title: Suicide and sleep: Is it a bad thing to be awake when reason sleeps?
abstract: Suicide is the second leading cause of death, worldwide, for those between the ages of 24 and 44 y old. In 2013, more than 41,000 suicides occurred in the United States. These statistics underscore the need to 1) understand why people die by suicide and 2) identify risk factors that are potentially modifiable. While it has been posited that sleep disturbance may represent one such factor, systematic research in this arena did not begin until the 2000s. Since that time, sleep disturbance has been reliably identified as a risk factor for suicidal ideation, suicide attempts, and suicide. While insomnia, nightmares, and other sleep disorders have each been found to contribute to the risk for suicidal ideation and behavior, it is also possible that these factors share some common variance. One possibility is that sleep disturbance results in being awake at night, and being awake at night also confers risk. The hypothesis proffered here is that being awake when one is not biologically prepared to be so results in "hypofrontality" and diminished executive function, and that this represents a common pathway to suicidal ideation and behavior. Such a proposition is highly testable under a variety of possible protocols. The current review summarizes the extant literature on suicide rates by time-of-day, and discusses circadian, psychosocial, and neurocognitive explanations of risk. Such a focus promises to enhance our understanding of how sleep disturbance may confer risk, allows for the identification of future lines of research, and further justifies the need for interventions that promote good sleep continuity among at-risk individuals.
authors.affiliation: Behavioral Sleep Medicine Program, Department of Psychiatry, University of Pennsylvania, United States; Center for Sleep and Circadian Neurobiology, University of Pennsylvania, United States; School or Nursing, University of Pennsylvania, United States. Electronic address: mperlis@upenn.edu.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Perlis
authors.affiliation: Department of Psychiatry, University of Arizona, United States.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Grandner
authors.affiliation: Behavioral Sleep Medicine Program, Department of Psychiatry, University of Pennsylvania, United States; Mental Illness Research, Education, and Clinical Center of the Philadelphia Veterans Affairs Medical Center, United States.
authors.forename: Subhajit
authors.initials: S
authors.lastname: Chakravorty
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, United States.
authors.forename: Rebecca A
authors.initials: RA
authors.lastname: Bernert
authors.affiliation: Center for the Prevention of Suicide, Department of Psychiatry, University of Pennsylvania, United States.
authors.forename: Gregory K
authors.initials: GK
authors.lastname: Brown
authors.affiliation: Mood & Anxiety Disorders Treatment & Research Program, Department of Psychiatry, University of Pennsylvania, United States.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Thase
mesh_terms: D002940:Circadian Rhythm / Q000502:physiology; D015438:Health Behavior; D006801:Humans; D012307:Risk Factors; D012890:Sleep / Q000502:physiology*; D059020:Suicidal Ideation; D013405:Suicide / Q000523:psychology / Q000706:statistics & numerical data*; D013406:Suicide, Attempted / Q000517:prevention & control / Q000523:psychology / Q000706:statistics & numerical data; D014851:Wakefulness; D000092864:Suicide Prevention
keywords: Circadian patterning; Executive function; Hypofrontality; Sleep disturbance; Suicide