Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military

doi:10.1016/j.jad.2011.09.049

Journal of Affective Disorders

Volume 136, Issue 3, February 2012, Pages 743-750

https://doi.org/10.1016/j.jad.2011.09.049 Get rights and content

Abstract

Background

Sleep problems appear to represent an underappreciated and important warning sign and risk factor for suicidal behaviors. Given past research indicating that disturbed sleep may confer such risk independent of depressed mood, in the present report we compared self-reported insomnia symptoms to several more traditional, well-established suicide risk factors: depression severity, hopelessness, PTSD diagnosis, as well as anxiety, drug abuse, and alcohol abuse symptoms.

Methods

Using multiple regression, we examined the cross-sectional and longitudinal relationships between insomnia symptoms and suicidal ideation and behavior, controlling for depressive symptom severity, hopelessness, PTSD diagnosis, anxiety symptoms, and drug and alcohol abuse symptoms in a sample of military personnel (N = 311).

Results

In support of a priori hypotheses, self-reported insomnia symptoms were cross-sectionally associated with suicidal ideation, even after accounting for symptoms of depression, hopelessness, PTSD diagnosis, anxiety symptoms and drug and alcohol abuse. Self-reported insomnia symptoms also predicted suicide attempts prospectively at one-month follow up at the level of a non-significant trend, when controlling for baseline self-reported insomnia symptoms, depression, hopelessness, PTSD diagnosis and anxiety, drug and alcohol abuse symptoms. Insomnia symptoms were unique predictors of suicide attempt longitudinally when only baseline self-reported insomnia symptoms, depressive symptoms and hopelessness were controlled.

Limitations

The assessment of insomnia symptoms consisted of only three self-report items. Findings may not generalize outside of populations at severe suicide risk.

Conclusions

These findings suggest that insomnia symptoms may be an important target for suicide risk assessment and the treatment development of interventions to prevent suicide.

Introduction

If asked to list the top few warning signs for imminent suicidal behavior, relatively few mental health professionals – even experienced ones; indeed even specialists – would list insomnia. But perhaps should, as mounting evidence makes clear (Ağargün and Cartwright, 2003, Bernert et al., 2005, Fawcett et al., 1990, Krakow et al., 2011, Turvey et al., 2002, Wojnar et al., 2009). Here, we extend this evidence by documenting robust links between sleep problems and suicidality, both cross-sectionally and longitudinally, and both with regard to suicidal ideation and suicidal behavior. Crucially, in all cases, we show that the links between sleep problems and suicidality exist beyond the involvement of factors mental health professionals would list as among the top few clinical risk indices for suicidality—namely, depression, hopelessness, PTSD, anxiety, and drug and alcohol abuse (Beck et al., 1990; Nock et al., 2010, Oquendo et al., 2002, Oquendo et al., 2004).

Section snippets

Why would sleep problems be involved in suicidality?

In the moments before their deaths, suicide decedents are almost never described by others as “sluggish” or “slowed down” – a perhaps surprising fact given the well-known association between depression – which can certainly slow people down – and suicidality. How are they usually described then? Descriptors of severe anxiety and terms such as “agitated,” “on edge,” and “keyed up” come up quite regularly (Busch and Fawcett, 2004, Hall et al., 1999). If others are queried about the days and

Past research on sleep problems and suicidality

Despite the lack of theoretical research on why sleep would be associated with suicide risk, a growing body of evidence suggests that disturbed sleep may constitute an important, modifiable risk factor for suicide. Multiple sleep problems appear to predict elevated risk for suicide including insomnia, poor sleep quality, and nightmares (Ağargün and Cartwright, 2003, Ağargün et al., 1998, Bernert et al., 2005, Fawcett et al., 1990, Tanskanen et al., 2001). Supporting the construct validity of

The present study

In the current study, the literature on insomnia and suicidality is built upon. As can be discerned in Table 1, studies conducted to date vary considerably in terms of whether they examine suicidal ideation, behavior, or death by suicide as outcomes, whether they consider depression or other covariates, whether their assessment approach included multi-method features, and whether their designs incorporated cross-sectional or longitudinal elements. As Table 1 shows, no study did all of these.

Participants

Participants for this study included 311 individuals (255 men [82%]; 56 women), evaluated as they entered a study on the efficacy of treatments for suicidal young adults (Rudd et al., 1996). All participants were referred for severe suicidality from two outpatient clinics, an inpatient facility, and an emergency room. All facilities were affiliated with a major U.S. Army Medical Center. Approximately 40% had a diagnosis of major depressive disorder, 15% had a bipolar spectrum diagnosis (i.e.

Results

Means, standard deviations, and intercorrelations for all variables are presented in Table 2. Notably, symptom scores are elevated at baseline. For the insomnia symptom index, the mean score was 4.42 (SD = 2.67). Mean MSSI scores were also elevated (M = 23.30, SD = 10.42), as expected. Participants reported an average score of 8.73 (SD = 6.36) on the BHS, 66.53 (SD = 13.43) on the MCMI depression subscale, 87.77 (SD = 20.35) on the MCMI anxiety subscale at baseline, 59.66 (SD = 17.63) on the MCMI alcohol

Discussion

The current study's findings converge with a growing body of research, indicating a relationship between sleep disturbance and suicidality (Goldstein et al., 2008, Goodwin and Marusic, 2008, Keshavan et al., 1994, Liu, 2004, Sabo et al., 1991, Sjöström et al., 2007). This link has been reported in both clinical (Ağargün and Cartwright, 2003, Bernert et al., 2005, Sabo et al., 1991) and nonclinical population-based samples (Fujino et al., 2005, Goodwin and Marusic, 2008, Turvey et al., 2002)

Role of funding source

The current project was supported, in part, by grants awarded to the Denver VA Medical Center and to Florida State University by the Department of Defense. The Department of Defense had no further role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. The views and opinions expressed do not represent those of the Department of Veterans Affairs, the Department of Defense, or the

Conflict of interest

All authors denied any possible conflict of interest with other people or organizations within 3 years of beginning the submitted work that could inappropriately influence the present research study.

Acknowledgments

The authors have no acknowledgments.

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^☆: This research was supported, in part, by grants awarded to the Denver VA Medical Center and to Florida State University by the Department of Defense. The Department of Defense had no further role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. The views and opinions expressed do not represent those of the Department of Veterans Affairs, the Department of Defense, or the United States Government.

¹: The views and opinions expressed do not represent those of the Department of Veterans Affairs or the United States Government.

View full text

Research reportSleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military☆

Abstract

Background

Methods

Results

Limitations

Conclusions

Introduction

Section snippets

Why would sleep problems be involved in suicidality?

Past research on sleep problems and suicidality

The present study

Participants

Results

Discussion

Role of funding source

Conflict of interest

Acknowledgments

Psychiatry Research

Journal of Psychiatric Research

Comprehensive Psychiatry

Journal of Affective Disorders

Sleep Medicine Reviews

Psychiatry Research

Sleep Medicine

Psychiatry Research

Journal of Affective Disorders

Psychosomatics: Journal of Consultation Liaison Psychiatry

Journal of affective disorders

Sleep Medicine

Journal of Affective Disorders

Journal of Affective Disorders

Psychiatry Research

The American Journal of Geriatric Psychiatry – Special Issue: Suicidal Behaviors in Older Adults

Journal of Psychiatric Research

Journal of the American Academy of Child and Adolescent Psychiatry

Sleep disturbances and suicidal behavior in patients with major depression

The Journal of Clinical Psychiatry

Depression followed by suicide: a comparison of depressed suicides with living depressives

Psychological Medicine

An inventory for measuring depression

Archives of General Psychiatry

The measurement of pessimism: the hopelessness scale

Journal of Consulting and Clinical Psychology

Relationship between hopelessness and ultimate suicide: a replication with psychiatric outpatients

American Journal of Psychiatriy

Objectively-assessed sleep variability uniquely predicts increased suicide risk in a prospective evaluation of young adults

Sleep: Abstract Supplement

Suicidality and sleep disturbances

Sleep

Sleep disturbance as a unique risk factor for completed suicide

Sleep

Insomnia and poor sleep quality as predictors of suicidal symptoms in a nonclinical sample

Insomnia and nightmares as predictors of elevated suicide risk among patients seeking admission to emergency mental health facility

Sleep: Abstract Supplement

Perceived stigma and barriers to care for psychological stressors: implications for reactions to stressors in different contexts

Journal of Social and Clinical Psychology

Does an attempted suicide have a cathartic effect?

Acta Psychiatrica Scandinavica

A fine grained study of inpatients who commit suicide

Psychiatric Annals

Clinical correlates of inpatient suicide

The Journal of Clinical Psychiatry

Efficacy of brief behavioral treatment for chronic insomnia in older adults

Archives of Internal Medicine

Additional support for the reliability and validity of the modified scale for suicide ideation

Psychological Assessment

Suicide Probability Scale

Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4–5 hours per night

Sleep Journal of Sleep and Sleep Disorders Research

The P4 screener: evaluation of a brief measure for assessing potential suicide risk in 2 randomized effectiveness trials of primary care and oncology patients

Primary Care Companion to The Journal of Clinical Psychiatry

Time-related predictors of suicide in major affective disorder

The American Journal of Psychiatry

Prospective cohort study of stress, life satisfaction, self-rated health, insomnia, and suicide death in Japan

Suicide & Life-Threatening Behavior

Sleep disturbance preceding completed suicide in adolescents

Journal of Consulting and Clinical Psychology

Association between short sleep and suicidal ideation and suicide attempt among adults in the general population

Sleep: Journal of Sleep and Sleep Disorders Research

Research report
Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military☆