The steadily rising rate of suicide in the US is a vexing public health crisis. Between 2007 and 2017, suicide was the 10th leading cause of death, claiming the lives of nearly half a million people.1 It is perhaps even more striking that suicide is the fourth leading cause of death for individuals aged 35 to 54 as well as the second leading cause for those aged 10 to 34. Based on 2018 epidemiologic data, 1.4 million adults per year make a non-fatal suicide attempt and 10.4 million have serious thoughts of suicide.2 Among the many risk factors for suicidal thoughts and behaviors, one that consistently emerges as an independent risk factor is sleep disturbance (broadly defined) along with the specific sleep disorders of insomnia, nightmares, and sleep apnea.3,4
One reason that this sleep-suicide relationship is so important is that sleep disorders represent a modifiable risk factor. As noted a decade ago, several sleep medicine interventions can potentially make a difference in the lives of individuals who may be on a trajectory to suicide.5
It has yet to be firmly established if improving sleep actually reduces suicide. However, in a recent analysis of a large medical record study, it was observed that having a sleep medicine consultation was a protective factor for subsequent suicide attempts among those with a sleep disorder.6 There are also some indications that cognitive-behavioral therapy for insomnia (CBT-I) reduces suicidal thoughts.7,8
Mechanisms by which improved sleep may reduce risk are also putative. Indirectly, we can say with some certainty that sleep disorders (eg, insomnia, sleep apnea) are strongly related to the development and course of depression and their reversal improves mood. Other hypothesized mechanisms through which poor sleep may be associated with suicidal thought and behavior include increased impulsivity, emotional dysregulation, and impaired executive functioning, each of which may be reversed with improved sleep.
What, then, are actionable items for the clinician wishing to address the sleep-suicide relationship? We present three focal areas:
• Sleep disturbance screening
• Suicide assessment and safety planning
• Sleep treatment options in the suicidal patient
Given the high prevalence of insomnia in psychiatric populations and the ability of psychiatrists to fully manage insomnia (as opposed to sleep apnea), the primary focus of treatment options is for insomnia disorder.
Dr Pigeon is Professor of Psychiatry and Public Health Sciences, University of Rochester Medical Center, Rochester, NY, and Executive Director, Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, US Department of Veterans Affairs; Dr Bishop is Assistant Professor of Psychiatry, University of Rochester Medical Center, and Health Science Specialist, Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center. Dr Pigeon reports that he is a consultant for CurAegis Technologies, Inc; Dr Bishop reports no conflicts of interest concerning the subject matter of this article.
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