Suicidality in sleep disorders: prevalence, impact, and management strategies

Figures & data

Table 1 Research reporting prevalence of suicide ideation in youth and adults with insomnia symptoms and sleep disturbance among youth, adult, and older adult suicide attempters (fatal and nonfatal)

	Youth	Adults	Older adults
Suicide ideation	Prevalence of suicide ideation was around 25% for French adolescents reporting insomnia symptoms.^Citation17	In a longitudinal study of 405 military veterans meeting criteria for insomnia disorder, 32% reported suicide ideation at baseline.^Citation18	–
Nonfatal suicide attempts	About 7% of French adolescents with insomnia symptoms reported a prior suicide attempt.^Citation17 About 60% of adolescents reporting intentional self-harm or suicide-related behavior at age 15–17 years reported sleeping problems at age 12–14 years.^Citation19 About 81% of adolescent suicide-attempt survivors reported sleep disturbances.^Citation20	About 46% of adult suicide-attempt survivors reported global insomnia symptoms and 92% reported difficulties with either initial, middle, or terminal insomnia.^Citation21 Around 89% of adult suicide-attempt survivors reported sleep disturbances, which included initial (73%), middle (69%), and terminal insomnia (58%).^Citation22	–
Suicide	Around 30% of US adolescent suicide decedents experienced insomnia in the week preceding suicide and 32% experienced symptoms around the time of death.^Citation23 About 33% of rural Chinese youth suicide decedents experienced insomnia symptoms in the week preceding suicide.^Citation24	Between 28 and 37% of Japanese suicide decedents experienced initial, middle, or terminal insomnia.^Citation25 About 60% of US military veteran suicide decedents with psychiatric symptoms reported sleep problems during a VHA visit in the last year of life (40% reported sleep problems at their last VHA visit). About 13% without psychiatric symptoms reported sleep problems (9% at last visit).^Citation192	About 11% of Taiwanese suicide decedents had a history of insomnia symptoms.^Citation26

Notes: Initial insomnia, sleep-onset difficulty; middle insomnia, sleep-maintenance difficulty; terminal insomnia, early-morning awakening.

Abbreviation: VHA, Veterans Health Administration.

Table 2 Inconsistencies in insomnia symptoms and suicidality research

Initial insomnia	Initial insomnia has been associated with current^Citation51 and past 12-month suicide ideation, suicide-attempt planning, and nonfatal suicide attempts,^Citation73 and has been independently associated with youth suicide,^Citation23,Citation24 but was shown to be protective against attempting suicide at age 15–20 years.^Citation193
Middle insomnia	Middle insomnia has been independently associated with suicide in youth^Citation24 and adult^Citation65 samples, and has been associated with an increased frequency of lifetime suicide attempts,^Citation140 with adolescents reporting middle insomnia showing a four-^Citation179 to sixfold^Citation193 greater likelihood of reporting a past suicide attempt than those without middle insomnia. The relation between middle insomnia and suicide ideation, however, has not been consistent, though it should be noted that the majority of studies have shown an association between these two variables and the few inconsistencies do not appear to depend on whether researchers adjusted for psychiatric illness or other covariates, given that this was done across the majority of studies.^Citation30,Citation31,Citation40,Citation42,Citation46,Citation57,Citation140
Terminal insomnia	Regarding terminal insomnia, a few studies have shown that terminal insomnia is associated with suicide ideation (independently of mood, anxiety, and substance-use disorders),^Citation140 greater intent to attempt suicide,^Citation128 and recent suicide attempts,^Citation73,Citation76 but not lifetime suicide attempts.^Citation140 A study of Chinese adolescents showed that terminal insomnia did not predict significantly greater odds of suicide ideation when adjusting for age, sex, father’s occupation, and depressive symptoms.^Citation117

Notes: Initial insomnia, sleep-onset difficulty; middle insomnia, sleep-maintenance difficulty; terminal insomnia, early-morning awakening.

Table 3 Summary of mechanisms examined in the insomnia–suicidality relation

Proposed mediator	Summary of research
Hopelessness	Hopelessness had an indirect effect on the insomnia–suicide ideation relation in a cross-sectional sample of US adults, independently of depressive symptoms.^Citation194 However, other studies have shown that the insomnia symptom–suicide ideation relation remains when adjusting for depressive symptoms and feelings of hopelessness.^Citation48 Additionally, a case study of a 64-year-old male admitted to a psychiatric hospital after a suicide attempt noted that the patient’s feelings of hopelessness were secondary to insomnia distress and resolved, along with suicide ideation, following sleep improvements.^Citation195 Finally, in a study of adults with depression, hopelessness did not relate to insomnia symptoms or dysfunctional beliefs and attitudes about sleep,^Citation43 which is notable, given that it has been argued that some of the items on the DBAS measure reflect feelings of hopelessness.^Citation196
Depression structure	Allan et al^Citation71 suggested that the structure of depression (ie, cognitive/affective symptoms vs somatic) may explain the discrepant depression-mediation results across studies. In their sample of 405 current and former US military personnel, cognitive/affective symptoms of depression had an indirect effect on the relation between insomnia symptoms and baseline and 12-month follow-up suicide-ideation levels.
Insomnia duration	Research has shown that the duration of insomnia symptoms is associated with suicide risk independently of current symptoms of insomnia, depression, anxiety, or PTSD.^Citation177 Furthermore, a random-digit-dial study of US adults showed that insomnia complaints were more strongly associated with suicide ideation than ratings of poor sleep,^Citation197 and other studies have shown higher levels of suicide ideation among participants whose sleep concerns did not improve over the course of the treatment (independently of baseline sleep concerns, depressive symptoms, and suicide ideation)^Citation198 and that sleep dissatisfaction can explain a significant portion of the relation between insomnia and the wish to die.^Citation129
DBAS	In addition to nightmares, it has been proposed by McCall et al that DBAS may explain part of the relation between insomnia symptoms and suicide ideation due to the indirect effect of DBAS approaching significance in their cross-sectional sample of adults with depression.^Citation43
Nightmares	Nightmares have received increased attention over the past decade with regard to their potential role as a mediator of the insomnia–suicide relation. Research has shown that nightmares are associated with insomnia symptoms,^Citation43,Citation199 independently predictive of suicide ideation in cross-sectional samples,^Citation38,Citation89,Citation165 and that the relation between insomnia symptoms and suicide ideation becomes nonsignificant when including nightmares^Citation43 and holding symptoms of anxiety, depression, and PTSD constant.^Citation38 Furthermore, coexisting insomnia symptoms and nightmares have been shown to increase the risk for a future suicide attempt in an adult sample of psychiatric outpatients,^Citation58 potentially supporting the supposition that nightmares may be one reason for middle insomnia.^Citation60
Hyperarousal	Insomnia and PTSD-related nightmares have both been proposed as conditions of hyperarousal,^Citation196 and hyperarousal during sleep has been proposed as a neurobiological correlate of suicide ideation in adults with major depressive disorder.^Citation200 Recent studies have examined the role of hyperarousal in suicide risk,^Citation201 and a study of US military personnel showed a stronger relation between insomnia symptoms and suicide ideation among those with heightened levels of agitation.^Citation35 A dated study of suicide-attempt survivors, however, showed that 89% of attempt survivors denied experiencing agitation in the week prior to their suicide attempt.^Citation21
Thwarted belongingness	Recent research has examined the indirect effect of thwarted belongingness, a variable included in the suicidal desire component of the IPTS,^Citation202 on the relation between insomnia symptoms, suicide ideation, and suicide risk, showing that the variable accounts for a significant portion of the relation between insomnia and suicide ideation across multiple samples.^Citation39,Citation47,Citation56 However, it should be noted that the indirect effect of thwarted belongingness on the relation between insomnia and suicide risk was not significant when adjusting for depressive symptoms,^Citation47 and prior research has shown that the IPTS or thwarted belongingness alone fail to mediate the relation between insomnia symptoms and past suicide attempts cross-sectionally.^Citation74 Furthermore, the results from Hom et al^Citation47 specifically showed that the indirect effect of thwarted belongingness on the relation between insomnia and suicide ideation was more meaningful for those with lower levels of perceived burdensomeness. This finding potentially conflicts with the IPTS as originally proposed,^Citation202 and suggests that the IPTS may not be able to explain how insomnia symptoms lead to increased suicide risk across all samples, which is consistent with previous research.^Citation74

Abbreviations: DBAS, dysfunctional beliefs and attitudes about sleep; PTSD, posttraumatic stress disorder; IPTS, interpersonal–psychological theory of suicide.

Table 4 Prevalence of suicide-related thoughts and behaviors among participants with nightmares and proposed mechanisms of the nightmare–suicidality relation

	Prevalence
	In a study of adults with a history of trauma, 62% who experienced nightmares during the past month reported suicide ideation, suicide attempt planning, or a nonfatal suicide attempt,^Citation172 and about 96% of adult participants in a separate study who reported melancholic features and a suicide attempt during a current depressive episode reported experiencing nightmares at least twice a week.^Citation76 Among adolescents who often experience nightmares, 40% reported suicide ideation (compared to 13% of those who denied nightmares); the percentage increased to 50% for those who reported experiencing nightmares very often.^Citation28
Proposed mediator	Summary of research
Insomnia	Some studies have suggested that insomnia symptoms may explain the relation between nightmares and suicide ideation or a suicide-attempt history. An 8-year observational study of adults with schizophrenia-spectrum disorders showed that nightmares were associated with a history of suicide attempts, but only baseline insomnia symptoms were associated with an increased risk of suicide attempt at follow-up, with coexisting insomnia symptoms and nightmares conferring an elevenfold-increased risk for a future suicide attempt.^Citation59 Additionally, among a primary-care clinic sample of older adults, insomnia symptoms had an indirect effect on the association shown between nightmares and suicide ideation,^Citation52 and nightmares and insomnia symptoms predicted suicide ideation after 1 month (independently of baseline suicide ideation) in an online sample of adults, but only insomnia symptoms independently predicted 1 month suicide ideation.^Citation203
Negative affect	Hochard et al^Citation204 showed in a university sample that nightmares significantly increased the risk for future self-harm ideation and behaviors and that negative affect had an indirect effect on this relation. However, the direct effect of nightmares on self-harm risk was larger than the indirect effect, suggesting that negative affect cannot explain the majority of this relation.^Citation182
Defeat, entrapment, and hopelessness	Littlewood et al^Citation172 showed that the relation between nightmares and suicide risk is partially mediated by feelings of defeat, entrapment, and hopelessness. Notably, the effects of this multiple-mediation model remained after adjusting for insomnia symptoms and depression diagnosis.
Nightmare distress	A cross-sectional study of undergraduates showed that nightmare frequency had an indirect effect on suicide ideation through nightmare distress, independently of insomnia symptoms.^Citation205 In a moderated mediation analysis with sex as the moderator, results showed that the indirect effect of nightmare distress on the nightmare frequency–suicide ideation relation was significant only for women.
IPTS	Three studies have examined whether the IPTS could explain the nightmare–suicidality relation, with two studies showing that the full IPTS could not fully account for this relation^Citation74,Citation173 and one showing that neither thwarted belongingness nor perceived burdensomeness could fully account for the nightmare distress–suicide ideation relation.^Citation206 However, it should be noted that in the latter study, perceived burdensomeness partially mediated the nightmare distress–suicide ideation relation, with a moderated mediation showing that this effect was significant only for women.^Citation206

Abbreviation: IPTS, interpersonal–psychological theory of suicide.

BaillyDBailly-LambinIQuerleuDBeuscartRCollinetCLe sommeil des adolescents et ses troubles une enquête en milieu scolaire. [Sleep in adolescents and its disorders: a survey in schools]Encephale200430352359 French15538310

 PubMed Web of Science ®Google Scholar

TrockelMKarlinBETaylorCBBrownGKManberREffects of cognitive behavioral therapy for insomnia on suicidal ideation in veteransSleep20153825926525515115

 PubMed Web of Science ®Google Scholar

WongMMBrowerKJZuckerRASleep problems, suicidal ideation, and self-harm behaviors in adolescenceJ Psychiatr Res20114550551120889165

 PubMed Web of Science ®Google Scholar

TishlerCLMcKenryPCMorganKCAdolescent suicide attempts: some significant factorsSuicide Life Threat Behav19811186927256821

 PubMed Web of Science ®Google Scholar

HallRCPlattDEHallRCSuicide risk assessment: a review of risk factors for suicide in 100 patients who made severe suicide attempts – evaluation of suicide risk in a time of managed carePsychosomatics19994018279989117

 PubMed Web of Science ®Google Scholar

SjöströmaNWaernMHettabJNightmares and sleep disturbances in relation to suicidality in suicide attemptersSleep200730919517310869

 PubMed Web of Science ®Google Scholar

GoldsteinTRBridgeJABrentDASleep disturbance preceding completed suicide in adolescentsJ Consult Clin Psychol200876849118229986

 PubMed Web of Science ®Google Scholar

SunLZhangJLiuXInsomnia symptom, mental disorder and suicide: a case-control study in Chinese rural youthsSleep Biol Rhythms20151318118825914606

 PubMed Web of Science ®Google Scholar

KodakaMMatsumotoTKatsumataYSuicide risk among individuals with sleep disturbances in Japan: a case-control psychological autopsy studySleep Med20141543043524657202

 PubMed Web of Science ®Google Scholar

BrittonPCIlgenMAValensteinMKnoxKClaassenCAConnerKRDifferences between veteran suicides with and without psychiatric symptomsAm J Public Health2012102S125S13022390586

 PubMed Web of Science ®Google Scholar

HungGCKwokCLYipPSGunnellDChenYYPredicting suicide in older adults: a community-based cohort study in Taipei City, TaiwanJ Affect Disord201517216517025451412

 PubMed Web of Science ®Google Scholar

SmithMTPerilsMLHaythornthwaiteJASuicidal ideation in outpatients with chronic musculoskeletal pain: an exploratory study of the role of sleep onset insomnia and pain intensityClin J Pain20042011111814770051

 PubMed Web of Science ®Google Scholar

WojnarMIlgenMAWojnarJMcCammonRJValensteinMBrowerKJSleep problems and suicidality in the National Comorbidity Survey replicationJ Psychiatr Res20094352653118778837

 PubMed Web of Science ®Google Scholar

NrughamLLarssonBSundAMSpecific depressive symptoms and disorders as associates and predictors of suicidal acts across adolescenceJ Affect Disord2008111839318395267

 PubMed Web of Science ®Google Scholar

FujinoYMizoueTTokuiNYoshimuraTProspective cohort study of stress, life satisfaction, self-rated health, insomnia, and suicide death in JapanSuicide Life Threat Behav20053522723715843339

 PubMed Web of Science ®Google Scholar

McGlincheyELCourtney-SeidlerEAGermanMMillerALThe role of sleep disturbance in suicidal and nonsuicidal self-injurious behavior among adolescentsSuicide Life Threat Behav20164710311127273654

 PubMed Web of Science ®Google Scholar

KoyawalaNStevensJMcBee-StrayerSMCannonEABridgeJASleep problems and suicide attempts among adolescents: a case-control studyBehav Sleep Med20151328529524654933

 PubMed Web of Science ®Google Scholar

WongMMBrowerKJThe prospective relationship between sleep problems and suicidal behavior in the National Longitudinal Study of Adolescent HealthJ Psychiatr Res20124695395922551658

 PubMed Web of Science ®Google Scholar

WongMMBrowerKJCraunEAInsomnia symptoms and suicidality in the National Comorbidity Survey: adolescent supplementJ Psychiatr Res2016811827355426

 PubMed Web of Science ®Google Scholar

ChakravortySGrandnerMAMavandadiSPerlisMLSturgisEBOslinDWSuicidal ideation in veterans misusing alcohol: relationships with insomnia symptoms and sleep durationAddict Behav20143939940524169371

 PubMed Web of Science ®Google Scholar

TangWKLuJYLiangHIs insomnia associated with suicidality in stroke?Arch Phys Med Rehabil2011922025202722133252

 PubMed Web of Science ®Google Scholar

ChakravortySSiuHYLalley-ChareczkoLSleep duration and insomnia symptoms as risk factors for suicidal ideation in a nationally representative samplePrim Care Companion CNS Disord Epub20151231

 Google Scholar

GunnellDChangSSTsaiMKTsaoCKWenCPSleep and suicide: an analysis of a cohort of 394,000 Taiwanese adultsSoc Psychiatry Psychiatr Epidemiol2013481457146523546638

 PubMed Web of Science ®Google Scholar

FerentinosPPorichiEChristodoulouCDikeosDPapageorgiouCDouzenisASleep disturbance as a proximal predictor of suicidal intent in recently hospitalized attemptersSleep Med2016191727198939

 PubMed Web of Science ®Google Scholar

AgargunMYBesirogluLCilliASNightmares, suicide attempts, and melancholic features in patients with unipolar major depressionJ Affect Disord20079826727016938351

 PubMed Web of Science ®Google Scholar

LiuXSleep and adolescent suicidal behaviorSleep2004271351135815586788

 PubMed Web of Science ®Google Scholar

WoosleyJALichsteinKLTaylorDJRiedelBWBushAJHopelessness mediates the relation between insomnia and suicidal ideationJ Clin Sleep Med2014101223123025325598

 PubMed Web of Science ®Google Scholar

RibeiroJDPeaseJLGutierrezPMSleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the militaryJ Affect Disord201213674375022032872

 PubMed Web of Science ®Google Scholar

CurtisAAgarwalGAttarianHTreatment of subjective total insomnia after suicide attempt with olanzapine and electroconvulsive therapyJ Clin Psychopharmacol20163617818026841124

 PubMed Web of Science ®Google Scholar

McCallWVBatsonNWebsterMNightmares and dysfunctional beliefs about sleep mediate the effect of insomnia symptoms on suicidal ideationJ Clin Sleep Med2013913514023372466

 PubMed Web of Science ®Google Scholar

McCallWVBlackCGThe link between suicide and insomnia: theoretical mechanismsCurr Psychiatry Rep20131538923949486

 PubMed Web of Science ®Google Scholar

AllanNPConnerKRPigeonWRGrosDFSalamiTKSteckerTInsomnia and suicidal ideation and behaviors in former and current U.S. service members: does depression mediate the relations?Psychiatry Res201725229630228301827

 PubMed Web of Science ®Google Scholar

NadorffMRNazemSFiskeAInsomnia symptoms, nightmares, and suicide risk: duration of sleep disturbance mattersSuicide Life Threat Behav20134313914923278677

 PubMed Web of Science ®Google Scholar

WoosleyJALichsteinKLTaylorDJRiedelBWBushAJInsomnia complaint versus sleep diary parameters: predictions of suicidal ideationSuicide Life Threat Behav201646889526052862

 PubMed Web of Science ®Google Scholar

NadorffMREllisTEAllenJGWinerESHerreraSPresence and persistence of sleep-related symptoms and suicidal ideation in psychiatric inpatientsCrisis20143539840525231857

 PubMedGoogle Scholar

Mirsu-PaunAJaussentIKomarGCourtetPLopez-CastromanJSleep complaints associated with wish to die after a suicide crisis: an exploratory studyJ Sleep Res Epub2017424

 Web of Science ®Google Scholar

SandmanNValliKKronholmEOllilaHLaatikainenTPaunioTPrevalence of nightmares among the general Finnish adult population and veterans of the Second World WarSleep Med201314e34

 Google Scholar

NadorffMRNazemSFiskeAInsomnia symptoms, nightmares, and suicidal ideation in a college student sampleSleep201134939821203379

 PubMed Web of Science ®Google Scholar

BernertRAJoinerTEJrCukrowiczKCSchmidtNBKrakowBSuicidality and sleep disturbancesSleep2005281135114116268383

 PubMed Web of Science ®Google Scholar

CukrowiczKCOtamendiAPintoJVBernertRAKrakowBJoinerTEJrThe impact of insomnia and sleep disturbances on depression and suicidalityDreaming200616110

 Google Scholar

LiSXLamSPYuMWZhangJWingYKNocturnal sleep disturbances as a predictor of suicide attempts among psychiatric outpatients: a clinical, epidemiologic, prospective studyJ Clin Psychiatry2010711440144621114949

 PubMed Web of Science ®Google Scholar

LopesMCBoronatACWangYPFu-ILSleep complaints as risk factor for suicidal behavior in severely depressed children and adolescentsCNS Neurosci Ther20162291592027534369

 PubMed Web of Science ®Google Scholar

DolsenMRChengPArnedtJTNeurophysiological correlates of suicidal ideation in major depressive disorder: hyperarousal during sleepJ Affect Disord201721216016628192765

 PubMed Web of Science ®Google Scholar

RogersMLSchneiderMETuckerRPLawKCAnestisMDJoinerTEOverarousal as a mechanism of the relation between rumination and suicidalityJ Psychiatr Res201792313728390221

 PubMed Web of Science ®Google Scholar

FisherKHoutsmaCAssavedoBLGreenBAAnestisMDAgitation as a moderator of the relationship between insomnia and current suicidal ideation in the militaryArch Suicide Res Epub2016719

 Web of Science ®Google Scholar

JoinerTEWhy People Die by SuicideCambridge (MA)Harvard University Press2005

 Google Scholar

ChuCHomMARogersMLIs insomnia lonely? Exploring thwarted belongingness as an explanatory link between insomnia and suicidal ideation in a sample of South Korean university studentsJ Clin Sleep Med20161264765226857060

 PubMed Web of Science ®Google Scholar

HomMAChuCSchneiderMEThwarted belongingness as an explanatory link between insomnia symptoms and suicidal ideation: findings from three samples of military service members and veteransJ Affect Disord201720911412327898373

 PubMed Web of Science ®Google Scholar

ChuCHomMARogersMLInsomnia and suicide-related behaviors: a multi-study investigation of thwarted belongingness as a distinct explanatory factorJ Affect Disord201720815316227770645

 PubMed Web of Science ®Google Scholar

NadorffMRAnestisMDNazemSHarrisHCWinerESSleep disorders and the interpersonal-psychological theory of suicide: independent pathways to suicidality?J Affect Disord2014152–154505512

 Web of Science ®Google Scholar

LittlewoodDLGoodingPAPanagiotiMKyleSDNightmares and suicide in posttraumatic stress disorder: the mediating role of defeat, entrapment, and hopelessnessJ Clin Sleep Med20161239339926564386

 PubMed Web of Science ®Google Scholar

ChoquetMMenkeHSuicidal thoughts during early adolescence: prevalence, associated troubles and help-seeking behaviorActa Psychiatr Scand1990811701772327280

 PubMed Web of Science ®Google Scholar

LiSXLamSPZhangJSleep disturbances and suicide risk in an 8-year longitudinal study of schizophrenia-spectrum disordersSleep2016391275128227091530

 PubMed Web of Science ®Google Scholar

NadorffMRFiskeASperryJAPettsRGreggJJInsomnia symptoms, nightmares, and suicidal ideation in older adultsJ Gerontol B Psychol Sci Soc Sci20136814515222929392

 PubMed Web of Science ®Google Scholar

NadorffMRDrapeauCWWinerESKilgoreJKNightmares and insomnia symptoms prospectively predict the development of suicidal ideationSleep201740A416

 Web of Science ®Google Scholar

HochardKDHeymNTownsendEThe unidirectional relationship of nightmares on self-harmful thoughts and behaviorsDreaming2015254458

 Web of Science ®Google Scholar

NadorffMRPearsonMDGoldingSExplaining the relation between nightmares and suicideJ Clin Sleep Med20161228929026857049

 PubMed Web of Science ®Google Scholar

LeeRSuhSNightmare distress as a mediator between night-mare frequency and suicidal ideationDreaming201626308318

 Web of Science ®Google Scholar

GoldingSNadorffMRWinerESWardKCUnpacking sleep and suicide in older adults in a combined online sampleJ Clin Sleep Med2015111385139226194726

 PubMed Web of Science ®Google Scholar

SuhSSchneiderMLeeRJoinerTPerceived interpersonal burdensomeness as a mediator between nightmare distress and suicidal ideation in nightmare sufferersFront Psychol20167180527917142

 PubMed Web of Science ®Google Scholar