, and physical abuse at the same time and identifying with chaotic chronotype showed a higher risk of attempting suicide. The findings provided a clinical reference to quickly identify those at high risk of suicide attempts among emerging adults with severe depressive symptoms.

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.

Loneliness and depressive symptoms among Australian female boarding school students

Loneliness in adolescence is a risk factor for the development and maintenance of a myriad of mental health conditions, especially among females. Adolescent females in boarding schools spend prolonged periods away from family and may therefore be more prone to experiencing loneliness and depression. Research into this significant issue is limited, however. The present study compared the levels of loneliness and depressive symptoms of 403, 13–17 year old adolescent females from a range of boarding and non-boarding secondary schools. Confirmatory Factor Analyses established the fit of the loneliness and depressive symptom measures. Multivariate Analysis of Variance revealed boarding school students scored significantly higher than non- boarding school students on levels of depressive symptoms and having a positive attitude to being alone. These differences remained significant when age was covaried. There were no differences in quality of friendships, feelings of isolation, and having a negative attitude to being alone. The implications of these findings for boarding schools are discussed.

Risk of current suicidal ideations associated with lifelong anhedonia and recent change of anhedonia in individuals with insomnia: A cross-sectional study

BACKGROUND

Individuals with insomnia are a subpopulation at high-risk of suicide. However, despite the elements in favour of an implication of anhedonia in the occurrence of current suicidal ideations (SI), no study has investigated the role played by this affective symptom in the occurrence of current SI in individuals with insomnia. The aim of this study was to investigate the risk of current SI associated with lifelong anhedonia and recent change of anhedonia in individuals with insomnia.

METHOD

Demographic and polysomnographic data from 493 individuals with insomnia selected retrospectively from the clinical database of the Erasme Hospital Sleep Laboratory were analysed. Current SI were considered present if the score in item 9 of the Beck Depression Inventory (BDI-II) was ≥1 and/or if they were highlighted during the systematic psychiatric assessment conducted on admission to the Sleep Laboratory. Logistic regression analyses were used to determine the risk of current SI associated with anhedonia in individuals with insomnia.

RESULTS

The prevalence of current SI was 21.5% in our sample of individuals with insomnia. After adjusting for major confounding factors, multivariate logistic regression analyses demonstrated that unlike lifelong anhedonia, only recent change of anhedonia was a risk factor for current SI in individuals with insomnia.

CONCLUSION

In this study, we demonstrated that in individuals with insomnia, recent change of anhedonia is a risk factor for current SI, which seems to justify more systematic research and adequate therapeutic management of this condition to allow better prevention in this particular subpopulation at high-risk of suicide.

Suicidality and Associated Factors Among Individuals Assessed for Fetal Alcohol Spectrum Disorder Across the Lifespan in Canada

OBJECTIVE

Individuals with fetal alcohol spectrum disorder (FASD) experience a range of complex neurodevelopmental, psychological, and socioenvironmental vulnerabilities. There is growing evidence that suicidal ideation, attempts, and death by suicide are significant concerns within this population. In this study, we (1) determined the rate of suicidal ideation/attempts in a large group of individuals with prenatal alcohol exposure (PAE) who were assessed for FASD in Canada and (2) investigated the associations between suicidal ideation/attempts and select demographic and biopsychosocial factors in this group.

METHOD

A secondary analysis of data from Canada's National FASD Database, a national repository of clinical information gathered through FASD assessment and diagnostic clinics across the country, was conducted. Descriptive analyses, chi-square/Fisher's exact tests, and binary logistic regression were used to examine demographic and biopsychosocial variables and their associations with suicidality.

RESULTS

In our sample of 796 participants (M_age = 17.7 years, range = 6-59; 57.6% male) assessed for FASD, 25.9% were reported to experience suicidal ideation/attempts. Numerous demographic and biopsychosocial factors were found to be significantly associated with suicidal ideation/attempts. The strongest associations with suicidal ideation/attempts were substance use, history of trauma/abuse, and impaired affect regulation.

CONCLUSIONS

With this study, we contribute to the emerging evidence of elevated risk of suicidality among individuals with PAE/FASD and improve our understanding of factors that may exacerbate this risk. Findings have relevance for improving screening, prevention, and proactive treatment approaches for individuals with PAE and FASD, their families, and wider support systems.

Impacts of the psychological stress response on nonsuicidal self-injury behavior in students during the COVID-19 epidemic in China: the mediating role of sleep disorders

Background

The sudden outbreak of COVID-19 had a great impact on the physical and mental health of people all over the world, especially for students whose physical and mental development was not yet mature. In order to understand the physical and mental conditions of students during the epidemic period and provide a theoretical basis for coping with psychological problems in public health emergencies, this study explored the mediating role of sleep disorders in the effect of the psychological stress response (PSR) on non-suicidal self-injury (NSSI), along with the moderating role of emotional management ability (EMA).

Methods

The SRQ-20, Pittsburgh Sleep Quality Index, NSSI Behavior Questionnaire, and Emotional Management Questionnaire were used to investigate the mental health of Chinese students in April 10–20 (Time point 1, T1) and May 20–30 (Time point 2, T2), 2020. A total of 1,955 students (Mage = 19.64 years, 51.4% male) were examined at T1 and 342 students (Mage = 20.06 years, 48.2% male) were reassessed at T2.

Results

Overall, the detection rate of PSR and NSSI were 17.60% (n = 344) and 24.90% (n = 486) respectively in the T1 sample, and were 16.37% (n = 56) and 25.44% (n = 87), in the T2 sample. We also found that sleep disorders played a mediating role in the effect of PSR on NSSI in the T1 and T2 samples. In addition, EMA was shown to regulate the effect of PSR on sleep disorders and the effect of sleep disorders on NSSI in the T1 samples.

Conclusion

We found that PSR resulting from public health emergency might lead to NSSI behaviors in individuals. PSR may also cause sleep disorders, which can bring about NSSI. However, these effects were also moderated by the EMA. This research expands our understanding of PSR and NSSI in students during the pandemic.

Predicting the Risk of Future Multiple Suicide Attempt among First-Time Suicide Attempters: Implications for Suicide Prevention Policy

Suicide is listed in the top ten causes of death in Taiwan. Previous studies have pointed out that psychiatric patients having suicide attempts in their history are more likely to attempt suicide again than non-psychiatric patients. Therefore, how to predict the future multiple suicide attempts of psychiatric patients is an important issue of public health. Different from previous studies, we collect the psychiatric patients who have a suicide diagnosis in the National Health Insurance Research Database (NHIRD) as the study cohort. Study variables include psychiatric patients’ characteristics, medical behavior characteristics, physician characteristics, and hospital characteristics. Three machine learning techniques, including decision tree (DT), support vector machine (SVM), and artificial neural network (ANN), are used to develop models for predicting the risk of future multiple suicide attempts. The Adaboost technique is further used to improve prediction performance in model development. The experimental results show that Adaboost+DT performs the best in predicting the behavior of multiple suicide attempts among psychiatric patients. The findings of this study can help clinical staffs to early identify high-risk patients and improve the effectiveness of suicide prevention.

A Comprehensive Review of the Literature on Sleep Difficulties and Suicidality in Youth to Inform an Integrative Developmental Model and Future Directions

Purpose of Review

Suicide is currently the second leading cause of death among youth. Identification of modifiable near-term risk factors can inform suicide prevention strategies. One promising, readily assessed factor is sleep. We critically review the literature on sleep and suicidal thoughts and behaviors among youth.

Recent Findings

Most studies examining the youth sleep-suicidality relationship are from epidemiological samples in which both sleep problems and suicidality were assessed over variable timeframes using limited items from scales not designed to measure these constructs. Nonetheless, these data overwhelmingly support an association between suicidality and a range of sleep difficulties (e.g., insomnia, short/long sleep, weekend oversleep), above and beyond depressive symptoms. Limited studies include clinical samples or prospective designs. We review potential mechanisms and present a developmentally-informed integrative model.

Summary

Literature supports a clear association between sleep difficulties and youth suicidality. Future directions include prospective longitudinal studies and targeted prevention efforts.

Proximal Risk for Suicide: A Daily Diary Study Protocol (Preprint)

Background

Suicide is a prevalent public health concern in the United States across all age groups. Research has emphasized the need to identify risk markers that prevent suicide along shorter timeframes, such as days to weeks. Furthermore, little has been done to explore the relative significance of factors that can predict short-term suicide risk or to evaluate how daily variability in these factors impacts suicidal ideation or behavior. This proposed project aims to identify risk factors that best predict near-time changes in suicidal ideation and examine potential interactions between these factors to predict transitions into suicidal thinking or behaviors.

Objective

The aim of this proposed study is threefold: (1) To identify which psychological risk factors are most strongly associated with proximal changes in suicide risk across days and weeks. (2) To evaluate theoretical assumptions of the Integrative-Motivational-Volitional Theory of Suicide. (3) To determine how disruptions in physiological arousal interact with theoretical mechanisms of risk to predict concurrent and short-term prospective increase in suicidal thoughts and behaviors.

Methods

A daily diary or ecological momentary assessment design will be utilized with 200 participants. Participants will complete 2 in-person visits separated by 3 weeks during which they will complete 3 brief daily assessments within their natural environments using the ilumivu research app on a smart device. Research will occur at the Mayo Clinic Health System (MCHS) Eau Claire site. Participants will be recruited through chart review and standard care delivery assessment.

Results

This manuscript outlines the protocol that will guide the conduct of the forthcoming study.

Conclusions

The proposed project aims to lead efforts using technological advances to capture microchanges in suicidal thinking/behavior over shorter timeframes and thereby guide future clinical assessment and management of suicidal patients. Results of this study will generate robust evidence to evaluate which risk factors predict proximal changes in suicidal ideation and behaviors. They will also provide the ability to examine potential interactions with multiple theoretically derived risk factors to predict proximal transitions into worsening suicidal thinking or behaviors. Such information will provide new targets for intervention that could ultimately reduce suicide-related morbidity and mortality.

International Registered Report Identifier (IRRID)

PRR1-10.2196/37583

Sleep architecture and emotional inhibition processing in adolescents hospitalized during a suicidal crisis

BACKGROUND

Suicide is the second leading cause of death in adolescents. Sleep disturbances could alter inhibitory processes and contribute to dangerous behaviors in this critical developmental period. Adolescents in suicidal crisis have been shown to have lighter sleep compared to healthy controls. Additionally, suicidal adolescents have lower neural resources mobilized by emotionally charged inhibition processing. The present exploratory study aimed to determine how sleep architecture in suicidal adolescents may relate to inhibition processing in response to emotional stimuli.

METHODS

Ten adolescents between 12 and 17 years of age with a diagnosis of major depressive disorder and who attempted suicide were recruited while hospitalized for a suicidal crisis in a psychiatric inpatient unit. Event-related potentials (ERPs) were recorded prior to bedtime during a Go/NoGo task involving pictures of sad, happy, and neutral faces. Polysomnography was then recorded throughout the night. Pearson correlations were conducted to investigate how inhibition performance and ERP parameters reflecting inhibition processing (i.e., P3d and N2d derived from difference waveform calculated as NoGo minus Go trials) relate to sleep architecture.

RESULTS

Poorer inhibition accuracy in response to emotional stimuli was significantly correlated with shorter REM sleep latency, higher REM sleep, and more frequent nocturnal awakenings. The P3d in response to sad faces was negatively correlated with NREM2 sleep and positively correlated with NREM3 sleep. No such association with the P3d was found for happy or neutral stimuli. There were no significant correlations for the N2d.

CONCLUSION

Altered sleep in adolescents with depression who are in a suicidal crisisis associated with behavioral inhibition difficulties and fewer neural resources mobilized by inhibitory processes in emotionally charged contexts. This highlights the importance of addressing sleep disturbances while managing suicidal crises in adolescents.

Shame and guilt in the suicidality related to traumatic events: A systematic literature review

BACKGROUND

Shame and guilt are involved in suicidality and in post-traumatic stress disorder. However, few studies have explored the implication of those emotions in the suicidality of patients exposed to traumatic events.

OBJECTIVE

The objective of this literature review was to examine the implication of shame and guilt in the suicidality of individuals who have experienced potentially traumatic events or been diagnosed with post-traumatic stress disorder. These two emotions are part of post-traumatic stress disorder and suicidality. Moreover, when individuals perceive that their coping strategies are inadequate, they may view suicide as a relief from suffering.

METHOD

This review was conducted according to PRISMA method. We used combinations of search words for traumatization, suicide ideation and behavior and shame and guilt to search for empirical studies in common databases in psychology and medicine.

RESULTS

Among 137 identified articles, 9 full texts were retained. Results suggest that shame and guilt were involved in all aspects of suicidality in patients who had experienced traumatic events or been diagnosed with post-traumatic stress disorder. The degree of shame and guilt differed with the type of traumatic event, notably affecting individuals who had experienced military combat, physical or sexual abuse, or emotional or physical neglect.

CONCLUSION

Shame and guilt are implicated in suicide's risk. Future research is now needed to determine whether greater attention to these two emotions would enhance our understanding and anticipation of suicidal behavior in those who have experienced a potentially traumatic event or been diagnosed with post-traumatic stress disorder.

Non-Constructive Ruminations, Insomnia and Nightmares: Trio of Vulnerabilities to Suicide Risk

OBJECTIVE

Nightmare distress, nightmare frequency and anxiety are related to suicidal risk. Ruminations are a factor maximizing the risk of suicide. Research has identified two types of ruminations: constructive ruminations and non-constructive ruminations. As per our knowledge, no study has verified the links between non-constructive ruminations and sleep disorders and their role in the development of suicidal risk. We aimed to highlight the impact of non-constructive ruminations on nightmares, anxiety and insomnia in the development of suicidal risk.

METHODS

A total of 429 French participants responded to an anonymous online survey using the Qualtrics^® software. To assess variables, we used the Mini Cambridge-Exeter Repetitive Thought Scale, the Suicide Behaviors Questionnaire-Revised, the Nightmare Distress Questionnaire, the Beck Anxiety Inventory, and the Sleep Condition Indicator. Nightmare frequency was assessed by subjective evaluation through a question. We tested the possible effects of confounding variables such as age, gender, marital status and depression (Beck Depression Inventory-II).

RESULTS

Nightmare frequency was found to mediate the link between anxiety and suicidal risk (32.9%). Nightmare distress (37%) and non-constructive thoughts (48%) were also seen to mediate this link. Additionally, we found a moderating effect of insomnia on the link between non-constructive ruminations and suicidal risk (Z = 7.42, p < 0.001).

CONCLUSION

Our results showed that the frequency of nightmares, distress and non-constructive ruminations are closely related to suicidal risk. The interoperability between these elements and insomnia has thus been newly explored. The processes related to nightmares and suicidal risk as well as the underlying cognitive processes between sleep disorders and suicidal risk have been shed light upon.

Imagery Rescripting and Imaginal Exposure in Nightmare Disorder Compared to Positive Imagery: A Randomized Controlled Trial

INTRODUCTION

Both imagery rescripting and imaginal exposure have been proven to be effective in the treatment of chronic nightmares when compared to a waitlist condition. Little is known about their comparative efficacy and their efficacy compared to an active control.

OBJECTIVE

The aims of this study were to compare the two treatments to one another and to positive imagery as an active control, and to explore covariates of the treatment effect.

METHODS

In this single-blinded randomized controlled trial, 96 patients with nightmare disorder (idiopathic nightmares) from an outpatient clinic were randomly assigned to a single individual treatment session of rescripting, exposure, or positive imagery and 4 weeks of practice at home. The primary outcome was nightmare distress, and the secondary outcomes were nightmare frequency, nightmare effects, self-efficacy, and general psychopathology.

RESULTS

Nightmare distress was reduced in all groups (imagery rescripting: Cohen's d = -1.04, imaginal exposure: d = -0.68, positive imagery: d = -0.57), as were nightmare frequency, nightmare effects, and psychopathology. Self-efficacy was enhanced. No differential treatment effects were found on any primary or secondary measure. Treatment gains were not associated with demographic or disorder characteristics, baseline values, treatment credibility, or the number of practice sessions.

CONCLUSIONS

Even short nightmare treatments are effective regardless of personal characteristics, and different interventions produce similar results. Future research should aim to clarify the mechanisms of action. Health care should make more use of these powerful and easy-to-administer nightmare treatments.

Suicidal ideation in people with tinnitus: a systematic review and meta-analysis

OBJECTIVE

Tinnitus is associated with a variety of cognitive, psychosocial and psychiatric disorders, and may contribute to suicidality. However, the prevalence of suicidal ideation (SI) in tinnitus populations has not previously been systematically reviewed.

METHOD

Medline, Embase and PsychInfo were searched in August 2020 to identify studies that assessed suicidal ideation in people aged 16 years and above with subjective tinnitus.

RESULTS

Six cross-sectional studies were included, representing 7192 tinnitus sufferers across 4 countries. The pooled prevalence of suicidal ideation in tinnitus populations was 20.6 per cent (95 per cent confidence interval, 10.8-30.3 per cent; I2 = 88 per cent). Two studies included a control population, in which the prevalence of suicidal ideation was significantly lower. The quality of included studies was variable.

CONCLUSION

It is not possible to arrive at any reasonable conclusion given the lack of quality studies, meaning the pooled prevalence should be interpreted very cautiously. Suicidal ideation may be more prevalent in tinnitus populations. Further large-scale epidemiological research investigating this relationship is needed, which may help psychiatric risk stratification.

Sleep Disturbances and Suicidal Behavior

Sleep disturbances, particularly insomnia, nightmares, and excessive daytime sleepiness (EDS), are significant, proximal, and modifiable risk factors for suicidal ideation and behaviors (SIB) and could be targeted for preventative interventions. In this chapter, we review the evidence supporting the association of insomnia, nightmares, and EDS with SIB. We also describe these sleep disturbances in the general population, as well as their association with psychiatric disorders. A PubMed search was conducted to identify the relevant literature. Insomnia is very frequent across mental disorders, but SIB patients are particularly exposed. Specific interventions focused on insomnia are useful in contending suicidal ideation. Nightmares seem to constitute an independent risk factor for SIB, beyond insomnia, particularly in young people and when experienced frequently. The evidence regarding the association of EDS and SIB is less clear and probably explained by the reduction of health-related quality of life and comorbid depression. The mechanisms underlying the relationship between sleep disturbances and SIB as well as the role of potential confounders and future perspectives in this field are also discussed.

Effect of adjunctive pimavanserin on suicidal ideation in patients with major depression: Analysis of the CLARITY study

BACKGROUND

Up to 15% of patients with major depressive disorder (MDD) attempt suicide and up to 2% complete suicide. This was a post-hoc analysis aimed to evaluate the risk of suicide ideation and behavior associated with adjunctive pimavanserin treatment in adults with MDD.

METHODS

CLARITY was a randomized, double-blind, placebo-controlled study in patients with MDD and an inadequate response to a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI). For this post-hoc analysis, the primary endpoint was mean change from baseline for HAMD item 3 (suicide). The incidence of suicidal ideation or behavior was also assessed from the Columbia-Suicide Severity Rating Scale (C-SSRS) and reports of adverse events.

RESULTS

During Stage 1, LS mean change for HAMD Item 3 was reduced from baseline at each week with pimavanserin with a significant difference between pimavanserin and placebo at Week 3 (p=0.012, effect size: 0.431). At any post-baseline assessment, suicidal ideation on the C-SSRS was reported in 28 (18.1%) of patients with placebo and 9 (17.3%) with pimavanserin during Stage 1 and in 7 (20.7%) with placebo and 4 (13.8%) with pimavanserin during Stage 2. No events of suicidal behavior were observed with either placebo or pimavanserin.

LIMITATIONS

The post hoc nature, exclusion of patients with any history of suicide from the primary study, and the small number of patients who demonstrated evidence of suicidal ideation.

CONCLUSIONS

Adjunctive pimavanserin was not associated with an increase in suicidal ideation in patients with MDD. Further study is needed to verify these results.

Secular trends in suicidal ideation and associated factors among adolescents

Objectives:

Suicide is one of the leading causes of death in adolescence, and the second most common cause of death among young people. The objective of this study was to identify trends in suicidal ideation by sex and ascertain factors associated with this outcome.

Methods:

Secular trend study with statewide coverage conducted at 5-year intervals, with 4,207 adolescents (2006), 6,264 adolescents (2011) and 6,026 adolescents (2016). Logistic regression was used to evaluate the secular trend of suicidal ideation. Multilevel logistic regressions evaluated the factors associated with suicidal ideation in the survey conducted in 2016.

Results:

There was a positive trend in suicidal ideation prevalence in 2016 compared to the prevalence in 2006 and 2011, in both boys and girls. Low social support, poor sleep quality, and low parental supervision were associated with suicidal ideation in boys and girls. Exposure to violence and bullying was associated with suicidal ideation only in girls. TV time and computer and videogame time were not associated with suicidal ideation in boys or girls.

Conclusion:

There is an alarming trend of increased suicidal ideation in adolescents. Several dimensions were associated with suicidal ideation in adolescents, especially social support, sleep quality, and parental supervision.

Suicidal Ideation and Insomnia in Bipolar Disorders: Idéation suicidaire et insomnie dans les troubles bipolaires

OBJECTIVE

Bipolar disorder (BD) confers elevated suicide risk and associates with misaligned circadian rhythm. Real-time monitoring of objectively measured sleep is a novel approach to detect and prevent suicidal behavior. We aimed at understanding associations between subjective insomnia and actigraphy data with severity of suicidal ideation in BDs.

METHODS

This prospective cohort study comprised 76 outpatients with a BD aged 18 to 65 inclusively. Main measures included 10 consecutive days of wrist actigraphy; the Athens Insomnia Scale (AIS); the Montgomery-Åsberg Depression Rating Scale (MADRS); the Quick Inventory of Depressive Symptoms-16, self-rating (QIDS-SR-16); and the Columbia Suicide Severity Rating Scale. Diagnoses, medications, and suicide attempts were obtained from chart review.

RESULTS

Suicidal ideation correlated moderately with subjective insomnia (AIS with QIDS-SR-16 item 12 ρ =0.26, P = 0.03; MADRS item 10 ρ = 0.33, P = 0.003). Graphical sleep patterns showed that suicidal patients were enriched among the most fragmented sleep patterns, and this was confirmed by correlations of suicidal ideation with actigraphy data at 2 visits. Patients with lifetime suicide attempts (n = 8) had more varied objective sleep (a higher standard deviation of center of daily inactivity [0.64 vs. 0.26, P = 0.01], consolidation of daily inactivity [0.18 vs. 0.10, P = <0.001], sleep offset [3.02 hours vs. 1.90 hours, P = <0.001], and total sleep [105 vs. 69 minutes, P = 0.02], and a lower consolidation of daily inactivity [0.65 vs. 0.79, P = 0.03]).

CONCLUSIONS

Subjective insomnia, a nonstigmatized symptom, can complement suicidality screens. Longer follow-ups and larger samples are warranted to understand whether real-time sleep monitoring predicts suicidal ideation in patient subgroups or individually.

Sleep problems and suicide risk in youth: A systematic review, developmental framework, and implications for hospital treatment

OBJECTIVE

Sleep problems are transdiagnostic symptoms that confer significant risk for suicidal thoughts and behaviors (STBs) in adults. However, less is known about the sleep-STB association in adolescence-a developmental period when rates of STBs increase drastically, and sleep problems may be particularly pernicious. This article provides a systematic review of research on the sleep-STB association in youth, an overview of changes in sleep regulation during adolescence that may make sleep problems particularly detrimental for youth, and a discussion of the clinical implications of the sleep-STB association for hospitalized youth.

METHOD

The systematic review included all longitudinal studies in which sleep problems were examined as prospective predictors of STBs in adolescents (aged 10-24 years). The search was conducted on December 1, 2017 using PsychINFO, PubMed, and Web of Science databases.

RESULTS

Ten studies qualified for inclusion in this review. Of these, seven studies found at least one type of sleep problem significantly predicted a STB outcome.

CONCLUSIONS

Although findings are mixed, growing research suggests that sleep problems may be a unique risk factor for STBs in youth. Sleep problems may be particularly important intervention target because they are easily assessed across healthcare settings and are amenable to treatment.

Sleep quality in medical students: a comprehensive meta-analysis of observational studies

PURPOSE

Poor sleep quality is common in medical students and is associated with a number of negative health outcomes. However, the prevalence estimates of poor sleep quality in medical students vary widely across studies. We thus conducted a meta-analysis of the prevalence of poor sleep quality and its mediating factors in medical students.

METHODS

A systematic literature search of PubMed, EMBASE, Web of Science, PsycINFO, and Medline Complete was performed. The random-effects model was used to analyze the pooled prevalence of poor sleep quality and its 95% confidence intervals (CIs).

RESULTS

A total of 57 studies with 25,735 medical students were included. The pooled prevalence of poor sleep quality was 52.7% (95% CI: 45.3% to 60.1%) using the Pittsburgh Sleep Quality Index (PSQI). The pooled mean total PSQI score across 41 studies with available data was 6.1 (95% CI: 5.6 to 6.5). Subgroup analyses found that PSQI cutoff value and study region were associated with the prevalence of poor sleep quality (P = 0.0003 VS. P = 0.005). Across the continents, poor sleep quality was most common in Europe, followed by the Americas, Africa, Asia, and Oceania. Meta-regression analyses found that smaller sample size (slope = - 0.0001, P = 0.009) was significantly associated with higher prevalence of poor sleep quality.

CONCLUSIONS

Poor sleep quality is common among medical students, especially in Europe and the Americas continets. Due to the negative health outcomes, regular screening of poor sleep quality and effective interventions are needed for medical students.

The Mediating Effect of Sleep Quality on the Relationship between Emotional and Behavioral Problems and Suicidal Ideation

Emotional and behavioral problems in adolescents are associated with suicidal ideation, but different dimensions of problems may be associated with different levels of suicidal ideation. The aim of this large-scale study was to explore the relationship between different dimensions of emotional and behavioral problems and suicidal ideation in Chinese adolescents and to determine whether sleep disorders play a mediating role in the relationship. In total, 20,475 students completed the questionnaire regarding emotional and behavioral problems, sleep quality and suicidal ideation. After adjustment for covariates, total emotional and behavioral difficulties (adjusted odds ratios (AOR) = 1.22, 95% confidence interval (CI) = 1.21-1.23) and sleep disorders (AOR = 4.17, 95% CI = 3.82-4.54) increased the risk of suicidal ideation, while prosocial problems (AOR = 0.91, 95% CI = 0.90-0.93) decreased the risk of suicidal ideation. Sleep quality partially mediated the relationship between emotional and behavioral problems and suicidal ideation. The standardized indirect effects of emotional and behavioral difficulties on suicidal ideation (standardized β estimate = 0.031, 95% CI = 0.020, 0.044) and the effects of prosocial problems on suicidal ideation (standardized β estimate = -0.039, 95% CI = -0.045, -0.035) mediated by sleep quality were statistically significant (p < 0.001). Our study indicates that emotional and behavioral problems increase the risk of suicidal ideation. Additionally, sleep quality plays a mediating role in the association between emotional and behavioral problems and suicidal ideation.

Recent advances in understanding and managing self-harm in adolescents

Adolescent suicide is a serious public health problem, and non-suicidal self-injury (NSSI) is both highly comorbid with suicidality among adolescents and a significant predictor of suicide attempts (SAs) in adolescents. We will clarify extant definitions related to suicidality and NSSI and the important similarities and differences between these constructs. We will also review several significant risk factors for suicidality, evidence-based and evidence-informed safety management strategies, and evidence-based treatment for adolescent self-harming behaviors. Currently, dialectical behavior therapy (DBT) for adolescents is the first and only treatment meeting the threshold of a well-established treatment for self-harming adolescents at high risk for suicide. Areas in need of future study include processes underlying the association between NSSI and SAs, clarification of warning signs and risk factors that are both sensitive and specific enough to accurately predict who is at imminent risk for suicide, and further efforts to sustain the effects of DBT post-treatment. DBT is a time- and labor-intensive treatment that requires extensive training for therapists and a significant time commitment for families (generally 6 months). It will therefore be helpful to assess whether other less-intensive treatment options can be established as evidence-based treatment for suicidal adolescents.

Sleep-related problems and suicide behavior and ideation among Black and White trauma-exposed psychiatric inpatients

OBJECTIVE

Sleep-related problems (SRPs) are associated with increased risk for suicide-related behavior and death. Given that Black adults report greater SRPs as compared to White adults, the purpose of the current study was to examine sleep problems, suicide-related psychiatric admission, and suicide ideation, in Black and White trauma-exposed adults.

METHOD

Suicide-related behavior (i.e., intent, plan, and/or behavior) as reason for hospital admission was obtained via medical records review for 172 Black and White adults who were admitted to an acute-care psychiatric facility; all participants completed validated measures of sleep quality and suicide ideation.

RESULTS

Adjusted logistic regression analyses revealed that sleep-related daytime dysfunction (AOR = 4.32, p < .05) and poor sleep quality (AOR = 3.64, p < .05) were associated with significantly increased odds that Black participants were admitted for suicide-related psychiatric care. Poorer sleep quality (AOR = 2.10, p < .05) was also associated with increased odds of suicide-related admission among White participants. However, shorter sleep duration was marginally associated with suicide ideation in Black participants only.

CONCLUSIONS

SRPs may be related to suicide-related behavior and ideation differently for vulnerable Black and White adults. More research is needed to understand potential race group differences and mechanisms by which SRPs increase risk for suicide crisis across racial groups.

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide-specific diagnosis

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self-reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence-based components-entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre-suicidal mental state, regardless of their self-reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.

Perceived burdensomeness, thwarted belongingness and suicidal ideation in patients with fibromyalgia and healthy subjects: a cross-sectional study

Perceived burdensomeness and thwarted belongingness are key factors in the development of suicidal behaviors that have been frequently observed among patients with fibromyalgia. The aim of the present study was to compare these two factors in patients with fibromyalgia with and without suicidal ideation and healthy subjects. Secondary objectives were to evaluate the relationship between these two factors and the secondary variables included in the study, such as depression, sleep quality or the degree of marital adjustment. Perceived burdensomeness and thwarted belongingness were assessed with the Interpersonal Needs Questionnaire, depression and suicidal ideation with the Patients Health Questionnaire-9, suicidal risk with the Plutchik Suicide Risk scale, sleep with the Insomnia Severity Index, and marital adjustment with the Locke-Wallace Marital Adjustment scale. Questionnaire scores were compared with the Kruskal-Wallis test. 49 healthy subjects, 38 patients with fibromyalgia without suicidal ideation and 15 patients with fibromyalgia and suicidal ideations were included. Perceived burdensomeness scores were significantly higher in patients with suicidal ideation than in patients without suicidal ideation and controls; thwarted belongingness scores were significantly higher in patients with suicidal ideation than in controls. Marital adjustment was also significantly poor in patients with suicidal ideation than in patients without suicidal ideation and controls. Among patients with fibromyalgia, perceived burdensomeness seems to be strongly related with suicidal ideation, whereas thwarted belongingness seems to play a less relevant role at this respect. Poor marital adjustment could be related with depression.