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BMC Psychiatry
Published in: BMC Psychiatry 1/2019

Open Access 01-12-2019 | Insomnia | Research article

Systematic review and meta-analysis of the relationship between sleep disorders and suicidal behaviour in patients with depression

Authors: Xiaofen Wang, Sixiang Cheng, Huilan Xu

Published in: BMC Psychiatry | Issue 1/2019

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Abstract

Background

The potential link between sleep disorders and suicidal behaviour has been the subject of several reviews. We performed this meta-analysis to estimate the overall association between sleep disorders and suicidal behaviour and to identify a more specific relationship in patients with depression.

Methods

A systematic search strategy was developed across the electronic databases PubMed, EMBASE and the Cochrane Library from inception to January 1, 2019 for studies that reported a relationship between sleep disorders and suicidal behaviour in depressed patients. The odds ratio (OR) and corresponding 95% confidence interval (CI) were used to measure the outcomes. Heterogeneity was evaluated by Cochran’s Q test and the I2 statistic. The Newcastle-Ottawa Scale (NOS) was adopted to evaluate the methodological quality of each of the included studies, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the evidence. We calculated the overall association between sleep disorders and suicidal behaviour and estimated more specific categories, including insomnia, nightmares, hypersomnia, suicidal ideation, suicide attempt, and completed suicide.

Results

A total of 18 studies were included in this study. Overall, sleep disorders were closely related to suicidal behaviour in patients with depression (OR = 2.45 95% CI: 1.33 4.52). The relatively increased risks of sleep disorders with suicidal ideation, suicide attempt and completed suicide ranged from 1.24 (95% CI: 1.00 1.53) to 2.41 (95% CI: 1.45 4.02). Nightmares were found to be highly correlated with the risk of suicidal behaviour (OR = 4.47 95% CI: 2.00 9.97), followed by insomnia (OR = 2.29 95% CI: 1.69 3.10). The certainty of the evidence was rated as very low for the overall outcome and the major depression subgroup and was rated as low for the depression subgroup.

Conclusions

This meta-analysis supports the finding that sleep disorders, particularly nightmares and insomnia, increase the risk of suicidal behaviour in depressed patients. Considering that all included studies were observational, the quality of the evidence is rated as very low. More well-designed studies are needed to confirm our findings and to better explain the mechanisms by which sleep disorders aggravate suicidal behaviour in depressed patients.
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Literature
1.
Wilcox HC, Wyman PA. Suicide prevention strategies for improving population health. Child Adolesc Psychiatr Clin N Am. 2016;25(2):219–33 (1558-0490 (Electronic)).CrossRefPubMed
2.
Fleischmann A, Arensman E, Berman A, Carli V, De Leo D, Hadlaczky G, Howlader S, Vijayakumar L, Wasserman D, Saxena S. Overview evidence on interventions for population suicide with an eye to identifying best-supported strategies for LMICs. Glob Ment Health (Camb). 2016;3:e5 (2054-4251 (Print)).CrossRef
3.
Wang SY, Li Y, Chi GB, Xiao SY, Ozanne-Smith J, Stevenson M, Phillips MR. Injury-related fatalities in China: an under-recognised public-health problem. Lancet. 2008;372(9651):1765–73 (1474-547X (Electronic)).CrossRefPubMed
4.
Bernert RA, Luckenbaugh DA, Duncan WC, Iwata NG, Ballard ED, Zarate CA. Sleep architecture parameters as a putative biomarker of suicidal ideation in treatment-resistant depression. J Affect Disord. 2017;208:309–15.CrossRefPubMed
5.
Naifeh JA, Ursano RJ, Kessler RCA, Zaslavsky AM, Nock MK, Dempsey CL, Bartolanzo D, Ng THH, Aliaga PA, Zuromski KL et al. Transition to suicide attempt from recent suicide ideation in U.S. Army soldiers: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). LID - https://​doi.​org/​10.​1002/​da.​22870 [doi]. Combined effects of depression and anxiety on suicide: a case-control psychological autopsy study in rural China. (1520-6394 (Electronic)).
6.
Wilks CR, Morland LA, Dillon KH, Mackintosh MA, Blakey SM, Wagner HR, Elbogen EB. Anger, social support, and suicide risk in U.S. military veterans. J Psychiatr Res. 2019;109:139–44 (1879-1379 (Electronic)).CrossRefPubMed
7.
Zhang J, Liu X, Fang L. Combined effects of depression and anxiety on suicide: A case-control psychological autopsy study in rural China. Psychiatry Res. 2019;271(1872-7123):370–3.CrossRefPubMed
8.
Oquendo MA, Malone KM, Mann JJ. Suicide: risk factors and prevention in refractory major depression. Depress Anxiety. 1997;5(4):202–11 (1091-4269 (Print)).CrossRefPubMed
9.
Coryell W, Young EA. Clinical predictors of suicide in primary major depressive disorder. J Clin Psychiatry. 2005;66(4):412–7 (0160-6689 (Print)).CrossRefPubMed
10.
Eikelenboom M, Beekman ATF, Penninx BWJH, Smit JH. A 6-year longitudinal study of predictors for suicide attempts in major depressive disorder. Psychol Med. 2018;49(6):911–21.
11.
12.
Smith K. Mental health: a world of depression. Nature. 2014;515(7526):181 (1476-4687 (Electronic)).CrossRefPubMed
13.
Gibbons JS, Horn SH, Powell JM, Gibbons JL. Schizophrenic patients and their families. A survey in a psychiatric service based on a DGH unit. Br J Psychiatry. 1984;144(1):70–7.CrossRefPubMed
14.
Vuorilehto M, Valtonen HM, Melartin T, Sokero P, Suominen K, Isometsa ET. Method of assessment determines prevalence of suicidal ideation among patients with depression. Eur Psychiatry. 2014;29(6):338–44 (1778-3585 (Electronic)).CrossRefPubMed
15.
Li H, Luo X, Ke X, Dai Q, Zheng W, Zhang C, Cassidy RM, Soares JC, Zhang X, Ning Y. Major depressive disorder and suicide risk among adult outpatients at several general hospitals in a Chinese Han population. PLoS One. 2017;12(10):e0186143.CrossRefPubMedPubMedCentral
16.
Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med. 1999;341(18):1329–35 (0028-4793 (Print)).CrossRefPubMed
17.
Tsuno N, Besset A, Ritchie K. Sleep and depression. J Clin Psychiatry. 2005;66(10):1254–69 (0160-6689 (Print)).CrossRefPubMed
18.
Chellappa SL, Araujo JF. Sleep disorders and suicidal ideation in patients with depressive disorder. Psychiatry Res. 2007;153(2):131–6.CrossRefPubMed
19.
Pan D, Xu Y, Zhang L, Su Q, Chen M, Li B, Xiao Q, Gao Q, Peng X, Jiang B, et al. Gene expression profile in peripheral blood mononuclear cells of postpartum depression patients. Sci Rep. 2018;8:10139 (2045-2322 (Electronic)).CrossRefPubMedPubMedCentral
20.
Zadka L, Dziegiel P, Kulus M, Olajossy M. Clinical phenotype of depression affects interleukin-6 synthesis. J Interferon Cytokine Res. 2017;37(6):231–45 (1557-7465 (Electronic)).CrossRefPubMed
21.
Fang X, Zhang C, Wu Z, Peng D, Xia W, Xu J, Wang C, Cui L, Huang J, Fang Y. The association between somatic symptoms and suicidal ideation in Chinese first-episode major depressive disorder. J Affect Disord. 2019;245:17–21.CrossRefPubMed
22.
Li SX, Lam SP, Chan JW, Yu MW, Wing YK. Residual sleep disturbances in patients remitted from major depressive disorder: a 4-year naturalistic follow-up study. Sleep. 2012;35(8):1153–61.CrossRefPubMedPubMedCentral
23.
Gallagher AM, De Vries F, Tylee AT, Lader MH, Donoghue J, Cockle SM, Van Staa TP, Nutt DJ. The risk of suicide and suicidal ideation in depressed patients with sleep disturbance. Eur Neuropsychopharmacol. 2009;19:S379–80.
24.
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4:1 (2046-4053 (Electronic)).CrossRefPubMedPubMedCentral
25.
Margulis AV, Pladevall M, Riera-Guardia N, Varas-Lorenzo C, Hazell L, Berkman ND, Viswanathan M, Perez-Gutthann S. Quality assessment of observational studies in a drug-safety systematic review, comparison of two tools: the Newcastle-Ottawa Scale and the RTI item bank. Clin Epidemiol. 2014;6:359–68 (1179-1349 (Print)).CrossRefPubMedPubMedCentral
26.
Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, Jaeschke R, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383–94 (1878-5921 (Electronic)).CrossRefPubMed
27.
Guyatt GH, Oxman AD, Schunemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011;64(4):380–2 (1878-5921 (Electronic)).CrossRefPubMed
28.
Agargun MY, Kara H, Solmaz M. Sleep disturbances and suicidal behavior in patients with major depression. J Clin Psychiatry. 1997;58(6):249–51.
29.
Agargun MY, Kara H, Solmaz M. Subjective sleep quality and suicidality in patients with major depression. J Psychiatr Res. 1997;31(3):377–81.CrossRefPubMed
30.
Lopes MC, Boronat AC, Wang YP, Fui L. Sleep complaints as risk factor for suicidal behavior in severely depressed children and adolescents. CNS Neurosci Ther. 2016;22(11):915–20.
31.
Yoshimasu K, Sugahara H, Akamine M, Kondo T, Fujisawa K, Tokunaga S, Kiyohara C, Miyashita K, Kubo C. Sleep disorders and suicidal ideation in Japanese patients visiting a psychosomatic clinic in a university hospital. Sleep Biol Rhythms. 2006;4(2):137–43.
32.
Aǧargün MY, Çilli AS, Kara H, Tarhan N, Kincir F, Öz H. Repetitive and frightening dreams and suicidal behavior in patients with major depression. Compr Psychiatry. 1998;39(4):198–202.
33.
Sit D, Luther J, Buysse D, Dills JL, Eng H, Okun M, Wisniewski S, Wisner KL. Suicidal ideation in depressed postpartum women: associations with childhood trauma, sleep disturbance and anxiety. J Psychiatr Res. 2015;66-67:95–104.
34.
Yoshimasu K, Sugahara H, Tokunaga S, Akamine M, Kondo T, Fujisawa K, Miyashita K, Kubo C. Gender differences in psychiatric symptoms related to suicidal ideation in Japanese patients with depression. Psychiatry Clin Neurosci. 2006;60(5):563–9.
35.
Agargun MY, Besiroglu L, Cilli AS, Gulec M, Aydin A, Inci R, Selvi Y. Nightmares, suicide attempts, and melancholic features in patients with unipolar major depression. J Affect Disord. 2007;98(3):267–70.CrossRefPubMed
36.
Stubbs B, Wu YT, Prina AM, Leng Y, Cosco TD. A population study of the association between sleep disturbance and suicidal behaviour in people with mental illness. J Psychiatr Res. 2016;82:149–54.
37.
Park SC, Lee MS, Hahn SW, Si TM, Kanba S, Chong MY, Yoon CK, Udomratn P, Tripathi A, Sartorius N et al. Suicidal thoughts/acts and clinical correlates in patients with depressive disorders in Asians: results from the REAP-AD study. Acta Neuropsychiatr. 2016;28(6):337–45.
38.
Guo L, Xu Y, Deng J, Huang J, Huang G, Gao X, Li P, Wu H, Pan S, Zhang WH et al. Association between sleep duration, suicidal ideation, and suicidal attempts among Chinese adolescents: the moderating role of depressive symptoms. J Affect Disord. 2017;208:355–62.
39.
Nrugham L, Larsson B, Sund AM. Specific depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence. J Affect Disord. 2008;111(1):83–93.
40.
McGirr A, Renaud J, Seguin M, Alda M, Benkelfat C, Lesage A, Turecki G. An examination of DSM-IV depressive symptoms and risk for suicide completion in major depressive disorder: a psychological autopsy study. J Affect Disord. 2007;97(1-3):203-9.
41.
Staner L, Kempenaers C, Simonnet MP, Fransolet L, Mendlewicz J. 5-HT2 receptor antagonism and slow-wave sleep in major depression. Acta Psychiatr Scand. 1992;86(2):133–7 (0001-690X (Print)).CrossRefPubMed
42.
Fau JM, Touret M. Indolamines and sleep: 5-HT or 5-HTP? Schweiz Rundsch Med Prax. 1988;77(34A):6–9.
43.
Benson KL, Faull KF, Zarcone VP Jr. The effects of age and serotonergic activity on slow-wave sleep in depressive illness. Biol Psychiatry. 1993;33(11-12):842–4 (0006-3223 (Print)).CrossRefPubMed
44.
Solomon RA, Sharpley AL, Cowen PJ. Increased slow wave sleep with 5-HT2 receptor antagonists: detection by ambulatory EEG recording and automatic sleep stage analysis. J Psychopharmacol. 1989;3(3):125–9 (0269-8811 (Print)).CrossRefPubMed
45.
Linnoila VM, Virkkunen M. Aggression, suicidality, and serotonin. J Clin Psychiatry. 1992;53(Suppl):46–51 (0160-6689 (Print)).PubMed
46.
McCall WV, Blocker JN, D’Agostino R Jr, Kimball J, Boggs N, Lasater B, Rosenquist PB. Insomnia severity is an indicator of suicidal ideation during a depression clinical trial. Sleep Med. 2010;11(9):822–7 (1878-5506 (Electronic)).CrossRefPubMedPubMedCentral
47.
Norra C, Richter N, Juckel G. Sleep disturbances and suicidality: a common association to look for in clinical practise and preventive care. EPMA J. 2011;2(3):295–307 (1878-5085 (Electronic)).CrossRefPubMedPubMedCentral
48.
Espie CA, Inglis SJ, Harvey L, Tessier S. Insomniacs’ attributions. psychometric properties of the Dysfunctional Beliefs and Attitudes about Sleep Scale and the Sleep Disturbance Questionnaire. J Psychosom Res. 2000;48(2):141–8 (0022-3999 (Print)).CrossRefPubMed
49.
Littlewood DA-O, Gooding PA-O, Kyle SD, Pratt D, Peters S. Understanding the role of sleep in suicide risk: qualitative interview study. BMJ Open. 2016;6(8):e012113 (2044-6055 (Electronic)).CrossRefPubMedPubMedCentral
50.
Anderson C, Platten CR. Sleep deprivation lowers inhibition and enhances impulsivity to negative stimuli. Behav Brain Res. 2011;217(2):463–6 (1872-7549 (Electronic)).CrossRefPubMed
51.
Sjostrom N, Waern M, Hetta J. Nightmares and sleep disturbances in relation to suicidality in suicide attempters. Sleep. 2007;30(1):91–5 (0161-8105 (Print)).CrossRefPubMed
52.
Russell K, Rasmussen S, Hunter SC. Insomnia and nightmares as markers of risk for suicidal ideation in young people: investigating the role of defeat and entrapment. J Clin Sleep Med. 2018;14(5):775–84.CrossRefPubMedPubMedCentral
53.
Soehner AM, Kaplan KA, Harvey AG. Prevalence and clinical correlates of co-occurring insomnia and hypersomnia symptoms in depression. J Affect Disord. 2014;167:93–7 (1573-2517 (Electronic)).CrossRefPubMedPubMedCentral
54.
Malik S, Kanwar A, Sim LA, Prokop LJ, Wang Z, Benkhadra K, Murad MH. The association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses: a systematic review and meta-analysis. Syst Rev. 2014;3(2046-4053 (Electronic)):18.CrossRefPubMedPubMedCentral
55.
Liu X, Buysse DJ. Sleep and youth suicidal behavior: a neglected field. Curr Opin Psychiatry. 2006;19(3):288–93.CrossRefPubMed
56.
Bernert R, Reeve J, Perlis MIL, Joiner TE. Insomnia and nightmares as predictors of elevated suicide risk among patients seeking admission to emergency mental health facility. Sleep. 2009;32:A365–6.
57.
Sher L, Grunebaum MF, Burke AK, Chaudhury S, Mann JJ, Oquendo MA. Depressed multiple-suicide-attempters - a high-risk phenotype. Crisis. 2017;38(6):367–75 (2151-2396 (Electronic)).CrossRefPubMed
58.
Oquendo MA, Stanley B, Ellis SP, Mann JJ. Protection of human subjects in intervention research for suicidal behavior. Am J Psychiatry. 2004;161(9):1558–63 (0002-953X (Print)).CrossRefPubMed
59.
Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Hazell P, Townsend E, van Heeringen K. Psychosocial interventions for self-harm in adults. Cochrane Db Syst Rev. 2016;(5) (1469-493X (Electronic)).
60.
Sayal K, Roe J, Ball H, Atha C, Kaylor-Hughes C, Guo B, Townsend E, Morriss R. Feasibility of a randomised controlled trial of remotely delivered problem-solving cognitive behaviour therapy versus usual care for young people with depression and repeat self-harm: lessons learnt (e-DASH). BMC Psychiatry. 2019;19(1):42 (1471-244X (Electronic)).CrossRefPubMedPubMedCentral
61.
Nadorff MR, Nazem S, Fiske A. Insomnia symptoms, nightmares, and suicide risk: duration of sleep disturbance matters. Suicide Life Threat Behav. 2013;43(2):139–49.CrossRefPubMed
62.
Talbot M. Nightmare scenario: can we learn to rewrite our bad dreams? 2009;(0028-792X (Print)):43–51.
63.
Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Huang X, Musacchio KM, Jaroszewski AC, Chang BP, Nock MK. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull. 2017;143(2):187–232.CrossRefPubMed
64.
Zimmermann C, Pfeiffer H. Sleep disorders in depression. Suggestions for a therapeutic approach. Nervenarzt. 2007;78(1):21–30.CrossRefPubMed
65.
Maes M, Meltzer HY, Suy E, Minner B, Calabrese J, Cosyns P. Sleep disorders and anxiety as symptom profiles of sympathoadrenal system hyperactivity in major depression. J Affect Disord. 1993;27(3):197–207.CrossRefPubMed
Metadata
Title
Systematic review and meta-analysis of the relationship between sleep disorders and suicidal behaviour in patients with depression
Authors
Xiaofen Wang
Sixiang Cheng
Huilan Xu
Publication date
01-12-2019
Publisher
BioMed Central
Published in
BMC Psychiatry / Issue 1/2019
Electronic ISSN: 1471-244X
DOI
https://doi.org/10.1186/s12888-019-2302-5

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