Research continues to mount showing associations between antidepressants and suicidal behavior in adolescents. In a study just published in the British Medical Journal or now popularly called, The BMJ, teenagers using common antidepressants [duloxetine (Cymbalta), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and venlafaxine (Effexor)]. You can read the article in its entirety at this link. While using these meds the risks for suicidal behavior, both attempts and actual deaths, appeared to be twice as high in teenagers compared to those receiving placebo pills. No increased risks were noted in adults.
While these studies are very important and informative, you will not be surprised to know this type of research rarely if ever examines whether these adolescents were suffering from co-occurring sleep disorders, such as insomnia, sleep-disordered breathing or leg movement conditions. The routine omission of sleep-related variables in psychiatric research is a growing concern, because in the research done to date on sleep and suicide, it is abundantly clear many connections are worthy of exploration, and on a practical level, many conditions such as insomnia and nightmares are treatable in these suicidal patients regardless of the other psychiatric conditions from which they may also be suffering. As research consistently shows nightmares or insomnia or both are associated with suicidal thinking and in some cases suicidal behavior, it is frustrating so little action is taken in this sphere.
From the sleep medicine perspective, the upper airway resistance syndrome or UARS is extremely common in patients with either insomnia or nightmares or both, and therefore, it would be most curious to know whether or not patients with suicidal ideation or behavior are suffering from an underlying sleep breathing disorder. If so, then parsimoniously, we know successful treatment of UARS might also alleviate some insomnia and nightmare complaints. Would it not be worthwhile then to conduct treatment research to find out whether or not the combined effects of a UARS therapy (e.g. PAP, OAT, nasal strips) would improve sleep quality, resolve insomnia and reduce nightmares in suicidal patients? And, if the therapy were to achieve these objectives, what changes would occur on the problems of suicidal thinking or actions?
We see a fair number of adolescents at our sleep center. And, when they present with either insomnia or nightmares or simply poor quality sleep, their most common diagnosis is UARS. Many of them are able to use PAP therapy, and anecdotally, most who successfully adapt to PAP therapy report improvements in insomnia and nightmares. Moreover, many also report enhanced sleep quality and concomitant decreases in daytime fatigue and sleepiness.
Untreated UARS, as you may recall (diagnosing UARS and treating UARS) causes direct effects of chronic sleep fragmentation, which in turn has been linked to cognitive impairment and degradation of mood. In time, chronic states of fatigue and sleepiness through the unremitting effects of nonrestorative sleep could be associated with compromised judgments and decision-making, increased agitation and irritability, and eventually corrosive mental states more vulnerable to self-destructive thinking and behaviors.
The insomnia caused by UARS produces its own direct and indirect effects on some of these same symptoms. Moreover, imagine the dispiriting mental state building in someone who awakens at night and cannot return to sleep. A festering cycle of low energy, weakened resiliency, and a pessimistic attitude can occur for anyone after one lousy night of sleep compromised by intermittent bouts of insomnia. It would be no surprise for this negativity to blossom in a more pronounced fashion in someone under the duress of chronic insomnia, night after night.
Nightmares play a similar role to insomnia simply because they cause or trigger bouts of sleeplessness. Some individuals develop fears just walking into their own bedrooms, knowing a nightmare may be awaiting them a few hours into their sleep cycle. But, nightmare sufferers describe the added damage from the disturbing and emotionally draining images that afflict them in their sleep. Thus, nightmares not only compound the insomnia and poor sleep quality, but also, they directly sour a person’s mood and sense of well-being because of the troubling and sometimes horrific images they must endure.
Wrapping up this part of the discussion, it seems fairly clearly how important it might turn out to study whether the UARS-insomnia-nightmare connections are just as important as depression in suicidal patients, and one of the tried and true experiments to gain this knowledge would be treatment studies treating all three components of the sleep disorders and monitoring what changes or lack thereof in the depression and suicidal symptoms. At the far end of speculation, it may also prove informative to tease apart whether the depression in some of these patients is primarily due to the undiagnosed and untreated UARS, or whether depression can cause sufficient sleep fragmentation to create vulnerability towards the development of UARS.
With this backdrop, I would like to finish up with a very interesting corollary subject on the timing of suicides and whether or not it might be related to time of day or time of night. Research in this area is surprisingly sparse. Very few studies in this area have been conducted, and among the studies completed, the data are not necessarily reliable due to the difficult problem of distinguishing between time of the suicide event and the actual time of death. Most death certificates for example will only mark the actual time of death. Therefore, if research looked only at this dimension, it most assuredly would be looking on average many hours or days following the suicide event. And, while some types of self-destructive behavior are nearly guaranteed to produce more immediate deaths, if the real-time of the actual suicidal effort is not available, it is very difficult to clarify the time of day or night.
That said, as a clinical sleep specialist who has experienced first-hand the exasperation of middle of the night insomnia and who has worked with numerous patients having experienced the same misery, I would have predicted that some suicide attempts are more likely to occur at night when someone becomes desperate to sleep and then “accidentally” overdoses on multiple medications or substances to try to solve the insomnia. In fact, some cases of this sort seem to occur. However, in looking at the research that attempts to deal with the confound of the suicide time vs the time of death, two consistent findings seem to emerge.
First, among adults, suicides occur more often during the period of 8 AM to 11 AM, whereas, secondly, in adolescents the higher prevalence occurs between 11 AM and 2 PM, neither of which necessarily coincides with a sleep cycle, unless these younger individuals were sleeping later than typical schedules. In fact, a fair amount of this same research suggests a lot of suicides do not occur between midnight and 8 AM, which is of course a more typical sleep cycle.
Immediate questions arise with these timing issues as might relate to sleep problems. The most obvious question is whether or not someone suffers from a horrible night of sleep and awakens eventually in a depressed or agitated state that then triggers thoughts about suicidality? In addition, an individual with severe sleep problems could awaken with feelings of exhaustion and unrefreshing sleep, which diminishes the individual’s motivation to start the day. The afternoon timing for adolescents raises similar questions: were these individuals sleeping on delayed phase schedules (going to bed late and waking up later)? And, they raise similar questions about whether or not the teenager hits a wall in the late morning or early afternoon and again loses motivation to pursue positive behaviors or think more constructively.
All these speculations are just that. I do not mean to overplay the sleep card, but there can be no doubt that bad sleep affects one’s mood and attitude and therefore would seem to have a potential to serve as a negative catalyst among individuals already moving down the dark path of suicidality.
For more scientific reading on this suicide topic, please visit this link at PubMed, and you will find a number of abstracts on papers dealing with the timing issue.