Sleep disturbances have been identified as a suicide risk factor, yet hypnotic medications, which are often used to treat sleep issues, have been linked to suicide-related thoughts, plans, and attempts. What’s the best way to assess and treat sleep disturbances in patients at risk of suicide?
Table 1. Brief summary of sleep disorder - suicide risk
Table 2. Recommendations for managing patients with sleep disorders and co-occurring suicidal ideation
Christopher W. Drapeau, PhD
To goal of this activity is to understand the link between sleep problems and suicidal ideation.
At the end of this CE activity, participants should be able to:
• Explain the clinical implications of the link between sleep disturbance and suicide risk
• Describe the risks associated with hypnotic medications
• Recognize the use of cognitive behavioral therapy for insomnia as a means to manage sleep problems
This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.
CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.
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Premiere Date: November 20, 2018
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Since 1999, the frequencies of suicide and outpatient visits for sleep problems have significantly increased in the US.1,2 Although the cause of these increases is not clear, research studies spanning this period have shown significant associations between sleep disturbances and suicide risk.3 An association between symptoms from several sleep disorders and increased risk for suicidal ideation, nonfatal suicide attempts, and suicide among adolescents and adults has also been seen (Table 1).4 Notably, these associations have remained significant even in the presence of concurrent symptoms of psychiatric conditions (eg, depression, anxiety).5
Despite the robust appearance of the sleep disturbance – suicide risk relation, some studies have shown null relations or a weaker relation after controlling for confounding variables. This fact and the increasing evidence for sleep disturbance as a suicide risk factor, and possible warning sign, have led researchers to explore for mechanisms behind the association of sleep disturbance and suicide.6 This research, still in its infancy, has the potential to improve our understanding of the contexts in which sleep disturbances confer increased risk for suicide.
Dissatisfaction with the quality, timing, and duration of sleep, as well as the subsequent distress or impairment during waking hours, are considered typical manifestations across all sleep-wake disorders. It is not clear if such dissatisfaction or impairment can uniformly explain why those with sleep problems are at increased risk for attempting suicide. It has been hypothesized, however, that difficulty sleeping through the night may confer increased suicide risk via a number of factors including hyperarousal, hypothalamic-pituitary-adrenal (HPA) axis dysfunction, and concomitant serotonin dysfunction.
It has been suggested that HPA axis dysfunction and poor serotonin turnover negatively affect frontal lobe functioning and subsequently result in executive dysfunction and poor decision making.7,8 Impaired decision making increases the risk for suicide when access to suicide methods increases and social support decreases. The hypothesis that being awake at night increases the risk for suicide was supported by findings from a recent study indicating that completed suicide was more likely to occur at night and in the early morning hours.9
Sleep is an important factor to weigh when evaluating psychiatric patients in light of data showing a bi-directional relationship between sleep problems and psychiatric illness.10 Given the prevalence of sleep problems in the general population and the growing evidence linking sleep problems with suicidal ideation, screening patients with sleep problems for suicide risk is prudent. Tools, such as the Columbia Suicide Severity Rating Scale (C-SSRS), can assist with differentiating suicidal ideation with different levels of risk.11 C-SSRS forms including the Lifetime-Recent, Risk Assessment, and the Last Contact can help guide assessment and management of suicide risk across patient appointments.
The BEARS pediatric sleep screening tool evaluates for Bedtime problems, Excessive daytime sleepiness, Awakenings during the night, Regularity and duration of sleep, and Snoring.12 It differentiates between developmental levels (preschool, school-aged, and adolescent) and can easily be inserted into a clinical interview. For screening adults, the Sleep Disorders Questionnaire is a self-report tool that has been designed specifically to help health care professionals identify individuals at elevated risk for a sleep disorder.13
Theories of suicide suggest that it may be certain variables (eg, pain and hopelessness, low connectedness, means for suicide) rather than a specific psychiatric condition that predict who may be at highest risk for attempted suicide. Although it is important to assess for and address suicide risk across multiple levels of care (eg, public health model, upstream prevention approaches), the primary focus must be on immediately alleviating the patient’s suffering by treating any problems that convey suicide risk. Such an approach does not mean that relieving symptoms of a psychiatric illness (or sleep condition) is irrelevant to decreasing suicide risk. Instead, it is argued that clinicians collaborate with the patient to identify and ameliorate what appears to be driving suicide risk.14 The following cases provide examples of instances in which sleep concerns appeared to be the main drivers of suicide risk.
Case Study 115
A 74-year-old man presented to his primary care physician with depressive symptoms (ie, depressed mood, hopelessness, anhedonia, impaired concentration, fatigue, suicidal ideation), excessive daytime sleepiness, snoring, sleep dissatisfaction due to frequent night-awakenings that likely followed periods of apnea, and three suicide attempt plans. He refused voluntary psychiatric hospitalization and stated that he would not attempt suicide in the near future (1-2 days). He also refused antidepressant medication for religious reasons. He reported that nothing was more distressing to him than his sleep problems and that he would believe that life was worth living if he could improve his ability to sleep at night and maintain alertness during the day. Polysomnography revealed severe sleep apnea that was subsequently treated via nasal continuous positive airway pressure. This treatment led to an improvement in sleep quality and consequent resolutions of sleep complaints, depressive symptoms, and suicide risk.
Case Study 216
A 64-year-old man was admitted to a psychiatric hospital after attempting suicide via an opiate overdose. A thorough review of his medical history revealed chronic insomnia disorder. The patient reported that his feelings of hopelessness and desire to attempt suicide were secondary to insomnia distress resulting from a worsening of symptoms (ie, 2 continuous days without sleep). The patient noted that he had experienced perceived short sleep duration, difficulty falling asleep, night-awakenings, and low quality of life for the past 25 years.
Standard insomnia treatments such as cognitive behavioral therapy for insomnia and pharmacotherapies (hypnotics, benzodiazepines, antidepressants) did not relieve symptoms. Symptoms ultimately remitted however, with a combination of electroconvulsive therapy and olanzapine. Once his sleep improved, feelings of hopelessness and suicide-related thoughts resolved.
Restless legs syndrome (Willis-Ekbom disease)
Restless legs syndrome (RLS) is another sleep problem that may promote increased suicide risk. Patients with RLS have a higher risk for conditions associated with suicide including depression, insomnia, anxiety, and pain disorders. Study data show that between 21% and 38% of sampled patients with RLS had suicide-related thoughts.17,18 Moreover, depressed patients were more likely to blame RLS symptoms as the reason for their depression, sleep disturbances, and suicidal ideation.16 In such instances, the argument can be made that focusing treatment on ameliorating sleep disorder symptoms is warranted as part of reducing the patient’s suicide risk.
Sleep medication and suicide risk
Hypnotic medication is often used for treating insomnia; however, these medications have been linked to suicide-related thoughts, plans, and attempts.19,20 Moreover, use of hypnotics has been shown to be a more robust predictor of suicidal ideation and suicide attempts than insomnia symptoms.21
It is unclear why hypnotic use may increase risk for suicide, but caution is needed when prescribing hypnotic medications. To decrease the risk for suicide when prescribing hypnotics, McCall and colleagues22 outlined 10 steps for physicians to follow, along with a thorough review of the current literature on individual hypnotic medications and suicide.
Cognitive behavioral therapy for insomnia (CBT-I) has demonstrated longer-lasting benefits for the treatment of insomnia than hypnotic medications alone.23 Based on the accumulating empiric evidence, the American Academy of Sleep Medicine (AASM) and the American College of Physicians recommend CBT-I as the first-line therapy for chronic insomnia in adults.24,25 The AASM practice guideline notes that “Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies when possible.” Readers are referred to the AASM practice guideline for additional information about CBT-I and recommendations about the pharmacologic treatment of chronic insomnia in the event that patients are unable to receive CBT-I or may continue to experience symptoms.
Sleep disturbances have been identified as a robust predictor of past and future suicide risk across the lifespan. This growing literature emphasizes the need for mental health professionals to remain cognizant of patient sleep concerns when assessing psychiatric symptoms and suicide risk, and to be thoughtful about prescribing hypnotics to improve sleep disturbances (Table 2). Treating sleep problems may be an effective method for decreasing suicide risk in patients whose sleep concerns are a primary driver of suicide risk. In such cases, clinicians are encouraged to seek the expertise of a licensed sleep specialist or sleep psychologist who can deliver evidence-based sleep treatments (eg, CBT-I, imagery rehearsal therapy for nightmares).
PLEASE NOTE THAT THE POST-TEST IS AVAILABLE ONLINE ONLY ON THE 20TH OF THE MONTH OF ACTIVITY ISSUE AND FOR 18 MONTHS AFTER.
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Dr Drapeau is Assistant Professor, Department of Education, Valparaiso University, Valparaiso, IN.
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