Skip to main content

Sleep apnea may be associated with suicidal ideation in adolescents


Suicide is a major threat to adolescent health. Sleep problems increase the risk of adolescent suicidal behavior, but the role of sleep-disordered breathing (e.g., sleep apnea) is unclear. We investigated whether sleep apnea had an effect on suicidal ideation that was independent of depression and perceived stress. We examined a series of sleep variables with suicidal ideation in 746 fifth and seventh graders using self-reported questionnaires to assess time in bed, sleep quality, insomnia, and sleep apnea while controlling depression and perceived stress. Overall, 8.8% of students aged 10–14 years reported having recent suicidal ideation, and 33% or 3.8%, depending on the screening criteria, reported having suspected sleep apnea. The sleep variables were all associated with an increased risk of suicidal ideation, but the magnitude of effects was largely attenuated when depression and perceived stress were included in the models. Suspected sleep apnea using daytime sleepiness as a screening criterion was independently associated with suicidal ideation (odds ratio = 2.25, p < 0.05). Suspected sleep apnea was associated with suicidal ideation that was partly independent of depression and stress, which reveals the pertinence of screening for sleep apnea among school students and designing proper prevention strategies for reducing youth suicidal behavior.

This is a preview of subscription content, access via your institution.



World Health Organization


Obstructive sleep apnea


Continuous positive airway pressure


Epworth’s Sleepiness Scale


Chinese version of the Pittsburg Sleep Quality Index


7-item modified Epworth’s Sleepiness Scale


Perceived Stress Scale


Center for Epidemiologic Studies Depression Scale


Cognitive behavioral therapy for insomnia


  1. World Health Organization (2017) World Health Statistics 2016. World Health Organization, Geneva.

    Google Scholar 

  2. Bishop TM, Ashrafioun L, Pigeon WR (2018) The association between sleep apnea and suicidal thought and behavior: an analysis of national survey data. J Clin Psychiatry 79:17m11480

    Article  PubMed  Google Scholar 

  3. Carotenuto M, Esposito M, Parisi L, Gallai B, Marotta R, Pascotto A, Roccella M (2012) Depressive symptoms and childhood sleep apnea syndrome. Neuropsychiatr Dis Treat 8:369–373

    Article  PubMed  PubMed Central  Google Scholar 

  4. Chan EY, Ng DK, Chan CH, Kwok KL, Chow PY, Cheung JM, Leung SY (2009) Modified Epworth Sleepiness Scale in Chinese children with obstructive sleep apnea: a retrospective study. Sleep Breath 13:59–63

    Article  PubMed  Google Scholar 

  5. Cheng CP, Yen CF, Ko CH, Yen JY (2012) Factor structure of the Center for Epidemiologic Studies Depression Scale in Taiwanese adolescents. Compr Psychiatry 53:299–307

    Article  PubMed  Google Scholar 

  6. Chiu H-Y, Lee H-C, Chen P-Y, Lai Y-F, Tu Y-K (2018) Associations between sleep duration and suicidality in adolescents: a systematic review and dose–response meta-analysis. Sleep Med Rev.

    Article  PubMed  Google Scholar 

  7. Chiu WH, Yang HJ, Kuo PH (2017) Chronotype preference matters for depression in youth. Chronobiol Int 34:933–941

    Article  PubMed  Google Scholar 

  8. Edwards C, Mukherjee S, Simpson L, Palmer LJ, Almeida OP, Hillman DR (2015) Depressive symptoms before and after treatment of obstructive sleep apnea in men and women. J Clin Sleep Med 11:1029–1038

    PubMed  PubMed Central  Google Scholar 

  9. Ejaz SM, Khawaja IS, Bhatia S, Hurwitz TD (2011) Obstructive sleep apnea and depression: a review. Innov Clin Neurosci 8:17–25

    PubMed  PubMed Central  Google Scholar 

  10. Fitzgerald CT, Messias E, Buysse DJ (2011) Teen sleep and suicidality: results from the youth risk behavior surveys of 2007 and 2009. J Clin Sleep Med 7:351–356

    PubMed  PubMed Central  Google Scholar 

  11. Franic T, Kralj Z, Marcinko D, Knez R, Kardum G (2014) Suicidal ideations and sleep-related problems in early adolescence. Early Interv Psychiatry 8:155–162

    Article  PubMed  Google Scholar 

  12. Goldstein TR, Bridge JA, Brent DA (2008) Sleep disturbance preceding completed suicide in adolescents. J Consult Clin Psychol 76:84–91

    Article  PubMed  PubMed Central  Google Scholar 

  13. Health USNIo (2017) Identifier numbers: NCT03595254, NCT02038075, NCT03603717.

  14. Jimenez-Correa U, Haro R, Poblano A, Arana-Lechuga Y, Teran-Perez G, Gonzalez-Robles RO, Velazquez-Moctezuma J (2009) Mexican version of the Epworth Sleepiness Scale. Open Sleep J 2:6–10

    Article  Google Scholar 

  15. Kim JH, Park EC, Lee SG, Yoo KB (2015) Associations between time in bed and suicidal thoughts, plans and attempts in Korean adolescents. BMJ Open 5:e008766

    Article  PubMed  PubMed Central  Google Scholar 

  16. Klonsky ED, May AM, Saffer BY (2016) Suicide, suicide attempts, and suicidal ideation. Annu Rev Clin Psychol 12:307–330

    Article  PubMed  Google Scholar 

  17. Koyawala N, Stevens J, McBee-Strayer SM, Cannon EA, Bridge JA (2015) Sleep problems and suicide attempts among adolescents: a case-control study. Behav Sleep Med 13:285–295

    Article  PubMed  Google Scholar 

  18. Krahn LE, Miller BW, Bergstrom LR (2008) Rapid resolution of intense suicidal ideation after treatment of severe obstructive sleep apnea. J Clin Sleep Med 4:64–65

    PubMed  PubMed Central  Google Scholar 

  19. Krakow B, Artar A, Warner TD, Melendrez D, Johnston L, Hollifield M, Germain A, Koss M (2000) Sleep disorder, depression, and suicidality in female sexual assault survivors. Crisis 21:163–170

    Article  CAS  PubMed  Google Scholar 

  20. Lee W, Nagubadi S, Kryger MH, Mokhlesi B (2008) Epidemiology of obstructive sleep apnea: a population-based perspective. Expert Rev Respir Med 2:349–364

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lee YJ, Cho SJ, Cho IH, Kim SJ (2012) Insufficient sleep and suicidality in adolescents. Sleep 35:455–460

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Liu X, Chen H, Bo QG, Fan F, Jia CX (2017) Poor sleep quality and nightmares are associated with non-suicidal self-injury in adolescents. Eur Child Adolesc Psychiatry 26:271–279

    Article  PubMed  Google Scholar 

  23. Lumeng JC, Chervin RD (2008) Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc 5:242–252

    Article  PubMed  PubMed Central  Google Scholar 

  24. Macey PM, Kumar R, Woo MA, Valladares EM, Yan-Go FL, Harper RM (2008) Brain structural changes in obstructive sleep apnea. Sleep 31:967–977

    PubMed  PubMed Central  Google Scholar 

  25. McCall WV, Black CG (2013) The link between suicide and insomnia: theoretical mechanisms. Curr Psychiatry Rep 15:389

    Article  PubMed  PubMed Central  Google Scholar 

  26. Ministry of Health and Welfare Taiwan (2017).

  27. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, Bruffaerts R, Chiu WT, de Girolamo G, Gluzman S, de Graaf R, Gureje O, Haro JM, Huang Y, Karam E, Kessler RC, Lepine JP, Levinson D, Medina-Mora ME, Ono Y, Posada-Villa J, Williams D (2008) Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry 192:98–105

    Article  PubMed  PubMed Central  Google Scholar 

  28. Ohida T, Osaki Y, Doi Y, Tanihata T, Minowa M, Suzuki K, Wada K, Suzuki K, Kaneita Y (2004) An epidemiologic study of self-reported sleep problems among Japanese adolescents. Sleep 27:978–985

    Article  PubMed  Google Scholar 

  29. Park JH, Yoo JH, Kim SH (2013) Associations between non-restorative sleep, short sleep duration and suicidality: findings from a representative sample of Korean adolescents. Psychiatry Clin Neurosci 67:28–34

    Article  PubMed  Google Scholar 

  30. Perfect MM, Archbold K, Goodwin JL, Levine-Donnerstein D, Quan SF (2013) Risk of behavioral and adaptive functioning difficulties in youth with previous and current sleep disordered breathing. Sleep 36:517–525

    PubMed  PubMed Central  Google Scholar 

  31. Pigeon WR, Caine ED (2010) Insomnia and the risk for suicide: does sleep medicine have interventions that can make a difference? Sleep Med 11:816–817

    Article  PubMed  PubMed Central  Google Scholar 

  32. Pigeon WR, Pinquart M, Conner K (2012) Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. J Clin Psychiatry 73:e1160–e1167

    Article  Google Scholar 

  33. Povitz M, Bolo CE, Heitman SJ, Tsai WH, Wang J, James MT (2014) Effect of treatment of obstructive sleep apnea on depressive symptoms: systematic review and meta-analysis. PLoS Med 11:e1001762

    Article  PubMed  PubMed Central  Google Scholar 

  34. Sharafkhaneh A, Giray N, Richardson P, Young T, Hirshkowitz M (2005) Association of psychiatric disorders and sleep apnea in a large cohort. Sleep 28:1405–1411

    Article  Google Scholar 

  35. Singareddy R, Krishnamurthy VB, Vgontzas AN, Fernandez-Mendoza J, Calhoun SL, Shaffer ML, Bixler EO (2013) Subjective and objective sleep and self-harm behaviors in young children: a general population study. Psychiatry Res 209:549–553

    Article  PubMed  PubMed Central  Google Scholar 

  36. Trockel M, Karlin BE, Taylor CB, Brown GK, Manber R (2015) Effects of cognitive behavioral therapy for insomnia on suicidal ideation in veterans. Sleep 38:259–265

    Article  PubMed  PubMed Central  Google Scholar 

  37. Tsai PS, Wang SY, Wang MY, Su CT, Yang TT, Huang CJ, Fang SC (2005) Psychometric evaluation of the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) in primary insomnia and control subjects. Qual Life Res 14:1943–1952

    Article  CAS  PubMed  Google Scholar 

  38. Winsler A, Deutsch A, Vorona RD, Payne PA, Szklo-Coxe M (2015) Sleepless in Fairfax: the difference one more hour of sleep can make for teen hopelessness, suicidal ideation, and substance use. J Youth Adolesc 44:362–378

    Article  PubMed  Google Scholar 

  39. Wong MM, Brower KJ (2012) The prospective relationship between sleep problems and suicidal behavior in the National Longitudinal Study of Adolescent Health. J Psychiatr Res 46:953–959

    Article  PubMed  PubMed Central  Google Scholar 

  40. Wong MM, Brower KJ, Craun EA (2016) Insomnia symptoms and suicidality in the National Comorbidity Survey—adolescent supplement. J Psychiatr Res 81:1–8

    Article  PubMed  PubMed Central  Google Scholar 

  41. Yang HJ, Soong WT, Kuo PH, Chang HL, Chen WJ (2004) Using the CES-D in a two-phase survey for depressive disorders among nonreferred adolescents in Taipei: a stratum-specific likelihood ratio analysis. J Affect Disord 82:419–430

    PubMed  Google Scholar 

  42. Yen CF, King BH, Tang TC (2010) The association between short and long nocturnal sleep durations and risky behaviours and the moderating factors in Taiwanese adolescents. Psychiatry Res 179:69–74

    Article  PubMed  Google Scholar 

Download references


This study was supported by the Ministry of Science and Technology in Taiwan (MST101-2314-B-002-128-MY3 grant to Dr. P–H Kuo and NSC99-2511-S-040-004-MY3 grant to Dr. H-J Yang). We would like to especially thank all subjects who agree to participate in this study. We also thank JH Shen, PC Chu, SS Huang, and WH Chiu who assisted for data collection and data management.

Author information

Authors and Affiliations



WCT hypothesized to test the associations between sleep-disordered breathing and suicidal ideation, and wrote the first draft of the manuscript. YCL and YLC assisted in data cleaning and analyses. MHS assisted in data collection and designing the coding book. HJY and PHK were in charge of the study design and the acquisition of the financial support from the government. PHK also coordinated this study, assisted to explain statistical analysis results, and made critical revision of the manuscript.

Corresponding author

Correspondence to Po-Hsiu Kuo.

Ethics declarations

Conflict of interest

There is no conflict of interest in the present study.

Ethical standards

This study was approved by the Institutional Review Board of National Taiwan University Hospital. All procedures performed in the present study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards, and all participants and one of their parents provided informed consent.

Additional information

Implications and contribution

We investigated the associations between suspected sleep apnea, several sleep variables, and suicidality among adolescents, and found that students with suspected sleep apnea were more likely to have suicidal ideation independent of depression or stress. The results revealed the need to screen for sleep apnea in addition to other sleep problems, in the hope of preventing youth suicide.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Tseng, WC., Liang, YC., Su, MH. et al. Sleep apnea may be associated with suicidal ideation in adolescents. Eur Child Adolesc Psychiatry 28, 635–643 (2019).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Sleep
  • Adolescents
  • Suicidal ideation
  • Sleep apnea