Prescription medications for insomnia are associated with suicidal thoughts and behaviors in two nationally representative samples

Trends in hypnotic drug use in depression 2007-2017: A Swedish population-based study

Insomnia is a common feature of depression; however, depression treatment guidelines provide limited recommendations regarding hypnotic drugs. Few studies have thoroughly investigated the use of hypnotic drugs in depression. In this cohort study using national Swedish registers, we included all patients ≥18 years with incident unipolar depression during 2007-2017. Patients were followed for 3 years, noting the annual and quarterly prevalence of hypnotic drug use from prescription fills. Prevalence ratios (PR) comparing 2017 to 2007 were calculated with 95% confidence intervals (CI). A total of 222,077 patients with depression were included (mean age 41 years, 59% women). In the year following diagnosis, 44.1% used any hypnotic drug in 2017, compared with 46.7% in 2007 (PR 0.94, 95% CI 0.92-0.97). The most commonly used drugs were Z-drugs (zopiclone, zolpidem, and zaleplon) with a prevalence of 27.6% in 2017 and 35.6% in 2007 (PR 0.78, 95% CI 0.75-0.80). Melatonin use increased sharply to 12.0% in 2017 from 0.4% in 2007 (PR 28.9, 95% CI 23.5-35.7). Hypnotic drug use was most prevalent in the first two quarters after diagnosis; however, after 3 years, the quarterly prevalence was still 19.2%. Hypnotics were more common among women, older patients, those with somatic comorbidities, more severe depression, or a history of suicide attempt. Evidence from this large register-based study demonstrates that hypnotics were used to a large extent in depression in Sweden 2007-2017. Z-drugs use declined and melatonin use increased dramatically. Hypnotic drug use remained high even 3 years after diagnosis.

[Insomniac symptoms and suicidality-link and management]

BACKGROUND

A link between insomniac symptoms and suicidality has long been suspected and deserves specific attention.

OBJECTIVE

We examine the current evidence for this relationship from epidemiology and neurobiology in order to propose a targeted management.

MATERIAL AND METHOD

Clinical example and selective Medline-literature research for insomnia symptoms and suicidality.

RESULTS

Epidemiological data and statistical analysis show that symptoms of insomnia are independent risk factors for suicidality. Neurobiological factors associated with combined insomnia symptoms and suicidality are: serotonergic dysfunction and circadian rhythm disorder leading to hypofrontality with reduced problem solving capacity and impaired emotional and impulse-control. Social isolation, recurrent rumination, comorbid psychiatric disorders, access to potentially lethal drugs or weapons need urgent evaluation in patients with a combination of suicidality and symptoms of insomnia.

CONCLUSION

patients with insomnia and further risk factors for suicide need to be treated resolutely and at an early stage. Modern sleep-promoting antidepressants with low toxicity and antipsychotics must be preferred in the treatment of patients with insomniac sleep disorders and suicidality. Multimodal anti-insomnia and anti-depressive therapy adapted to the circadian rhythm can exert a favorable influence both on depressive-suicidal and insomnia symptoms and their inherent risks.

Intentional benzodiazepine poisoning in older adults reported to United States Poison Centers

INTRODUCTION

Despite known contraindications, benzodiazepines are frequently prescribed for older adults. This study utilizes poison control center data on benzodiazepine-involved cases aged 50 and above to compare the characteristics of suspected suicide attempt with other intentional misuse cases. We also examined associations of major medical outcomes (major effect/death) with demographic characteristics and other co-used substances in each group.

METHODS

The study employed data from the America's Poison Center National Poison Data System from 2015-2022. Descriptive statistics and binary logistic regression models were used.

RESULTS

Of the benzodiazepine-poisoning cases of intentional misuse (n = 93,245), 85 percent were suicide attempts and 15 percent were other intentional misuses. Reports to poisons centers showed a decline from 2019-2022 when compared to 2015-2016. However, the likelihood of a reported suicide attempt, compared to other intentional misuse, was greater in 2019-2022 compared to 2015-2016 and among those who co-used antidepressants, anxiolytics, atypical antipsychotics, other benzodiazepines, other analgesics, anticonvulsants, and alcohol. The odds of major effect/death in both groups were also greater in 2019-2022, with suicide attempt cases in advanced ages showing higher odds. The co-use of antidepressants, prescription opioids, atypical antipsychotics, anticonvulsants, and other analgesics were associated with a higher likelihood of major effect/death in both exposure groups. For instance, adjusted odds ratios for co-used prescription opioids were 2.20 (95 percent confidence intervals: 2.09-2.31) among suicide attempt cases and 3.51 (95 percent confidence intervals: 3.10-3.97) among other intentional misuse cases.

DISCUSSION

Healthcare providers need to screen for suicidal ideation among benzodiazepine users, with special attention to an increased risk of suicide attempt among those who co-use antidepressants and opioids and to decreasing adverse outcomes in all misuse cases. Assessments of underlying mental health and substance use problems and medication regimens to minimize polypharmacy and drug interactions are needed to reduce adverse outcomes.

CONCLUSIONS

Though the numbers of benzodiazepine-involved suicide attempt and other intentional misuse cases reported to United States poison centers decreased in recent years, the likelihood of major medical effect/death among these cases have increased.

Prediction of adverse events risk in patients with comorbid post-traumatic stress disorder and alcohol use disorder using electronic medical records by deep learning models

BACKGROUND

Identifying co-occurring mental disorders and elevated risk is vital for optimization of healthcare processes. In this study, we will use DeepBiomarker2, an updated version of our deep learning model to predict the adverse events among patients with comorbid post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD), a high-risk population.

METHODS

We analyzed electronic medical records of 5565 patients from University of Pittsburgh Medical Center to predict adverse events (opioid use disorder, suicide related events, depression, and death) within 3 months at any encounter after the diagnosis of PTSD+AUD by using DeepBiomarker2. We integrated multimodal information including: lab tests, medications, co-morbidities, individual and neighborhood level social determinants of health (SDoH), psychotherapy and veteran data.

RESULTS

DeepBiomarker2 achieved an area under the receiver operator curve (AUROC) of 0.94 on the prediction of adverse events among those PTSD+AUD patients. Medications such as vilazodone, dronabinol, tenofovir, suvorexant, modafinil, and lamivudine showed potential for risk reduction. SDoH parameters such as cognitive behavioral therapy and trauma focused psychotherapy lowered risk while active veteran status, income segregation, limited access to parks and greenery, low Gini index, limited English-speaking capacity, and younger patients increased risk.

CONCLUSIONS

Our improved version of DeepBiomarker2 demonstrated its capability of predicting multiple adverse event risk with high accuracy and identifying potential risk and beneficial factors.

Associations between insomnia medications and risk of death by suicide

PURPOSE

Insomnia is a modifiable risk factor for suicide often treated with medications. However, little is known about the associations between insomnia medications and risk of death by suicide. The purpose of this study is to model the comparative risk of suicide by each insomnia medication compared to zolpidem, a sedative-hypnotic approved for insomnia.

METHODS

First prescription fills of medications commonly used to treat insomnia were identified in electronic medical records. Date and cause of death were identified in death certificates. Cox proportional hazards models were used to analyze time from insomnia prescription to suicide.

RESULTS

More than 2 million patients filled a new insomnia prescription between 2005 and 2015, and 518 of them died by suicide within 12 months. Compared to zolpidem, the tricyclic antidepressants (amitriptyline, doxepin) were associated with a 64% lower risk of suicide (HR 0.36 (95% CI 0.22-0.66) and the sedating antihistamines (hydroxyzine, diphenhydramine) a 40% lower risk of suicide (HR 0.60 (0.41-0.89)). In contrast, the tetracyclic antidepressant (mirtazapine) was associated with a 62% higher risk of suicide (HR 1.62 (95% CI 1.10-2.38) compared to zolpidem.

CONCLUSION

Insomnia is a modifiable risk factor for suicide, yet many medications used to treat insomnia have never been tested for the indication in clinical trials. To define efficacy in the prevention of suicide, trials are warranted.

Recurrent prescription of sleep medication among primary care patients with type 2 diabetes: an observational study of real-world registry data

BACKGROUND

Little knowledge exists on the prevalence of recurrent sleep medication prescriptions among primary care patients with type 2 diabetes (T2D). Our aims were to examine the prevalence of recurrent sleep medication prescriptions and to elucidate the most often prescribed sleep medications in a Finnish primary care T2D population.

METHODS

The study examined 4,508 T2D patients who consulted a primary health care center between 2011 and 2019 in Rovaniemi, Finland. All the data were retrieved from patient records, and recurrent sleep medication was defined as two or more prescriptions within the study period. We used the Chi-square and Kruskal-Wallis tests to compare patients who did and did not have recurrent sleep medication prescriptions.

RESULTS

Altogether 28.1% of the T2D patients had been prescribed recurrent sleep medication. Benzodiazepine-like medication, melatonin, and mirtazapine were most often prescribed (to 56.9%, 44.4%, and 35.8%, respectively). Only 22.0% of the patients with recurrent sleep medication prescriptions had been diagnosed with a sleep disorder.

CONCLUSIONS

Recurrent sleep medication prescriptions are frequent among primary care T2D patients. It seems that sleep disorders are underdiagnosed in relation to this. Primary care clinicians should carefully estimate the need for sleep medication when treating T2D patients' sleep problems and emphasize the diagnostic patterns of sleep problems.

Insomnia and treatment-resistant depression

Depression and sleep disturbance are related closely with bidirectional relationship. The heterogenic diagnostic criteria of major depressive disorder composed by the myriad combination of symptoms including sleep disturbance. Insomnia is an identifiable risk factor for depression and the treatment of insomnia might be able to prevent subsequent major depressive episodes which draws psychiatrists' attention to the interface of psychiatry and sleep medicine field. It is important to identify occult sleep disturbance in patients with treatment-resistant depression to improve treatment outcome. New tools to objectively measure sleep at home environment represent a great march in clinical care and research modalities but need further validation before they can be applying widespread at sleep and depression intersection. Careful evaluation and measurement of the phenotype and nature of sleep disturbance will continue to advance understanding of the biological bases of psychiatric disorders and the connections with sleep.

Insomnia and the Interpersonal Theory of suicide among civilians, service members, and veterans

BACKGROUND

Insomnia is associated with suicide risk in civilian and military populations. Thwarted belongingness is proposed as a mediator of this relationship under the Interpersonal Theory of Suicide (IPTS). The present study explored how insomnia relates to suicidal ideation in conjunction with thwarted belongingness among civilians, Service members, and Veterans.

METHODS

Data from the Military Suicide Research Consortium for N = 6556 individuals (6316 with non-missing suicidal ideation status) were divided into 4 subgroups: civilians, never deployed Service members, previously deployed Service members, and Veterans. Robust Poisson models evaluated the associations between insomnia severity/subtype and current suicidal ideation, with bootstrap mediation models assessing thwarted belongingness as a mediator.

RESULTS

A 5-point increase in insomnia severity was associated with a 38% increased risk for current suicidal ideation among civilians, a 56% greater risk among never deployed Service members, an 83% greater risk among previously deployed Service members, and a 37% greater risk among Veterans. Moreover, active Service members showed greater associations between difficulty falling asleep and staying asleep with suicidal ideation than civilians. These associations were independent of covariates and only mediated by thwarted belongingness among Veterans.

CONCLUSIONS

The relationship between insomnia and suicide is not purely explained by thwarted belongingness except among Veterans. Future research should explore additional psychological and neurobiological mechanisms connecting insomnia and suicidality.

Genetic evidence for a potential causal relationship between insomnia symptoms and suicidal behavior: a Mendelian randomization study

Insomnia and restless leg syndrome (RLS) are associated with increased risk for suicidal behavior (SB), which is often comorbid with mood or thought disorders; however, it is unclear whether these relationships are causal. We performed a two-sample Mendelian randomization study using summary-level genetic associations with insomnia symptoms and RLS against the outcomes of risk of major depressive disorder (MDD), bipolar disorder (BP), schizophrenia (SCZ), and SB. The inverse-variance weighted method was used in the main analysis. We performed replication and sensitivity analyses to examine the robustness of the results. We identified outcome cohorts for MDD (n = 170,756 cases/329,443 controls), BP (n = 20,352/31,358), SCZ (n = 69,369/236,642), SB-Cohort-2019 (n = 6569/14,996 all with MDD, BP or SCZ; and SB within individual disease categories), and SB-Cohort-2020 (n = 29,782/519,961). Genetically proxied liability to insomnia symptoms significantly associated with increased risk of MDD (odds ratio (OR) = 1.23, 95% confidence interval (CI) = 1.2-1.26, P = 1.37 × 10-61), BP (OR = 1.15, 95% CI = 1.07-1.23, P = 5.11 × 10-5), SB-Cohort-2019 (OR = 1.17, 95% CI = 1.07-1.27, P = 2.30 × 10-4), SB-Cohort-2019 in depressed patients (OR = 1.34, 95% CI = 1.16-1.54, P = 5.97 × 10-5), and SB-Cohort-2020 (OR = 1.24, 95% CI = 1.18-1.3, P = 1.47 × 10-18). Genetically proxied liability to RLS did not significantly influence the risk of any of the outcomes (all corrected P > 0.05). Results were replicated for insomnia with MDD and SB in Mass General Brigham Biobank and were consistent in multiple lines of sensitivity analyses. In conclusion, human genetic evidence supports for the first time a potentially independent and causal effect of insomnia on SB and encourages further clinical investigation of treatment of insomnia for prevention or treatment of SB.

Clonidine is better than zopiclone for insomnia treatment in chronic pain patients

STUDY OBJECTIVES

Chronic pain is associated with insomnia. The objective of this clinical study was to compare the efficacy and safety of different prescribed doses of zopiclone and clonidine for the management of insomnia in patients with chronic pain.

METHODS

This prospective observational crossover study included 160 consenting adult patients receiving pain management treatment. For insomnia treatment, each patient ingested different prescribed doses of zopiclone or clonidine on alternate nights. Each patient used a special validated sleep diary to collect data including pain score, sleep scores, sleep duration, sleep medication dose, and adverse effects. Each patient completed the diary for 3 continuous weeks. Pain was measured using a numeric pain rating scale. Sleep score was measured using the Likert Sleep Scale. A change in the pain or sleep scores by 2 points was considered significant. Of the 160 study participants, 150 (93.8%) completed the study successfully, and their data were analyzed with IBM SPSS Statistics 25 (IBM Corporation, Armonk, NY) using Student's t test, analysis of variance, Pearson chi-square test, and regression analysis. A P value < .05 was considered significant.

RESULTS

Pain score was lower with clonidine than zopiclone (P = .025). Time to fall asleep was shorter with clonidine than zopiclone (P = .001). Feeling rested on waking in the morning was better with clonidine than zopiclone (P = .015). Overall sleep quality was better with clonidine than zopiclone (P = .015). Total Likert sleep score was better with clonidine than zopiclone (P = .005). Total sleep duration was better with clonidine than zopiclone (P = .013). Adverse effects were commoner with zopiclone, including collapse, fall, confusion, amnesia, mood disorder, hallucination, nightmare, nocturnal restlessness, locomotor dysfunction, nausea and headache. A minor adverse effect of dry mouth was commoner with clonidine.

CONCLUSIONS

Clonidine is significantly better than zopiclone with respect to sleep quality, analgesia, tolerability profile, and patient safety. Further studies comparing clonidine with other insomnia medications will be beneficial.

CITATION

Bamgbade OA, Tai-Osagbemi J, Bamgbade DO, et al. Clonidine is better than zopiclone for insomnia treatment in chronic pain patients. J Clin Sleep Med. 2022;18(6):1565-1571.

The Evolving Nexus of Sleep and Depression

Sleep disturbances and depression are closely linked and share a bidirectional relationship. These interconnections can inform the pathophysiology underlying each condition. Insomnia is an established and modifiable risk factor for depression, the treatment of which offers the critical opportunity to prevent major depressive episodes, a paradigm-shifting model for psychiatry. Identification of occult sleep disorders may also improve outcomes in treatment-resistant depression. Sleep alterations and manipulations may additionally clarify the mechanisms that underlie rapid-acting antidepressant therapies. Both sleep disturbance and depression are heterogeneous processes, and evolving standards in psychiatric research that consider the transdiagnostic components of each are more likely to lead to translational progress at their nexus. Emerging tools to objectively quantify sleep and its disturbances in the home environment offer great potential to advance clinical care and research, but nascent technologies require further advances and validation prior to widespread application at the interface of sleep and depression.