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The link between suicide and sleep
According to the Centers for Disease Control and Prevention, suicide is the 10th leading cause of mortality in the United States, with rates of suicide rising over the past 2 decades. In 2016, completed suicides accounted for approximately 45,000 deaths in the United States (Ivey-Stephenson AZ, et al. MMWR Surveill Summ. 2017;66[18]:1). While progress has been made to lower mortality rates of other leading causes of death, very little progress has been made on reducing the rates of suicide. The term “suicide,” as referred to in this article, encompasses suicidal ideation, suicidal behavior, and suicide death.
Researchers have been investigating potential risk factors and prevention strategies for suicide. The relationship between suicide and sleep disturbances, specifically insomnia and nightmares, has been well documented in the literature. Given that insomnia and nightmares are potentially modifiable risk factors, it continues to be an area of active exploration for suicide rate reduction. While there are many different types of sleep disorders, including excessive daytime sleepiness, parasomnias, obstructive sleep apnea, and restless legs syndrome, this article will focus on the relationship between insomnia and nightmares with suicide.
Insomnia
Insomnia disorder, according to the American Psychiatric Association’s DSM-5, is a dissatisfaction of sleep quantity or quality that occurs at least three nights per week for a minimum of 3 months despite adequate opportunity for sleep. This may present as difficulty with falling asleep, staying asleep, or early morning awakenings. The sleep disturbance results in functional impairment or significant distress in at least one area of life (American Psychiatric Association. Arlington, Virginia: APA; 2013). While insomnia is often a symptom of many psychiatric disorders, research has shown that insomnia is an independent risk factor for suicide, even when controlling for mental illness. Studies have shown that there is up to a 2.4 relative risk of suicide death with insomnia after adjusting for depression severity (McCall W, et al. J Clin Sleep Med. 2013;32[9]:135).
Nightmares
Nightmares, as defined by the American Psychiatric Association’s DSM-5, are “typically lengthy, elaborate, story-like sequences of dream imagery that seem real and incite anxiety, fear, or other dysphoric emotions” (American Psychiatric Association. Arlington, Virginia: APA; 2013). They are common symptoms in posttraumatic stress disorder (PTSD), with up to 90% of individuals with PTSD experiencing nightmares following a traumatic event (Littlewood DL, et al. J Clin Sleep Med. 2016;12[3]:393). Nightmares have also been shown to be an independent risk factor for suicide when controlling for mental illness. Studies have shown that nightmares are associated with an elevated risk factor of 1.5 to 3 times for suicidal ideation and 3 to 4 times for suicide attempts. The data suggest that nightmares may be a stronger risk factor for suicide than insomnia (McCall W, et al. Curr Psychiatr Rep. 2013;15[9]:389).
Proposed Mechanism
The mechanism linking insomnia and nightmares with suicide has been theorized and studied by researchers. A couple of the most noteworthy proposed psychological mechanisms involve dysfunctional beliefs and attitudes about sleep, as well as deficits in problem solving capability. Dysfunctional beliefs and attitudes about sleep (DBAS) are negative cognitions pertaining to sleep, and they have been shown to be related to the intensity of suicidal ideations. Many of the DBAS are pessimistic thoughts that contain a “hopelessness flavor” to them, which lead to the perpetuation of insomnia. Hopelessness has been found to be a strong risk factor for suicide. In addition to DBAS, insomnia has also shown to lead to impairments in complex problem solving. The lack of problem solving skills in these patients may lead to fewer quantity and quality of solutions during stressful situations and leave suicide as the perceived best or only option.
The biological theories focus on serotonin and hyperarousal mediated by the hypothalamic-pituitary-adrenal (HPA) axis. Serotonin is a neurotransmitter that is involved in the induction and maintenance of sleep. Of interesting note, low levels of serotonin’s main metabolite, 5-hydroxyindoleacetic acid (5-HIAA) have been found in the cerebrospinal fluid of suicide victims. Evidence has also shown that sleep and the HPA axis are closely related. The HPA axis is activated by stress leading to a cascade of hormones that can cause susceptibility of hyperarousal, REM alterations, and suicide. Hyperarousal, shared in context with PTSD and insomnia, can lead to hyperactivation of the noradrenergic systems in the medial prefrontal cortex, which can lead to decrease in executive decision making (McCall W, et al. Curr Psychiatr Rep. 2013;15[9]:389).
Treatment Strategies
The benefit of treating insomnia and nightmares, in regards to reducing suicidality, continues to be an area of active research. Many of the previous studies have theorized that treating symptoms of insomnia and nightmares may indirectly reduce suicide. Pharmaceutical and nonpharmaceutical treatments are currently being used to help treat patients with insomnia and nightmares, but the benefit for reducing suicidality is still unknown.
One of the main treatment modalities for insomnia is hypnotic medication; however, these medications carry their own potential risk for suicide. Reports of suicide death in conjunction with hypnotic medication has led the FDA to add warnings about the increased risk of suicide with these medications. Some of these medications include zolpidem, zaleplon, eszopiclone, doxepin, ramelteon, and suvorexant. A review of research studies and case reports was completed in 2017 and showed that there was an odds ratio of 2 to 3 for hypnotic use in suicide deaths. However, most of the studies that were reviewed reported a potential confounding bias of the individual’s current mental health state. Furthermore, many of the suicide case reports that involved hypnotics also had additional substances detected, such as alcohol. Hypnotic medication has been shown to be an effective treatment for insomnia, but caution needs to be used when prescribing these medications. Strategies that may be beneficial when using hypnotic medication to reduce the risk of an adverse outcome include using the lowest effective dose and educating the patient of not combining the medication with alcohol or other sedative/hypnotics (McCall W, et al. Am J Psychiatry. 2017;174[1]:18).
For patients who have recurrent nightmares in the context of PTSD, the alpha-1 adrenergic receptor antagonist, prazosin, may provide some benefit; however, the literature is divided. There have been several randomized, placebo-controlled clinical trials with prazosin, which has shown a moderate to large effect for alleviating trauma-related nightmares and improving sleep quality. Some of the limitations of these studies were that the trials were small to moderate in size, and the length of the trials was 15 weeks or less. In 2018, Raskin and colleagues completed a follow-up randomized, placebo-controlled study for 26 weeks with 304 participants and did not find a significant difference between prazosin and placebo in regards to nightmares and sleep quality (Raskind MA, et al. N Engl J Med. 2018;378[6]:507).
Cognitive behavioral therapy for insomnia (CBT-I) and image rehearsal therapy (IRT) are two sleep-targeted therapy modalities that are evidence based. CBT-I targets dysfunctional beliefs and attitudes regarding sleep (McCall W, et al. J Clin Sleep Med. 2013;9[2]:135). IRT, on the other hand, specifically targets nightmares by having the patient write out a narrative of the nightmare, followed by re-scripting an alternative ending to something that is less distressing. The patient will rehearse the new dream narrative before going to sleep. There is still insufficient evidence to determine if these therapies have benefit in reducing suicide (Littlewood DL, et al. J Clin Sleep Med. 2016;12[3]:393).
While the jury is still out on how best to target and treat the risk factors of insomnia and nightmares in regards to suicide, there are still steps that health-care providers can take to help keep their patients safe. During the patient interview, new or worsening insomnia and nightmares should prompt further investigation of suicidal thoughts and behaviors. After a thorough interview, treatment options, with a discussion of risks and benefits, can be tailored to the individual’s needs. Managing insomnia and nightmares may be one avenue of suicide prevention.
Drs. Locrotondo and McCall are with the Department of Psychiatry and Health Behavior at the Medical College of Georgia, Augusta University, Augusta, Georgia.
According to the Centers for Disease Control and Prevention, suicide is the 10th leading cause of mortality in the United States, with rates of suicide rising over the past 2 decades. In 2016, completed suicides accounted for approximately 45,000 deaths in the United States (Ivey-Stephenson AZ, et al. MMWR Surveill Summ. 2017;66[18]:1). While progress has been made to lower mortality rates of other leading causes of death, very little progress has been made on reducing the rates of suicide. The term “suicide,” as referred to in this article, encompasses suicidal ideation, suicidal behavior, and suicide death.
Researchers have been investigating potential risk factors and prevention strategies for suicide. The relationship between suicide and sleep disturbances, specifically insomnia and nightmares, has been well documented in the literature. Given that insomnia and nightmares are potentially modifiable risk factors, it continues to be an area of active exploration for suicide rate reduction. While there are many different types of sleep disorders, including excessive daytime sleepiness, parasomnias, obstructive sleep apnea, and restless legs syndrome, this article will focus on the relationship between insomnia and nightmares with suicide.
Insomnia
Insomnia disorder, according to the American Psychiatric Association’s DSM-5, is a dissatisfaction of sleep quantity or quality that occurs at least three nights per week for a minimum of 3 months despite adequate opportunity for sleep. This may present as difficulty with falling asleep, staying asleep, or early morning awakenings. The sleep disturbance results in functional impairment or significant distress in at least one area of life (American Psychiatric Association. Arlington, Virginia: APA; 2013). While insomnia is often a symptom of many psychiatric disorders, research has shown that insomnia is an independent risk factor for suicide, even when controlling for mental illness. Studies have shown that there is up to a 2.4 relative risk of suicide death with insomnia after adjusting for depression severity (McCall W, et al. J Clin Sleep Med. 2013;32[9]:135).
Nightmares
Nightmares, as defined by the American Psychiatric Association’s DSM-5, are “typically lengthy, elaborate, story-like sequences of dream imagery that seem real and incite anxiety, fear, or other dysphoric emotions” (American Psychiatric Association. Arlington, Virginia: APA; 2013). They are common symptoms in posttraumatic stress disorder (PTSD), with up to 90% of individuals with PTSD experiencing nightmares following a traumatic event (Littlewood DL, et al. J Clin Sleep Med. 2016;12[3]:393). Nightmares have also been shown to be an independent risk factor for suicide when controlling for mental illness. Studies have shown that nightmares are associated with an elevated risk factor of 1.5 to 3 times for suicidal ideation and 3 to 4 times for suicide attempts. The data suggest that nightmares may be a stronger risk factor for suicide than insomnia (McCall W, et al. Curr Psychiatr Rep. 2013;15[9]:389).
Proposed Mechanism
The mechanism linking insomnia and nightmares with suicide has been theorized and studied by researchers. A couple of the most noteworthy proposed psychological mechanisms involve dysfunctional beliefs and attitudes about sleep, as well as deficits in problem solving capability. Dysfunctional beliefs and attitudes about sleep (DBAS) are negative cognitions pertaining to sleep, and they have been shown to be related to the intensity of suicidal ideations. Many of the DBAS are pessimistic thoughts that contain a “hopelessness flavor” to them, which lead to the perpetuation of insomnia. Hopelessness has been found to be a strong risk factor for suicide. In addition to DBAS, insomnia has also shown to lead to impairments in complex problem solving. The lack of problem solving skills in these patients may lead to fewer quantity and quality of solutions during stressful situations and leave suicide as the perceived best or only option.
The biological theories focus on serotonin and hyperarousal mediated by the hypothalamic-pituitary-adrenal (HPA) axis. Serotonin is a neurotransmitter that is involved in the induction and maintenance of sleep. Of interesting note, low levels of serotonin’s main metabolite, 5-hydroxyindoleacetic acid (5-HIAA) have been found in the cerebrospinal fluid of suicide victims. Evidence has also shown that sleep and the HPA axis are closely related. The HPA axis is activated by stress leading to a cascade of hormones that can cause susceptibility of hyperarousal, REM alterations, and suicide. Hyperarousal, shared in context with PTSD and insomnia, can lead to hyperactivation of the noradrenergic systems in the medial prefrontal cortex, which can lead to decrease in executive decision making (McCall W, et al. Curr Psychiatr Rep. 2013;15[9]:389).
Treatment Strategies
The benefit of treating insomnia and nightmares, in regards to reducing suicidality, continues to be an area of active research. Many of the previous studies have theorized that treating symptoms of insomnia and nightmares may indirectly reduce suicide. Pharmaceutical and nonpharmaceutical treatments are currently being used to help treat patients with insomnia and nightmares, but the benefit for reducing suicidality is still unknown.
One of the main treatment modalities for insomnia is hypnotic medication; however, these medications carry their own potential risk for suicide. Reports of suicide death in conjunction with hypnotic medication has led the FDA to add warnings about the increased risk of suicide with these medications. Some of these medications include zolpidem, zaleplon, eszopiclone, doxepin, ramelteon, and suvorexant. A review of research studies and case reports was completed in 2017 and showed that there was an odds ratio of 2 to 3 for hypnotic use in suicide deaths. However, most of the studies that were reviewed reported a potential confounding bias of the individual’s current mental health state. Furthermore, many of the suicide case reports that involved hypnotics also had additional substances detected, such as alcohol. Hypnotic medication has been shown to be an effective treatment for insomnia, but caution needs to be used when prescribing these medications. Strategies that may be beneficial when using hypnotic medication to reduce the risk of an adverse outcome include using the lowest effective dose and educating the patient of not combining the medication with alcohol or other sedative/hypnotics (McCall W, et al. Am J Psychiatry. 2017;174[1]:18).
For patients who have recurrent nightmares in the context of PTSD, the alpha-1 adrenergic receptor antagonist, prazosin, may provide some benefit; however, the literature is divided. There have been several randomized, placebo-controlled clinical trials with prazosin, which has shown a moderate to large effect for alleviating trauma-related nightmares and improving sleep quality. Some of the limitations of these studies were that the trials were small to moderate in size, and the length of the trials was 15 weeks or less. In 2018, Raskin and colleagues completed a follow-up randomized, placebo-controlled study for 26 weeks with 304 participants and did not find a significant difference between prazosin and placebo in regards to nightmares and sleep quality (Raskind MA, et al. N Engl J Med. 2018;378[6]:507).
Cognitive behavioral therapy for insomnia (CBT-I) and image rehearsal therapy (IRT) are two sleep-targeted therapy modalities that are evidence based. CBT-I targets dysfunctional beliefs and attitudes regarding sleep (McCall W, et al. J Clin Sleep Med. 2013;9[2]:135). IRT, on the other hand, specifically targets nightmares by having the patient write out a narrative of the nightmare, followed by re-scripting an alternative ending to something that is less distressing. The patient will rehearse the new dream narrative before going to sleep. There is still insufficient evidence to determine if these therapies have benefit in reducing suicide (Littlewood DL, et al. J Clin Sleep Med. 2016;12[3]:393).
While the jury is still out on how best to target and treat the risk factors of insomnia and nightmares in regards to suicide, there are still steps that health-care providers can take to help keep their patients safe. During the patient interview, new or worsening insomnia and nightmares should prompt further investigation of suicidal thoughts and behaviors. After a thorough interview, treatment options, with a discussion of risks and benefits, can be tailored to the individual’s needs. Managing insomnia and nightmares may be one avenue of suicide prevention.
Drs. Locrotondo and McCall are with the Department of Psychiatry and Health Behavior at the Medical College of Georgia, Augusta University, Augusta, Georgia.
According to the Centers for Disease Control and Prevention, suicide is the 10th leading cause of mortality in the United States, with rates of suicide rising over the past 2 decades. In 2016, completed suicides accounted for approximately 45,000 deaths in the United States (Ivey-Stephenson AZ, et al. MMWR Surveill Summ. 2017;66[18]:1). While progress has been made to lower mortality rates of other leading causes of death, very little progress has been made on reducing the rates of suicide. The term “suicide,” as referred to in this article, encompasses suicidal ideation, suicidal behavior, and suicide death.
Researchers have been investigating potential risk factors and prevention strategies for suicide. The relationship between suicide and sleep disturbances, specifically insomnia and nightmares, has been well documented in the literature. Given that insomnia and nightmares are potentially modifiable risk factors, it continues to be an area of active exploration for suicide rate reduction. While there are many different types of sleep disorders, including excessive daytime sleepiness, parasomnias, obstructive sleep apnea, and restless legs syndrome, this article will focus on the relationship between insomnia and nightmares with suicide.
Insomnia
Insomnia disorder, according to the American Psychiatric Association’s DSM-5, is a dissatisfaction of sleep quantity or quality that occurs at least three nights per week for a minimum of 3 months despite adequate opportunity for sleep. This may present as difficulty with falling asleep, staying asleep, or early morning awakenings. The sleep disturbance results in functional impairment or significant distress in at least one area of life (American Psychiatric Association. Arlington, Virginia: APA; 2013). While insomnia is often a symptom of many psychiatric disorders, research has shown that insomnia is an independent risk factor for suicide, even when controlling for mental illness. Studies have shown that there is up to a 2.4 relative risk of suicide death with insomnia after adjusting for depression severity (McCall W, et al. J Clin Sleep Med. 2013;32[9]:135).
Nightmares
Nightmares, as defined by the American Psychiatric Association’s DSM-5, are “typically lengthy, elaborate, story-like sequences of dream imagery that seem real and incite anxiety, fear, or other dysphoric emotions” (American Psychiatric Association. Arlington, Virginia: APA; 2013). They are common symptoms in posttraumatic stress disorder (PTSD), with up to 90% of individuals with PTSD experiencing nightmares following a traumatic event (Littlewood DL, et al. J Clin Sleep Med. 2016;12[3]:393). Nightmares have also been shown to be an independent risk factor for suicide when controlling for mental illness. Studies have shown that nightmares are associated with an elevated risk factor of 1.5 to 3 times for suicidal ideation and 3 to 4 times for suicide attempts. The data suggest that nightmares may be a stronger risk factor for suicide than insomnia (McCall W, et al. Curr Psychiatr Rep. 2013;15[9]:389).
Proposed Mechanism
The mechanism linking insomnia and nightmares with suicide has been theorized and studied by researchers. A couple of the most noteworthy proposed psychological mechanisms involve dysfunctional beliefs and attitudes about sleep, as well as deficits in problem solving capability. Dysfunctional beliefs and attitudes about sleep (DBAS) are negative cognitions pertaining to sleep, and they have been shown to be related to the intensity of suicidal ideations. Many of the DBAS are pessimistic thoughts that contain a “hopelessness flavor” to them, which lead to the perpetuation of insomnia. Hopelessness has been found to be a strong risk factor for suicide. In addition to DBAS, insomnia has also shown to lead to impairments in complex problem solving. The lack of problem solving skills in these patients may lead to fewer quantity and quality of solutions during stressful situations and leave suicide as the perceived best or only option.
The biological theories focus on serotonin and hyperarousal mediated by the hypothalamic-pituitary-adrenal (HPA) axis. Serotonin is a neurotransmitter that is involved in the induction and maintenance of sleep. Of interesting note, low levels of serotonin’s main metabolite, 5-hydroxyindoleacetic acid (5-HIAA) have been found in the cerebrospinal fluid of suicide victims. Evidence has also shown that sleep and the HPA axis are closely related. The HPA axis is activated by stress leading to a cascade of hormones that can cause susceptibility of hyperarousal, REM alterations, and suicide. Hyperarousal, shared in context with PTSD and insomnia, can lead to hyperactivation of the noradrenergic systems in the medial prefrontal cortex, which can lead to decrease in executive decision making (McCall W, et al. Curr Psychiatr Rep. 2013;15[9]:389).
Treatment Strategies
The benefit of treating insomnia and nightmares, in regards to reducing suicidality, continues to be an area of active research. Many of the previous studies have theorized that treating symptoms of insomnia and nightmares may indirectly reduce suicide. Pharmaceutical and nonpharmaceutical treatments are currently being used to help treat patients with insomnia and nightmares, but the benefit for reducing suicidality is still unknown.
One of the main treatment modalities for insomnia is hypnotic medication; however, these medications carry their own potential risk for suicide. Reports of suicide death in conjunction with hypnotic medication has led the FDA to add warnings about the increased risk of suicide with these medications. Some of these medications include zolpidem, zaleplon, eszopiclone, doxepin, ramelteon, and suvorexant. A review of research studies and case reports was completed in 2017 and showed that there was an odds ratio of 2 to 3 for hypnotic use in suicide deaths. However, most of the studies that were reviewed reported a potential confounding bias of the individual’s current mental health state. Furthermore, many of the suicide case reports that involved hypnotics also had additional substances detected, such as alcohol. Hypnotic medication has been shown to be an effective treatment for insomnia, but caution needs to be used when prescribing these medications. Strategies that may be beneficial when using hypnotic medication to reduce the risk of an adverse outcome include using the lowest effective dose and educating the patient of not combining the medication with alcohol or other sedative/hypnotics (McCall W, et al. Am J Psychiatry. 2017;174[1]:18).
For patients who have recurrent nightmares in the context of PTSD, the alpha-1 adrenergic receptor antagonist, prazosin, may provide some benefit; however, the literature is divided. There have been several randomized, placebo-controlled clinical trials with prazosin, which has shown a moderate to large effect for alleviating trauma-related nightmares and improving sleep quality. Some of the limitations of these studies were that the trials were small to moderate in size, and the length of the trials was 15 weeks or less. In 2018, Raskin and colleagues completed a follow-up randomized, placebo-controlled study for 26 weeks with 304 participants and did not find a significant difference between prazosin and placebo in regards to nightmares and sleep quality (Raskind MA, et al. N Engl J Med. 2018;378[6]:507).
Cognitive behavioral therapy for insomnia (CBT-I) and image rehearsal therapy (IRT) are two sleep-targeted therapy modalities that are evidence based. CBT-I targets dysfunctional beliefs and attitudes regarding sleep (McCall W, et al. J Clin Sleep Med. 2013;9[2]:135). IRT, on the other hand, specifically targets nightmares by having the patient write out a narrative of the nightmare, followed by re-scripting an alternative ending to something that is less distressing. The patient will rehearse the new dream narrative before going to sleep. There is still insufficient evidence to determine if these therapies have benefit in reducing suicide (Littlewood DL, et al. J Clin Sleep Med. 2016;12[3]:393).
While the jury is still out on how best to target and treat the risk factors of insomnia and nightmares in regards to suicide, there are still steps that health-care providers can take to help keep their patients safe. During the patient interview, new or worsening insomnia and nightmares should prompt further investigation of suicidal thoughts and behaviors. After a thorough interview, treatment options, with a discussion of risks and benefits, can be tailored to the individual’s needs. Managing insomnia and nightmares may be one avenue of suicide prevention.
Drs. Locrotondo and McCall are with the Department of Psychiatry and Health Behavior at the Medical College of Georgia, Augusta University, Augusta, Georgia.