Insomnia is a risk factor for suicide, and specifically treating severe insomnia in suicidal patients may help reduce suicidal thoughts, according to a new study published in the American Journal of Psychiatry.
“If you have a patient who complains that their sleep has taken a turn for the worse then there is reason to open the door to a question about suicide,” said Dr. Vaughn McCall, chair of the Department of Psychiatry and Health Behavior at the Medical College of Georgia (MCG) at Augusta University.
“If your patient says their sleep problem is really bad and they have had thoughts of killing themselves, maybe they should have a targeted treatment for their insomnia,” said McCall, corresponding author of the study and an expert on the triple threat of insomnia, depression and suicide.
More than 30 studies have linked insomnia to suicidal thoughts or actions, however suicide risk and prevention are largely overlooked in the treatment of insomnia, McCall said.
He is hoping the REST-IT — Reducing Suicidal Ideation Through Insomnia Treatment — study, the first clinical trial to investigate whether targeted insomnia treatment reduces suicide risk, will help change that.
“While the results do not argue for the routine prescription of hypnotics for mitigating suicidal ideation in all depressed outpatients with insomnia, they suggest that co-prescription of a hypnotic during initiation of an antidepressant may be beneficial in suicidal outpatients, especially in patients with severe insomnia,” the researchers write.
The study at MCG, Duke University and the University of Wisconsin involved 103 participants ages 18 to 65 with major depressive disorder, insomnia and suicidal thoughts.
In total, 30% of the participants had a prior suicide attempt; individuals with an active and imminent plan to commit suicide were excluded out of concern for their safety since it was an outpatient study, McCall says.
All participants took an antidepressant for the eight-week duration of the trial and half also took the sedative-hypnotic zolpidem at bedtime.
During the study, participants filled out regular self-reports of their insomnia severity and completed a daily sleep diary that included details like how many times they woke up during the night and how long they actually slept.
The researchers also analyzed distorted thoughts about sleep, like participants thinking they would never again have a good night’s sleep, something McCall has previously shown is itself a risk factor for suicide. The frequency and intensity of disturbing dreams or nightmares, also a factor in insomnia-related suicide, were measured.
Patients wore a wrist device to track their rest/activity cycles. Depression severity was measured by psychiatry staff at each study visit, and participants also completed the Beck Hopelessness Scale, which measures pessimism and negative expectations and is considered a predictor of suicidal behavior.
Those taking the sleep aid showed both significant immediate and longer-term improvement in their reported insomnia severity. While both groups reported significant improvement in their feelings about hopelessness, quality of life, nightmares and dysfunctional beliefs about sleep, as well as related insomnia and suicidality, the group taking the sleep aid had a greater reduction in suicidal thinking.
The sleep aid was most effective in reducing suicidal thoughts in patients with the most severe insomnia. There were no deaths or suicide attempts by participants during the course of the study.
The researchers note the safety of using narcotics in patients with suicidal thoughts and the fact that participants largely followed study protocols very well also were important findings. Both lay the groundwork for doing additional outpatient trials for patients with suicidal thoughts, McCall said.
Hypnotics, like the drug they used for the study, are a common means to commit suicide, and there are also concerns about becoming dependent on them.
To address these concerns, participants only received a week’s supply of the sleep aid until their suicidal thoughts began to abate, and the sleep aid was stopped after eight weeks. Afterward their condition remained the same or continued to improve, McCall said. Eight weeks is the timeframe McCall uses in prescribing the drug in his practice.
Two weeks after the study concluded both study groups — including those not taking the sleep aid — appeared to have maintained progress with reduced depression scores and suicidal thoughts. A possible reason all participants benefited could be the extra attention they received over the course of the study, McCall noted.
Insomnia dramatically increases the risk of depression and vice versa and both increase suicide risk, McCall said. Depression studies often exclude those with strong suicidality, he said. Now he wants to understand more about why insomnia is a risk for suicide and how treating it reduces that risk.