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Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU

Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU. Introduction. Suicide is a major preventable public health problem. In 2007, it was the tenth leading cause of death in the U.S., accounting for 34,598 deaths.

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Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU

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  1. Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU

  2. Introduction • Suicide is a major preventable public health problem. • In 2007, it was the tenth leading cause of death in the U.S., accounting for 34,598 deaths. • The overall rate was 11.3 suicide deaths per 100,000 people.An estimated 11 attempted suicides occur per every suicide death.

  3. Global Suicide Rate

  4. Global Suicide Rate

  5. National Suicide Rate Map

  6. USA Epidemiology • Children ages 10 to 14 — 0.9 per 100,000 • Adolescents ages 15 to 19 — 6.9 per 100,000 • Young adults ages 20 to 24 — 12.7 per 100,000 • Ages 65 and older, 14.3 died by suicide of every 100,000 people in 2007. This figure is higher than the national average of 11.3 suicides per 100,000 people in the general population.

  7. USA Epidemiology • Non-Hispanic white men age 85 or older had an even higher rate, with 47 suicide deaths per 100,000. • Suicide was the seventh leading cause of death for males and the fifteenth leading cause of death for females in 2007. • Almost four times as many males as females die by suicide.

  8. USA Epidemiology • Firearms, suffocation, and poisoning(overdose) are by far the most common methods of suicide, overall. However, men and women differ in the method used, as shown below.

  9. Ethnic Groups • Highest rates: • American Indian and Alaska Natives — 14.3 per 100,000 • Non-Hispanic Whites — 13.5 per 100,000 • Lowest rates: • Non-Hispanic Blacks — 5.1 per 100,000 • Hispanics — 6.0 per 100,000 • Asian and Pacific Islanders — 6.2 per 100,000

  10. Number of Suicides 2007 USA

  11. Suicide Rates 2007 in USA

  12. No of Suicide in India

  13. Rate of suicide in India

  14. 1999-2007 Suicide Rate Trends USA

  15. Suicide risk factors Non Modifiable Risk Factors: • Advancing age • Male gender • Caucasian/American Indian ethnicity • Previous suicide attempt • History of trauma or abuse • Family history of suicide • Family history of mental disorder or substance abuse • Some major physical illnesses • Local epidemics of suicide

  16. Suicide risk factors Modifiable risk factors: • Mental disorders, particularly mood disorders, schizophrenia, anxiety disorders and certain personality disorders • Alcohol and other substance use disorders • Hopelessness • Impulsive and/or aggressive tendencies • Easy access to lethal means • Environmental Risk Factors: Job or financial loss, Relational or social loss,

  17. What about Insomnia ? • Insomnia is another symptom/condition which has been relatively under recognized as a marker for vulnerability for suicide. • Several Textbooks like APA psychiatry textbook and APA geriatric psychiatry textbooks has listed insomnia as one of the risk factor for suicide. • Some of the literature suggests sleep disturbance has prognostic significance in patients with affective disturbance.

  18. Sleep and Suicide • Increasing evidence suggests that disturbances in sleep are associated with an elevated risk for suicidal behaviors. • Several cross-sectional investigations indicate a unique association between nightmares and suicidal ideation. • Identification of insomnia as a risk factors for suicidal behaviors may enhance our ability to intervene and prevent suicide.

  19. Sleep and Suicide • 90% people who commit suicide suffers from mental health issues. • Insomnia is a frequent symptom of mental health issues as well as last symptom to improve. • Prevalence of insomnia ranges from 6% to 30%. • Due to its chronicity, insomnia is associated with substantial impairments in an individual's quality of life.

  20. Dsm iv tr criteria for insomnia • A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month.  • B. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.  • C. The sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-Related Sleep disorder, Circadian Rhythm Sleep Disorder, or a parasomnias.  • D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, a Delirium).  • E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

  21. What is Sleep ? • Sleep is a complex biological process that is influenced by many neuroendocrine parameters. • Sleep plays an important role in reparative and integrative process of the brain and body.

  22. Sleep • The stages of sleep were first described in 1937 by Alfred Lee Loomis and his coworkers, who separated the different electroencephalography (EEG) features of sleep into five levels from wakefulness to deep sleep. • In 1953, REM sleep was discovered as distinct phase of sleep, and thus sleep was reclassified into four NREM stages and REM. • The staging criteria were standardized in 1968 by Allan Rechtschaffen and Anthony Kales in the "R&K sleep scoring manual.

  23. American Academy of Sleep Medicine (AASM) • In 2004, the AASM commissioned the AASM Visual Scoring Task Force to review the R&K scoring system. • The American Academy of Sleep Medicine (AASM) further divides NREM into three stages: N1, N2, and N3, the last of which is also called delta sleep or slow-wave sleep (SWS).

  24. Non-rapid eye movement (NREM) Sleep Stage N1: • Transition of the brain from alpha waves having a frequency of 8–13 Hz (common in the awake state) to theta waves having a frequency of 4–7 Hz. • Sudden twitches and hypnic jerks are common during this phase. • Loss of some muscle tone. • Also referred as somnolence or drowsy sleep.

  25. Non-rapid eye movement (NREM) Sleep Stage N2 • EEG shows sleep spindles ranging from 11 to 16 Hz (most commonly 12–14 Hz) and K-complexes. • Muscular activity further decreases, and conscious awareness of the external environment disappears. • This stage occupies 45–55% of total sleep in adults.

  26. Non-rapid eye movement (NREM) Sleep Stage N3 • Also known as deep or slow-wave sleep) due to the presence of a minimum of 20% delta waves ranging from 0.5–2Hz. • Parasomnias such as night terrors, nocturnal enuresis, sleepwalking and somniloquy occur. • Many illustrations and descriptions still show a stage N3 with 20–50% delta waves and a stage N4 with greater than 50% delta waves; these have been combined as stage N3.

  27. Rapid eye movement (REM) Sleep • REM sleep (paradoxical sleep), accounts for 20–25% of total sleep time and four to six periods of REM sleep in most human adults. • Shorter at the beginning of the night and longer toward the end. • REM sleep normally occurs close to morning. • Most memorable dreaming occurs in this stage.

  28. Hypnogram

  29. Clinical and epidemiological investigations • Fawcett and colleagues(1990) conducted one of the first studies to prospectively examine sleep, depression, and suicide. • They recruited 954 patients with major affective disorders starting from 1978 and observed for 10yrs. • Results showed association of 6 clinical features including Global insomnia as a risk factor for committing suicide in next 1year.

  30. Retrospective study • Agargun et al (1997a): Recruited 113 patients with major depression. 17 item HAM-D, SADS(Schedule for affective disorder and schizophrenia) and SADS suicide subscale was used to rate depression, sleep and suicide. • Study demonstrated depressed subjects suffering from either hypersomnia or insomnia showed significantly higher scores on measures of suicidality.

  31. Clinical and epidemiological investigations • Turvey et al (2002): 1. Community based prospective study recruited 14456 elderly participants and 21 committed suicide over the 10years observation period. 2. Study showed an association between poor sleep quality and completed suicide in this prospective study population more than 65yrs old.

  32. Polysomnographic Studies • Sabo et al: Retrospectively studied the electroencephalography (EEG) of major depressives patients with and without a history of suicide attempts. • Suicide attempters had longer sleep latency, lower sleep efficiency, and fewer late-night delta wave counts than normal controls. • Non-attempters, compared to attempters, had less rapid eye movement (REM) time and activity in period 2, but more delta wave counts in non-REM period 4.

  33. Problems with above studies • Although sleep disturbances are linked to suicidality, this relationship may largely be explained by higher depression ratings. • In all of these studies, depression was not accounted for when examining the association between sleep and completed suicide. • Only a few studies have examined the connection between suicide and sleep complaints beyond that explained by depression.

  34. Polysomnographic Studies • Keshavan et al (1994) examined REM sleep in psychotic patients with and without a history of suicide attempts or ideation. • Patients with a history of suicidal behavior showed more REM activity, and REM sleep parameters were not correlated with depression scores.

  35. Recent Study • Study done at Army Medical center was published in J. of Affective disorder. • Study recruited 311 individuals with different psychiatric diagnosis. • Insomnia symptoms were assessed by Beck Depression Inventory items 16 & 17.

  36. Cont,,,,,,, • Suicidal ideations were assessed through Suicide Probability Scale and Modified Scale for Suicidal ideation. • This study suggested insomnia is a unique predictor assessed cross sectionally for suicidal ideation in comparison to other risk factors.

  37. Questions • Do we know enough about this association between Sleep and Suicide? • What can be the possible explanation of association?

  38. Role of serotonin • Serotonin has also been documented to play an important role in onset and maintenance of slow wave sleep. • Serotonergic function has been found to be low in patients who attempted and/or completed suicide, particularly those who used violent methods. • Levels of 5-Hydroxyindoleacetic acid(5-HIAA) is low in patients with insomnia as well as in patients who commit/attempt suicides. • 5HT2 receptor antagonists helps to improve slow wave sleep.

  39. Possible Explanation • Serotonergic dysregulation play a key role in underlying mechanisms of the association with suicidal tendency and sleep disturbance.

  40. Also….. • Other possible reason by which it can be explained is that poor sleep is a stressor that may independently increase the risk of suicide by Impairing judgment Impulse control Fatigue Hopelessness Frustration

  41. What about modifying this risk factor? • Needs assessment of insomnia • Need to find appropriate strategies to improve sleep. • Non-pharmacological • Sleep Hygiene. • Stimulus control therapy.

  42. Cont,,,,,,, • Pharmacological : • Benzodiazepines: Decrease sleep latency, increases total sleep time and decreases slow wave sleep. • TCA: Reduce REM sleep percentage and increase REM sleep latency. Inconsistent activity on NREM Stage 3/4. TCA do not worsen sleep apnea and may have a small beneficial effect. • Zolpidem: Very mild effect on REM sleep and does not affect stage 3/4 NREM sleep. Tend to perverse the sleep architecture.

  43. Cont,,,,, • Trazodone: Little effect on REM sleep & increase in NREM Stage 3/4. Rebound insomnia can occur. • Antihistaminics: Improvement in sleep latency, decrease nocturnal awakenings and sleep quality. • Mirtazepine: Decreases sleep latency and awakenings. Some evidence suggest increases Stage 3/4 NREM sleep.

  44. In Summary,,,,,,,,, • Sparse research in this area shows there is an association between insomnia and suicide. • But we definitely need more research in this area. • Is it the time we need to start screening patients for insomnia as a part of suicide risk assessment?

  45. In Summary,,,,,,,,, • Would identifying insomnia as risk factor for suicide improve our ability to intervene and prevent suicide significantly in comparison to other risk factors? • We need to find better drugs to treat insomnia (particularly sleep maintenance insomnia) without having potential of abuse, dependence or lethal effects on overdose.

  46. Evidenced based suicide modifiers • CBT reduced the rate of repeated suicide attempts by 50 percent during a year of follow-up. • Clozapine is approved by the Food and Drug Administration for suicide prevention in people with schizophrenia. • Dialectical behavior therapy reduced suicide attempts by half in people with borderline personality disorder. • Lithium and ECT have strong evidence for a specific anti-suicide effect in mood disorders.

  47. What the Future holds ? • 5 HT₂ₐ antagonist helps maintaining slow wave sleep and seems promising future treatment for insomnia(Sleep maintenance insomnia).

  48. Reference • Fawcett J;Scheftner WA;Fogg L;Clark DC;Young MA;Hedeker D;Gi, Time-related predictors of suicide in major affective disorder, Am J Psychiatry 1990 Sep;147(9):1189-94 • Ribeiro J;Pease J;Gutierrez P;Silva C;Bernert R;Rudd M;Joine, Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. J Affect Disord 2012 Feb;136(3):743-50. • Agargun M, Kara H, Solmaz M. Subjective Sleep Quality and Suicidality in Patients with Major Depression. J Psychiat Res 1997;31:377–381. • Agargun MY, Kara H, Solmaz M. Sleep disturbances and suicidal behavior in patients with major depression. J Clin Psychiatry 1997;58:249–251. • Agargun M, Cilli A, Kara H, et al. Repetitive and Frightening Dreams and Suicidal Behavior in Patients with Major Depression. Comprehensive Psychiatry 1998;39:198–202.

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