Sleep and Suicide
Girish Dhorajia, MD
PG Y III Med-Psych Resident
ETSU
INTRODUCTION
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Suicide is a major preventable public health
problem.
In 2007, it was the tenth leading cause of death
in the U.S., accounting for 34,598 deaths.
The overall rate was 11.3 suicide deaths per
100,000 people. An estimated 11 attempted
suicides occur per every suicide death.
GLOBAL SUICIDE RATE
GLOBAL SUICIDE RATE
NATIONAL SUICIDE RATE MAP
USA EPIDEMIOLOGY
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Children ages 10 to 14 — 0.9 per 100,000
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Adolescents ages 15 to 19 — 6.9 per 100,000
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Young adults ages 20 to 24 — 12.7 per 100,000
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Ages 65 and older, 14.3 died by suicide of every 100,000
people in 2007. This figure is higher than the national
average of 11.3 suicides per 100,000 people in the general
population.
USA EPIDEMIOLOGY
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Non-Hispanic white men age 85 or older had an
even higher rate, with 47 suicide deaths per
100,000.
Suicide was the seventh leading cause of death
for males and the fifteenth leading cause of death
for females in 2007.
Almost four times as many males as females die
by suicide.
USA EPIDEMIOLOGY
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Firearms, suffocation, and poisoning(overdose)
are by far the most common methods of suicide,
overall. However, men and women differ in the
method used, as shown below.
Suicide By
Male
Female
Firearms
56
30
Suffocation
24
21
Poisoning
13
40
ETHNIC GROUPS
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Highest rates:
American Indian and Alaska Natives — 14.3 per
100,000
– Non-Hispanic Whites — 13.5 per 100,000
–
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Lowest rates:
Non-Hispanic Blacks — 5.1 per 100,000
– Hispanics — 6.0 per 100,000
– Asian and Pacific Islanders — 6.2 per 100,000
–
NUMBER OF SUICIDES 2007 USA
SUICIDE RATES 2007 IN USA
NO OF SUICIDE IN INDIA
RATE OF SUICIDE IN INDIA
1999-2007 SUICIDE RATE TRENDS USA
SUICIDE RISK FACTORS
Non Modifiable Risk Factors:
 Advancing age
 Male gender
 Caucasian/American Indian ethnicity
 Previous suicide attempt
 History of trauma or abuse
 Family history of suicide
 Family history of mental disorder or substance
abuse
 Some major physical illnesses
 Local epidemics of suicide
SUICIDE RISK FACTORS
Modifiable risk factors:
 Mental disorders, particularly mood disorders,
schizophrenia, anxiety disorders and certain
personality disorders
 Alcohol and other substance use disorders
 Hopelessness
 Impulsive and/or aggressive tendencies
 Easy access to lethal means
 Environmental Risk Factors: Job or financial
loss, Relational or social loss,
WHAT ABOUT INSOMNIA ?
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Insomnia is another symptom/condition which
has been relatively under recognized as a marker
for vulnerability for suicide.
Several Textbooks like APA psychiatry textbook
and APA geriatric psychiatry textbooks has listed
insomnia as one of the risk factor for suicide.
Some of the literature suggests sleep disturbance
has prognostic significance in patients with
affective disturbance.
SLEEP AND SUICIDE
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Increasing evidence suggests that disturbances in
sleep are associated with an elevated risk for suicidal
behaviors.
Several cross-sectional investigations indicate a
unique association between nightmares and suicidal
ideation.
Identification of insomnia as a risk factors for suicidal
behaviors may enhance our ability to intervene and
prevent suicide.
SLEEP AND SUICIDE
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90% people who commit suicide suffers from
mental health issues.
Insomnia is a frequent symptom of mental health
issues as well as last symptom to improve.
Prevalence of insomnia ranges from 6% to 30%.
Due to its chronicity, insomnia is associated with
substantial impairments in an individual's
quality of life.
DSM IV TR CRITERIA FOR INSOMNIA
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A. The predominant complaint is difficulty initiating or
maintaining sleep, or nonrestorative sleep, for at least 1 month.
B. The sleep disturbance (or associated daytime fatigue) causes
clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
C. The sleep disturbance does not occur exclusively during the
course of Narcolepsy, Breathing-Related Sleep disorder, Circadian
Rhythm Sleep Disorder, or a parasomnias.
D. The disturbance does not occur exclusively during the course of
another mental disorder (e.g., Major Depressive
Disorder, Generalized Anxiety Disorder, a Delirium).
E. The disturbance is not due to the direct physiological effects of
a substance (e.g., a drug of abuse, a medication) or a general
medical condition.
WHAT IS SLEEP ?
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Sleep is a complex biological process that is
influenced by many neuroendocrine parameters.
Sleep plays an important role in reparative and
integrative process of the brain and body.
SLEEP
The stages of sleep were first described in 1937
by Alfred Lee Loomis and his coworkers, who
separated the different electroencephalography
(EEG) features of sleep into five levels from
wakefulness to deep sleep.
 In 1953, REM sleep was discovered as distinct
phase of sleep, and thus sleep was reclassified
into four NREM stages and REM.
 The staging criteria were standardized in 1968
by Allan Rechtschaffen and Anthony Kales in the
"R&K sleep scoring manual.
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AMERICAN ACADEMY OF SLEEP
MEDICINE (AASM)
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In 2004, the AASM commissioned the AASM
Visual Scoring Task Force to review the R&K
scoring system.
The American Academy of Sleep Medicine
(AASM) further divides NREM into three stages:
N1, N2, and N3, the last of which is also called
delta sleep or slow-wave sleep (SWS).
NON-RAPID EYE MOVEMENT (NREM)
SLEEP
Stage N1:
 Transition of the brain from alpha waves having a
frequency of 8–13 Hz (common in the awake state)
to theta waves having a frequency of 4–7 Hz.
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Sudden twitches and hypnic jerks are common
during this phase.
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Loss of some muscle tone.
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Also referred as somnolence or drowsy sleep.
NON-RAPID EYE MOVEMENT (NREM)
SLEEP
Stage N2
 EEG shows sleep spindles ranging from 11 to
16 Hz (most commonly 12–14 Hz) and Kcomplexes.
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Muscular activity further decreases, and
conscious awareness of the external environment
disappears.
This stage occupies 45–55% of total sleep in
adults.
NON-RAPID EYE MOVEMENT (NREM)
SLEEP
Stage N3
 Also known as deep or slow-wave sleep) due to the
presence of a minimum of 20% delta waves ranging
from 0.5–2Hz.
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Parasomnias such as night terrors, nocturnal
enuresis, sleepwalking and somniloquy occur.
Many illustrations and descriptions still show a
stage N3 with 20–50% delta waves and a stage N4
with greater than 50% delta waves; these have
been combined as stage N3.
RAPID EYE MOVEMENT (REM) SLEEP
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REM sleep (paradoxical sleep), accounts for 20–
25% of total sleep time and four to six periods of
REM sleep in most human adults.
Shorter at the beginning of the night and longer
toward the end.
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REM sleep normally occurs close to morning.
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Most memorable dreaming occurs in this stage.
HYPNOGRAM
CLINICAL AND EPIDEMIOLOGICAL
INVESTIGATIONS
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Fawcett and colleagues(1990) conducted one of
the first studies to prospectively examine sleep,
depression, and suicide.
They recruited 954 patients with major affective
disorders starting from 1978 and observed for
10yrs.
Results showed association of 6 clinical features
including Global insomnia as a risk factor for
committing suicide in next 1year.
RETROSPECTIVE STUDY
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Agargun et al (1997a): Recruited 113 patients
with major depression. 17 item HAM-D,
SADS(Schedule for affective disorder and
schizophrenia) and SADS suicide subscale was
used to rate depression, sleep and suicide.
Study demonstrated depressed subjects suffering
from either hypersomnia or insomnia showed
significantly higher scores on measures of
suicidality.
CLINICAL AND EPIDEMIOLOGICAL
INVESTIGATIONS
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Turvey et al (2002):
1. Community based prospective study recruited
14456 elderly participants and 21 committed
suicide over the 10years observation period.
2. Study showed an association between poor
sleep quality and completed suicide in this
prospective study population more than 65yrs
old.
POLYSOMNOGRAPHIC STUDIES
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Sabo et al: Retrospectively studied the
electroencephalography (EEG) of major depressives
patients with and without a history of suicide
attempts.
Suicide attempters had longer sleep latency, lower
sleep efficiency, and fewer late-night delta wave
counts than normal controls.
Non-attempters, compared to attempters, had less
rapid eye movement (REM) time and activity in
period 2, but more delta wave counts in non-REM
period 4.
PROBLEMS WITH ABOVE STUDIES
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Although sleep disturbances are linked to
suicidality, this relationship may largely be
explained by higher depression ratings.
In all of these studies, depression was not
accounted for when examining the association
between sleep and completed suicide.
Only a few studies have examined the connection
between suicide and sleep complaints beyond
that explained by depression.
POLYSOMNOGRAPHIC STUDIES
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Keshavan et al (1994) examined REM sleep in
psychotic patients with and without a history of
suicide attempts or ideation.
Patients with a history of suicidal behavior
showed more REM activity, and REM sleep
parameters were not correlated with depression
scores.
RECENT STUDY
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Study done at Army Medical center was
published in J. of Affective disorder.
Study recruited 311 individuals with different
psychiatric diagnosis.
Insomnia symptoms were assessed by Beck
Depression Inventory items 16 & 17.
CONT,,,,,,,
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Suicidal ideations were assessed through Suicide
Probability Scale and Modified Scale for Suicidal
ideation.
This study suggested insomnia is a unique
predictor assessed cross sectionally for suicidal
ideation in comparison to other risk factors.
QUESTIONS
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Do we know enough about this association
between Sleep and Suicide?
What can be the possible explanation of
association?
ROLE OF SEROTONIN
Serotonin has also been documented to play an
important role in onset and maintenance of slow
wave sleep.
 Serotonergic function has been found to be low in
patients who attempted and/or completed suicide,
particularly those who used violent methods.
 Levels of 5-Hydroxyindoleacetic acid(5-HIAA) is
low in patients with insomnia as well as in
patients who commit/attempt suicides.
 5HT2 receptor antagonists helps to improve slow
wave sleep.
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POSSIBLE EXPLANATION
 Serotonergic
dysregulation play a key role
in underlying mechanisms of the
association with suicidal tendency and
sleep disturbance.
ALSO…..
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Other possible reason by which it can be
explained is that poor sleep is a stressor that may
independently increase the risk of suicide by
Impairing judgment
Impulse control
Fatigue
Hopelessness
Frustration
WHAT ABOUT MODIFYING THIS RISK
FACTOR?
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Needs assessment of insomnia
Need to find appropriate strategies to improve
sleep.
Non-pharmacological
Sleep Hygiene.
 Stimulus control therapy.
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CONT,,,,,,,
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Pharmacological :
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Benzodiazepines: Decrease sleep latency, increases
total sleep time and decreases slow wave sleep.
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TCA: Reduce REM sleep percentage and increase
REM sleep latency. Inconsistent activity on NREM
Stage 3/4. TCA do not worsen sleep apnea and may
have a small beneficial effect.
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Zolpidem: Very mild effect on REM sleep and does
not affect stage 3/4 NREM sleep. Tend to perverse
the sleep architecture.
CONT,,,,,
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Trazodone: Little effect on REM sleep &
increase in NREM Stage 3/4. Rebound
insomnia can occur.
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Antihistaminics: Improvement in sleep
latency, decrease nocturnal awakenings and
sleep quality.
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Mirtazepine: Decreases sleep latency and
awakenings. Some evidence suggest increases
Stage 3/4 NREM sleep.
IN SUMMARY,,,,,,,,,
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Sparse research in this area shows there is an
association between insomnia and suicide.
But we definitely need more research in this
area.
Is it the time we need to start screening patients
for insomnia as a part of suicide risk assessment?
IN SUMMARY,,,,,,,,,
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Would identifying insomnia as risk factor for
suicide improve our ability to intervene and
prevent suicide significantly in comparison to
other risk factors?
We need to find better drugs to treat insomnia
(particularly sleep maintenance insomnia)
without having potential of abuse, dependence or
lethal effects on overdose.
EVIDENCED BASED SUICIDE MODIFIERS
CBT reduced the rate of repeated suicide
attempts by 50 percent during a year of followup.
 Clozapine is approved by the Food and Drug
Administration for suicide prevention in people
with schizophrenia.
 Dialectical behavior therapy reduced suicide
attempts by half in people with borderline
personality disorder.
 Lithium and ECT have strong evidence for a
specific anti-suicide effect in mood disorders.
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WHAT THE FUTURE HOLDS ?
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5 HT₂ₐ antagonist helps maintaining slow wave
sleep and seems promising future treatment for
insomnia(Sleep maintenance insomnia).
REFERENCE
1.
Fawcett J;Scheftner WA;Fogg L;Clark DC;Young MA;Hedeker D;Gi,
Time-related predictors of suicide in major affective disorder, Am J
Psychiatry 1990 Sep;147(9):1189-94
2.
Ribeiro J;Pease J;Gutierrez P;Silva C;Bernert R;Rudd M;Joine,
Sleep problems outperform depression and hopelessness as crosssectional and longitudinal predictors of suicidal ideation and
behavior in young adults in the military. J Affect Disord 2012
Feb;136(3):743-50.
3.
Agargun M, Kara H, Solmaz M. Subjective Sleep Quality and
Suicidality in Patients with Major Depression. J Psychiat Res
1997;31:377–381.
4.
Agargun MY, Kara H, Solmaz M. Sleep disturbances and suicidal
behavior in patients with major depression. J Clin Psychiatry
1997;58:249–251.
5.
Agargun M, Cilli A, Kara H, et al. Repetitive and Frightening
Dreams and Suicidal Behavior in Patients with Major Depression.
Comprehensive Psychiatry 1998;39:198–202.
REFERENCE
6.
Ann Clin Psychiatry, Sleep and suicide in psychiatric patients. 2001
Jun;13(2):93-101.
7.
Sabo E, Reynolds CF 3rd, Kupfer DJ, Berman SR, Sleep,
depression, and suicide. Psychiatry Res.1991 Mar;36(3):265-77.
8.
Keshavan MS, Reynolds CF, Montrose D, Miewald J, Downs C,
Sabo EM. Sleep and suicidality in psychotic patients.
9.
Tanskanen A, Tuomilehto J, Vinamaki H, et al. Nightmares as
Predictors of Suicide. Sleep 2001;24:844–847.
10.
Turvey CL, Conwell Y, Jones MP, et al. Risk factors for late-life
suicide: a prospective, community based study. Am J Geriatr
Psychiatry 2002;10:398–406.