title: Sleep disturbances as an evidence-based suicide risk factor.
abstract: 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.
authors.affiliation: Suicide Prevention Research Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA, USA, rbernert@stanford.edu.
authors.forename: Rebecca A
authors.initials: RA
authors.lastname: Bernert
authors.forename: Joanne S
authors.initials: JS
authors.lastname: Kim
authors.forename: Naomi G
authors.initials: NG
authors.lastname: Iwata
authors.forename: Michael L
authors.initials: ML
authors.lastname: Perlis
mesh_terms: D003863:Depression / Q000523:psychology; D003866:Depressive Disorder / Q000523:psychology; D004325:Dreams / Q000523:psychology; D019317:Evidence-Based Medicine; D006801:Humans; D012307:Risk Factors; D007319:Sleep Initiation and Maintenance Disorders / Q000523:psychology; D012893:Sleep Wake Disorders / Q000150:complications / Q000523:psychology*; D059020:Suicidal Ideation; D013405:Suicide / Q000523:psychology* / Q000706:statistics & numerical data; D013406:Suicide, Attempted / Q000523:psychology