Nearly one million people die of suicide each year, according to the World Health Organization,1 and sleep may play a bigger role in the problem than you think. Patients with sleep issues have an increased risk for suicidal ideation, self-harm and/or suicide than the general population, studies suggest.

Sleep problems at baseline were strongly associated with suicide risk in the HUNT study, a prospective cohort study that involved 74,977 Norwegian citizens.2 The prevalence of sleep issues among the study population was as follows: 3% said they experienced sleep problems every night, 5%  said often and 31% said sometimes. A total of 188 participants died from suicide during the follow-up period.

Compared with participants who reported no sleep issues, the hazard ratio for suicide increased along with the frequency of reported sleep issues at baseline. Sex and age adjusted hazard ratios increased from 1.9 (95% CI: 1.3–2.6) among the group that sometimes reported sleep problems, to 2.7 (95% CI:  1.4–5.0) among the “often” group and 4.3 (95% CI: 2.3–8.3) among those who reported problems almost every night, Johan Håkon Bjørngaard, MA, PhD, of the Department of Public Health and General Practice in Trondheim, Norway, and colleagues reported in Sleep.

Associations between sleep problems and suicide association was highest among individuals younger than 50 years, the researchers found. They acknowledged several study limitations including inability to determine the affect of comorbid issues, including anxiety, depression and alcohol use on study findings, as well as whether patients who reported anxiety and depression experienced symptoms before or after the onset of sleep problems.

In a separate metaanalysis, sleep complaints including nightmares, parasomnias, difficulty falling asleep, difficulty maintaining sleep, awakenings during the night and waking too early were associated with suicidality. Published in the European Association for Predictive, Preventative and Personalized Medicine Journal, the metaanalysis included data from 23 studies published from 1997 to 2011. Interestingly, none of the studies found an association between suicidality and narcolepsy.

As healthcare providers it is important to ask questions about your patients sleep habits, as it affects their mental and physical well being in profound ways. Patients that do not sleep well may entertain thoughts of suicide, and some will die, despite the fact that most sleep disorders are treatable. We must take caution not to over prescribe sleep aids, but we must balance this threat against the risk that goes with not treating a patient’s sleep complaints.

Go a step further and ask your patients that report sleep disorders whether they have ever considered suicide. Patients who do not sleep well often say they feel hopeless regarding their situation. Always stress the importance of good sleep hygiene, and remind them that regular exercise also promotes better sleep.

Be sure to follow-up with these patients on a regular basis, or ask them to call you if their sleep does not improve. Remind patients that they may need to try several different therapies or medication before they find what works best. This can encourage them and give them the hope that they need. Also remember that these patients may  have uncontrolled anxiety and depression, so it is important to treat these problems as well.

Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.

References

  1. World Health Organization. “Suicide prevention.” Accessed online: October 2, 2012.
  2. Bjorngaard JH, Bjerkeset O, Romundstad P et al. “Sleeping Problems and Suicide in 75,000 Norwegian Adults: A 20 Year Follow-up of the HUNT 1 Study.” Sleep Vol. 34.No. 9 (2011): 1155-159.