Increasing research indicates that sleep disturbances may confer increased risk for suicidal behaviors, including suicidal ideation, suicide attempts, and death by suicide. Despite increased investigation, a number of methodological problems present important limitations to the validity and generalizability of findings in this area, which warrant additional focus. To evaluate and delineate sleep disturbances as an evidence-based suicide risk factor, a systematic review of the extant literature was conducted with methodological considerations as a central focus. The following methodologic criteria were required for inclusion: the report (1) evaluated an index of sleep disturbance; (2) examined an outcome measure for suicidal behavior; (3) adjusted for presence of a depression diagnosis or depression severity, as a covariate; and (4) represented an original investigation as opposed to a chart review. Reports meeting inclusion criteria were further classified and reviewed according to: study design and timeframe; sample type and size; sleep disturbance, suicide risk, and depression covariate assessment measure(s); and presence of positive versus negative findings. Based on keyword search, the following search engines were used: PubMed and PsycINFO. Search criteria generated N = 82 articles representing original investigations focused on sleep disturbances and suicide outcomes. Of these, N = 18 met inclusion criteria for review based on systematic analysis. Of the reports identified, N = 18 evaluated insomnia or poor sleep quality symptoms, whereas N = 8 assessed nightmares in association with suicide risk. Despite considerable differences in study designs, samples, and assessment techniques, the comparison of such reports indicates preliminary, converging evidence for sleep disturbances as an empirical risk factor for suicidal behaviors, while highlighting important, future directions for increased investigation.
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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Krug E, Dahlberg L, Mercy J, Zwi A, Lozano R. World report on violence health. World Health Organization; 2002.
Goldsmith S, Pellmar T, Kleinman A. Reducing suicide: a national imperative: Institute of Medicine 2002.
Murphy S, Xu J, Kochanek M. Deaths: final data for 2010. Natl Vital Stat Rep. 2013;61(4):1–118.
World Health Organization (WHO). WHO mental health action plan 2013–2020. World Health Organization; 2013.
Bernert R, Joiner TJ, Cukrowicz K, Schmidt N, Krakow B. Suicidality and sleep disturbances. Sleep. 2005;28(9):1135–41.
Ribeiro J, Pease J, Gutierrez P, Silva C, Bernert R, Rudd M, et al. Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. J Affect Disord. 2012;136(3):743–50. doi:10.1016/j.jad.2011.09.049. Sleep-related symptoms were significantly associated with increased risk for suicidal ideation and future suicide attempts—independent of both depression and hopelessness—among a high-suicide risk, military group.
Goldstein T, Bridge J, Brent D. Sleep disturbance preceding completed suicide in adolescents. J Consult Clin Psychol. 2008;76(1):84–91. doi:10.1037/0022-006x.76.1.84.
Bernert R, Turvey C, Conwell Y, Joiner Jr T. Association of poor subjective sleep quality with risk for death by suicide during a 10-year period: a longitudinal, population-based study of late life. JAMA Psychiatr. 2014. doi:10.1001/jamapsychiatry.2014.1126. This is the first report in a representative, population-based prospective community sample of older adults to evaluate poor subjective sleep quality as an independent risk factor for death by suicide.
Pigeon WR, Pinquart M, Conner K. Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. J Clin Psychiatry. 2012;73(9):e1160–7. doi:10.4088/JCP.11r07586. This was the first meta-analysis of sleep disturbance and suicide literature.
National Mental Health Information Center. Suicide warning signs. Substance Abuse and Mental Health Services Administration (SAMHSA); 2005.
Association AP. Diagnostic and statistical manual of mental disorders: text revision. 4th ed. Washington, DC: 2000.
Yoshimasu K, Kiyohara C, Kazuhisa M. Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies. Environ Health Prev Med. 2008;13(5):243–56.
Conwell Y, Brent D. Suicide and aging i: patterns of psychiatric diagnosis. Int Psychogeriatr. 1995;7(2):149–64.
Keshavan MS, Reynolds CF, Montrose D, Miewald J, Downs C, Sabo EM. Sleep and suicidality in psychotic patients. Acta Psychiatr Scand. 1994;89(2):122–5.
Sabo E, Reynolds 3rd CF, Kupfer DJ, Berman SR. Sleep, depression, and suicide. Psychiatry Res. 1991;36(3):265–77.
Agargun M, Cartwright R. REM sleep, dream variables and suicidality in depressed patients. Psychiatr Res. 2003;119(1–2):33–9.
Liu X. Sleep and adolescent suicidal behavior. Sleep. 2004;27(7):1351–8.
Roberts R, Roberts C, Chen I. Functioning of adolescents with symptoms of disturbed sleep. J Youth Adolesc. 2001;30(1):1–18. doi:10.1023/A:1005230820074.
Lapierre S, Boyer R, Desjardins S, Dubé M, Lorrain D, Préville M, et al. Daily hassles, physical illness, and sleep problems in older adults with wishes to die. Int Psychogeriatr. 2012;24(2):243–52.
Wong M, Brower K, Zucker R. Sleep problems, suicidal ideation, and self-harm behaviors in adolescence. J Psychiatr Res. 2011;45(4):505–11.
Cukrowicz K, Otamendi A, Pinto J, Bernert R, Krakow B, Joiner T. The impact of insomnia and sleep disturbances on depression and suicidality. Dreaming. 2006;16(1):1–10.
Nadorff M, Nazem S, Fiske A. Insomnia symptoms, nightmares, and suicide risk: duration of sleep disturbance matters. Suicide Life Threat Behav. 2013;43(2):139–49. doi:10.1111/sltb.12003.
Nadorff M, Nazem S, Fiske A. Insomnia symptoms, nightmares, and suicidal ideation in a college student sample. Sleep. 2011;34(1):93–8.
Sjostrom N, Waern M, Hetta J. Nightmares and sleep disturbances in relation to suicidality in suicide attempters. Sleep. 2007;30(1):91–5.
Tang W, Lu J, Liang H, Chan T, Mok V, Ungvari G, et al. Is insomnia associated with suicidality in stroke? Arch Phys Med Rehabil. 2011;92(12):2025–7. doi:10.1016/j.apmr.2011.06.030.
Smith M, Perlis M, Haythornthwaite J. Suicidal ideation in outpatients with chronic musculoskeletal pain: an exploratory study of the role of sleep onset insomnia and pain intensity. Clin J Pain. 2004;20(2):111–8.
McCall WV, Blocker JN, D’Agostino Jr R, Kimball J, Boggs N, Lasater B, et al. Insomnia severity is an indicator of suicidal ideation during a depression clinical trial. Sleep Med. 2010;11(9):822–7. doi:10.1016/j.sleep.2010.04.004.
Wojnar M, Ilgen MA, Wojnar J, McCammon RJ, Valenstein M, Brower KJ. Sleep problems and suicidality in the National Comorbidity Survey Replication. J Psychiatr Res. 2009;43(5):526–31. doi:10.1016/j.jpsychires.2008.07.006.
Diagnostic and statistical manual of mental disorders. 5 ed. Washington, DC: American Psychiatric Association; 2013.
Wong MM, Brower KJ. The prospective relationship between sleep problems and suicidal behavior in the National Longitudinal Study of Adolescent Health. J Psychiatr Res. 2012;46(7):953–9. doi:10.1016/j.jpsychires.2012.04.008.
Kodaka M, Matsumoto T, Katsumata Y, Akazawa M, Tachimori H, Kawakami N, et al. Suicide risk among individuals with sleep disturbances in Japan: a case–control psychological autopsy study. Sleep Med. 2014;15(4):430–5.
van Houwelingen C, Beersma D. Seasonal changes in 24-h patterns of suicide rates: a study on train suicides in the Netherlands. J Affect Disord. 2001;66(2–3):215–23.
Preti A, Miotto P. Diurnal variations in suicide by age and gender in Italy. J Affect Disord. 2001;65(3):253–61.
Williams P, Tansella M. The time for suicide. Acta Psychiatr Scand. 1987;75(5):532–5.
Maldonado G, Kraus J. Variation in suicide occurrence by time of day, day of the week, month, and lunar phase. Suicide Life Threat Behav. 1991;21(2):174–87.
Perlis M, Grandner M, Basner M, Chakravorty S, Brown G, Morales K, et al. When accounting for wakefulness, completed suicides exhibit an increased likelihood during circadian night. Sleep. 2014;37:272. Investigated diurnal variation in suicide incidence while accounting for the proportion of individuals likely to be awake at each hour of the day.
Rebecca A. Bernert and Michael L. Perlis are supported in part by grants from the National Institutes of Health (K23MH093490 and R01AG041783, respectively).
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Joanne S. Kim, Naomi G. Iwata, Rebecca A. Bernert, and Michael L. Perlis declare that they have no conflict of interest.
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This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Sleep Disorders
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Bernert, R.A., Kim, J.S., Iwata, N.G. et al. Sleep Disturbances as an Evidence-Based Suicide Risk Factor. Curr Psychiatry Rep 17, 15 (2015). https://doi.org/10.1007/s11920-015-0554-4
- Sleep disturbances
- Sleep quality