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The association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses: a systematic review and meta-analysis

  • Shaista Malik1, 2,
  • Amrit Kanwar3,
  • Leslie A Sim4,
  • Larry J Prokop5,
  • Zhen Wang6, 7, 8Email author,
  • Khalid Benkhadra7 and
  • Mohammad Hassan Murad1
Systematic Reviews20143:18

https://doi.org/10.1186/2046-4053-3-18

Received: 2 October 2013

Accepted: 12 February 2014

Published: 25 February 2014

Abstract

Background

Identifying patients with increased risk of suicidal behaviors is a constant challenge and concern for clinicians caring for patients with psychiatric conditions. We conducted a systematic review to assess the association between suicidal behaviors and sleep disturbances in psychiatric patients.

Methods

A systematic literature search of Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycInfo, Ovid Cochrane Database of Systematic Reviews, Ovid Cochrane Central Register of Controlled Trials, and Scopus was conducted using earliest inclusive dates to 28 June 2013. Eligible studies were comparative observational studies that reported sleep disturbances in psychiatric patients and the outcome of interest (any type of suicidal behaviors). Pairs of reviewers extracted descriptive data, study quality, and outcomes. Odds ratios (OR) and 95% confidence intervals (CI) were pooled across studies using the random-effects model. Newcastle-Ottawa scale was used to critically appraise study quality.

Results

Nineteen studies met the inclusion criteria. Compared to those without sleep disturbances, patients with psychiatric diagnoses and co-morbid sleep disturbances were significantly more likely to report suicidal behaviors (OR = 1.99, 95% CI 1.72, 2.30, P <0.001). The association was also demonstrated across several psychiatric conditions including depression (OR = 3.05, 95% CI 2.07, 4.48, P <0.001), post-traumatic stress disorder (PTSD) (OR = 2.56, 95% CI 1.91, 3.43, P <0.001), panic disorder (OR = 3.22, 95% CI 1.09, 9.45, P = 0.03), and schizophrenia (OR = 12.66, 95% CI 1.40, 114.44, P = 0.02). In subgroup analysis based on the type of sleep disorder, we also found suicidal behavior to be significantly associated with the presence of insomnia, parasomnias, and sleep-related breathing disorders, but not hypersomnias.

Conclusions

This systematic review and meta-analysis suggests that in patients with psychiatric diagnoses, sleep disturbances are associated with the increased risk of suicidal behaviors.

Keywords

Sleep disturbancesSuicidal behaviorsSystematic reviewsMeta-analysis

Background

Psychiatric patients are thought to be at high risk of suicidal behaviors. However, clinicians face challenges of identifying patients at risk [1]. The literature suggests that the severity of psychiatric illness is not always predictive of suicide attempts [2]; and the sensitivity and specificity of risk factors, including gender, prior suicide attempts, and suicidal ideations, remain low in predicting future suicide [3]. There is a great need to find additional risk factors. Given that sleep disturbances are fairly common in psychiatric patients, it is suggested that sleep disturbances may constitute a modifiable risk factor for suicidal behaviors [4, 5].

Direct relationship between sleep disturbances and suicide has been evaluated in multiple studies. A recent systematic review and meta-analysis of 39 studies found patients with sleep problems had significantly increased risk of suicidal ideations, suicide attempts, and completed suicides [6]. That study focused on the general population although it reported that depression did not moderate the association between sleep and suicide. However, other studies found significant associations between suicides and sleep disturbances among psychiatric patients. A study of 954 patients with affective disorders found that global insomnia was significantly associated with attempted suicide [1]. In another study, both insomnia and hypersomnia had prognostic significance in predicting suicide among patients with major depression [7]. Moreover, in an epidemiologic prospective study of 1,231 psychiatric outpatients, nocturnal sleep disturbances, particularly frequent insomnia and recurrent nightmares, were independently associated with enhanced suicidal risk [8].

Considering the lack of a systematic review that focuses on the effect of sleep on suicide risk in patients with psychiatric conditions and the conflicting results from the literature, we conducted this study to assess the association between suicidal behaviors and sleep disturbances in psychiatric patients.

Methods

A review protocol was developed at the beginning of this study. The reporting of this systematic review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement [9].

Inclusion and exclusion criteria

Eligible studies were comparative observational studies that reported sleep disturbances in psychiatric patients and the outcome of interest (any type of suicidal behaviors). We used the original study’s definition of sleep disturbances, which ranged from snoring, nightmares, hypersomnia insomnia, sleep panic attacks, and sleep deprivation. With respect to suicidal behaviors, we include suicide ideations, suicide attempts, completed suicides, and any other suicidal behaviors defined by the original studies. Studies were excluded if they did not report outcomes for psychiatric patients or did not provide sufficient data to quantitatively estimate the association between suicidal behaviors and sleep disturbances. We also excluded publications without original data (clinical reviews, editorials, letters, or erratum). No language or country restrictions were used.

Data sources and search strategy

An expert reference librarian and study authors with expertise in conducting systematic reviews developed the search strategy. A comprehensive search of databases from each database’s earliest inclusive dates to 26 June 2013 was conducted. The databases included Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycInfo, Ovid Cochrane Database of Systematic Reviews, Ovid Cochrane Central Register of Controlled Trials, and Scopus. Controlled vocabulary, supplemented with keywords, was used to search for the concept areas: suicide, sleep disorders, and psychiatric conditions. The database search strategy is available in Additional file 1. We also searched additional references from a recent systematic review [6].

Study selection and data extraction

Reviewers working independently and in duplicate assessed each abstract for eligibility. Disagreements yielded an automatic inclusion into the following level of screening. Included studies were retrieved and full text screening commenced in duplicate as well. Disagreements at this level were resolved by discussion and consensus. Two reviewers working independently and in duplicate extracted baseline and outcome data and assessed the quality of each included study. A third reviewer compared the reviewers’ data and resolved inconsistencies by referring to the full text article.

Reviewers independently extracted study details from the full text articles, using a pilot-tested form. The following data were abstracted: study design, country, patient characteristics (sex, age), psychiatric diagnoses, sleep disturbances, and suicidal behaviors. We extracted numbers of patients with outcomes (suicidal behaviors) at the longest duration of complete follow-up.

Assessment of study quality and publication bias

Using the Newcastle-Ottawa scale, we assessed the quality of included observational studies by determining outcome ascertainment, adjustment for confounders, and proportion of patients lost to follow-up as well as sample selection. We assessed potential publication bias by visual inspection of funnel plots and the Egger’s regression asymmetry tests.

Statistical analysis

The outcome of interest was suicidal behaviors, including suicidal ideations, suicide attempts, and completed suicides. Outcomes were either dichotomized by the individual study or when presented as a scale, were converted to log transformed OR (logOR) based on the commonly used formula suggested by Borenstein et al. [10].

We pooled the logOR from all of the included studies using the DerSimonian & Laird random effects method with the estimate of heterogeneity from the Mantel-Haenszel model [11]. We conducted a priori planned subgroup analysis based on the type of suicidal behaviors (ideations, attempts, and completed suicides). We subsequently evaluated separately the different types of sleep disturbances (insomnia, hypersomnia, parasomnia, sleep-related breathing disorders, and mixed/unclear types) to further explore heterogeneity across studies. When one study reported outcomes for multiple subgroups, these outcomes were pooled separately in each subgroup. When multiple outcomes were reported in one subgroup, we chose the one that clearly defined and/or objectively measured.

We used the I2 statistic to measure heterogeneity across the studies. Statistical analyses were conducted using STATA version 12 (StataCorp, College Station, TX, USA) and R software version 3.0.1 (R Foundation for Statistical Computing, Vienna, Austria).

Results

Description and quality of included studies

Our search identified 372 candidate references (Figure 1). After deleting duplicated studies and excluding irrelevant studies, 19 studies met the inclusion criteria and were included in this analysis. The characteristics of these studies are summarized in Table 1. Overall, 104,436 patients were included in this review. The average age was 49.4 years (range, 17-79 years). Fifty-eight percent of the patients were female. The average length of follow-up in the prospective studies was 9.9 years (range, 3 days - 27 years). Of 19 studies, 13 (68.4%) reported outcomes in depressive patients. The other psychiatric diagnoses included were post-traumatic stress disorder (PTSD), panic disorder, schizophrenia, and anxiety. Eleven studies (57.9%) were prospective studies, four (21.1%) were cross-sectional, and three (15.87%) were retrospective.
Figure 1

Flow diagram for selection of studies included in the systematic review.

Table 1

Basic characteristics of the included studies

Author, year

Study design

Patients ( n)

Female (%)

Age (years)

Psychiatric diagnoses

Suicidal behaviors

Sleep disturbances

Agargun, 1997 [7]

Retrospective

113

74%

Mean: 32.6 range: 18-70

Major depression

Ideation

Insomnia and hypersomnia assessed by SCID-I

Li, 2010 [8]

Cross-sectional

1,231

68.20%

Mean: 42.4, range 18-65

Major depression, Bipolar, Other

Attempt

Self-reported insomnia and recurrent nightmares assessed by a questionnaire

McGirr, 2007 [12]

Prospective

156

19.20%

Mean: 42.4

Major depression

Completed suicide

Insomnia and hypersomnia assessed by SCID-I

Nrugham, 2008 [13]

Prospective

2,464

50.80%

Mean age 13.7

Depressive symptom and disorder

Ideation, attempt

Insomnia, hypersomnia, non-restorative sleep assessed by K-SADS and MFQ

Paffenbarger, 1994 [14]

Prospective

21,582

0

Range: 35-74

Depressive disorder

Completed suicide

Self-reported insomnia assessed by a questionnaire

Pompili, 2009 [15]

Retrospective

40

10%

Mean: 40 Range: 23-76

Schizophrenia

Completed suicide

Insomnia defined as difficulty initiating or maintaining sleep, or non-restorative sleep causing impaired functioning or suffering that was long-lasting or demanded treatment and recorded from patients’ medical records

Sjostrom, 2009 [16]

Prospective

165

78%

Range: 18-69

Axis 1 DSM disorders

Attempt

Difficulties initiating sleep, problems maintaining sleep and early morning awakening assessed by USI

Agargun, 1997 [17]

Prospective

41

76%

Mean: 34.6 SD: 10.8

Major depression

SADS suicidality score

Subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping medications, daytime dysfunction, and global severity measured by PSQI

Agargun, 1998 [18]

Prospective

63

76%

Mean: 34.1 SD: 10.8

Major depression

Ideation, attempts

Frequency of nightmares

Agargun, 1998 [19]

Unclear

67

73.10%

Mean: 31.9 SD: 8.8

Panic disorder

Ideation

Sleep panic and insomnia ascertained from SADS

Agargun, 2003 [20]

Prospective

26

61.50%

Unclear

Major depression

HDRS suicide scores

REM latency, REM%, REM periods measured by three nights of polysomnography

Chellappa, 2007 [21]

Cross-sectional

70

62.90%

Mean:: 40.5 SD: 12.54

Major depression

Ideation

Insomnia or excessive sleepiness assessed by the SHQ and ICSD

Krakow, 2000 [22]

Prospective

153

100%

Mean: 36.4 SD: 11.1

PTSD

Hamilton Depression and suicidality scores

SMD and SDB assessed by AASM 1997 and ASDA 1997

Agargun, 2007 [23]

Retrospective

100

52%

Mean: 32.1 SD: 10.7

Unipolar major depression

Attempt

Nightmares assessed by ICSD-R; insomnia assessed by the HDRS items 6, 7, and 8

Yoshimasu, 2006 [24]

Cross-sectional

231

57.10%

Mean: 36.3 SD: 28.5

Major depression

Ideation

Insomnia assessed by SDS, KMI, and patients’ three most painful complaints

Bjorngaard 2011 [25]

Prospective

74,977

51%

Mean: 37.9 SD: 16.0

Anxiety, depression

Completed suicide

Self-reported sleep difficulties assessed by a questionnaire

Li 2012 [26]

Prospective

419

81.80%

Mean: 44.6 SD: 10.4

Major depression

Ideation

Insomnia, nightmares, and frequency of sleep disturbances measured by a questionnaire

Krakow 2011 [27]

Cross-sectional

1,584

55%

Mean: 49.8 SD: 66.4

Depression

Attempt

Sleep disturbances measured by SMH, ISI DDNSI, FOSQ, and TMB-10

Fawcett, 1990 [1]

Prospective

954

58%

Mean: 38.1 Range: 17-79

Major affective disorder

Completed suicide

Insomnia assessed by SADS

AASM: American Academy of Sleep Medicine; ASDA: American Sleep Disorders Association; DDNSI: Disturbing Dream and Nightmare Severity Index; FOSQ: Functional Outcomes Sleep Questionnaire; HDRS: Hamilton Depression Rating Scale; ICSD: International Classification of Sleep Disorders diagnostic criteria for sleep disorders due to mood disorders; ICSD-R: International Classification of Sleep Disorders, revised; ISI: Insomnia Severity Index; KMI: Kyudai Medical Inventory; K-SADS: Kiddie-Schedule for Affective Disorders and Schizophrenia; MFQ: Mood and Feelings Questionnaire; PSQI: Pittsburgh Sleep Quality Index; PTSD: Post-traumatic stress disorder; REM: Rapid eye movement; SADS: Schedule for Affective Disorders and Schizophrenia; SCID-I: Structured Clinical Interview for DSM-IV-TR Axis I Disorders; SD: standard deviation; SDB: Sleep-disordered Breathing; SDS: Self-rating Depression Scale; SHQ: Sleep Habits questionnaire; SMD: Sleep-related Movement Disorders; SMH: Sleep Medicine History; TMB-10: Time Monitoring Behavior; USI: Uppsala Sleep Inventory.

Figure 2 shows the quality indicators of the included studies. We found variable quality across studies. Most (68.4%) of the studies did not adjust for risk factors. However, 15 studies reported low risk of bias for the ascertainment of outcomes. Using the Egger regression asymmetry test and visual inspection of the funnel plot, we found potential publication bias in this body of evidence. Across the included studies, substantial heterogeneity was observed in most of the pooled outcomes (>50%) [28]. In summary, the risk of bias is moderate to high due to potential publication bias and substantial heterogeneity.
Figure 2

Quality assessment of the included studies.

Figure 3 shows the pooled odds ratios (ORs) from all of the included studies. Compared to those without sleep disturbances, patients with psychiatric diagnoses and co-morbid sleep disturbances were significantly more likely to report suicidal behaviors (OR = 1.99, 95% CI 1.72, 2.30, P <0.001). Regarding to specific psychiatric conditions, we found strong association between suicidal behaviors and sleep disturbances in depression (OR = 3.05, 95% CI 2.07, 4.48, P <0.001), PTSD (OR = 2.56, 95% CI 1.91, 3.43, P <0.001), panic disorders (OR = 3.22, 95% CI 1.09, 9.45, P = 0.03), and schizophrenia (OR = 12.66, 95% CI 1.40, 114.44, P = 0.02). Table 2 shows the pooled OR for different suicidal behaviors. Sleep disturbances were also significantly associated with suicide ideations, suicide attempts, and completed suicides. Subgroup analysis based on the type of sleep disturbance showed that insomnia, parasomnia, and sleep-related breathing disorders were significantly associated with increased risk of suicidal behaviors (Table 3). The only exception was hypersomnias (OR = 1.91, 95% CI: 0.60, 6.06, P = 0.27).
Figure 3

Forest plot of the association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses.

Table 2

Subgroup analysis based on suicidal behaviors

Suicidal behaviors

OR

95% CI

P value

I2

Ideation

2.69

1.62, 4.48

<0.001

73.5%

Attempt

4.36

2.28, 8.33

<0.001

0.0%

Completed suicide

1.59

1.17, 2.17

<0.01

45.0%

Table 3

Subgroup analysis based on sleep disturbance type

Sleep disturbance type

Studies ( n)

OR

95% CI

P value

I2

Insomnia

11

2.66

1.74, 4.07

<0.001

75.4%

Hypersomnia

3

1.91

0.60, 6.06

0.27

85.8%

Parasomnia

6

4.69

2.58, 8.51

<0.001

0.0%

Sleep-related breathing disorder

1

2.56

1.91, 3.43

<0.001

n/a

Other/unclear

7

4.16

1.96, 8.81

<0.001

81.7%

Sleep-related breathing disorder (SBD): only one study (Krakow, 2000) reported SBD and no objective test was used to confirm the diagnosis.

Discussion

We conducted a systematic review and meta-analysis to investigate the association between the presence of sleep disturbances and risk of suicidal behaviors in patients with psychiatric diagnoses. Nineteen studies with 104,436 patients were included in the analysis. We found significantly increased risk of suicidal behaviors among patients with sleep disturbances and psychiatric diagnoses compared to those without sleep disturbances.

Nevertheless, the causal role or mechanism of sleep disturbances in suicidal behavior remains unclear. It is suggested that sleep disturbances exacerbates psychological distress [4, 5], rendering psychiatric patients more vulnerable to suicidal behavior as a way to reduce or escape from such distress. There is also evidence that fatigue subsequent to sleep problems may impair problem solving and decrease emotion regulation increasing one’s risk for suicidal behavior through vulnerability to impulsive behavior [29]. Other possibilities may include changes in sleep architecture that render one vulnerable to suicide. Certainly, future research is necessary to examine the specific mechanism of vulnerability because such knowledge may lead to an effective intervention. Research should establish whether there are specific problems in sleep or sleep architecture that promotes vulnerability, and should determine whether there are specific sleep profiles (for example, nightmares, insomnia, early morning awakening) that may discriminate between individuals who are at risk to suicide behaviors and those who actually complete suicide.

Clinical implications

Given the findings of this study, the presence of sleep disturbances in individuals with psychiatric illness may trigger the need for further evaluation of increased risk for suicide. In particular, clinicians evaluating psychiatric patients who report acute changes in sleep should be aware that this may represent a specific vulnerability for suicide, and a careful suicide risk assessment may be warranted. Correspondingly, a comprehensive suicide risk assessment may include an evaluation of sleep quality and maintenance. Screening measures such as the Pittsburgh Sleep Quality Index (PSQI) [30], which assesses sleep quality, efficiency, duration, disturbances, and daytime dysfunction, and has good reliability and validity in detecting sleep problems, may assist in this effort. A suicide risk assessment that includes evaluation of sleep disturbances may not only add to the estimation of risk, but it may also provide a potential target for intervention. This is particularly promising given that many of the previously established risk factors are person variables such as age, type of psychiatric disorder, and family history of suicide attempts, and thereby not amenable to intervention.

In terms of intervention, there is considerable evidence for the efficacy of Cognitive Behavioral Therapy for Insomnia (CBT-I) with large effect sizes found in meta-analytic studies [31]. Not only is CBT-I effective for treating primary sleep disorders, research examining CBT-I in patients with major depression and co-morbid insomnia found that the treatment led to improvements in both disorders [32]. Although CBT-I is considered to be a first-line treatment for insomnia [33], pharmacological treatments may also be given consideration for insomnia and other sleep problems. However, caution should be taken as studies found sedative-hypnotics were associated with increased suicidal behaviors [3437]. A large cohort study demonstrated that receiving hypnotic prescriptions was associated with greater than three-fold increased hazards of death even when prescribed <18 pills/year. This association held in separate analyses for several commonly used hypnotics and for newer shorter-acting drugs [38].

Limitations and strengths

Strengths of the study include the comprehensive literature search, application of bias protection measures in the study selection, and careful evaluation of methodological quality. There are important limitations. Observational studies are subject to high risk of bias due to potential outcome confounding. Substantial heterogeneity was observed across the studies. Publication bias may have also affected our results. At last, we observed substantial variations of how the included studies define sleep disturbances and suicidal behaviors, and of how these studies measure them. All of the above may affect our findings. Based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, the strength of the current evidence is low due to potential publication bias and heterogeneity [39].

Conclusions

The current evidence and the results of this systematic review and meta-analysis suggest that in patients with psychiatric diagnoses, sleep disturbances are associated with the increased risk of suicidal behaviors.

Abbreviations

95% CI: 

95% Confidence interval

CBT-I: 

Cognitive behavioral therapy for insomnia

GRADE: 

Grading of recommendations assessment development and evaluation

OR: 

Odds ratio

PRISMA: 

Preferred Reporting Items for Systematic Reviews and Meta-analyses

PSQI: 

Pittsburgh Sleep uality Index

PTSD: 

Post-traumatic stress disorder.

Declarations

Authors’ Affiliations

(1)
Division of Preventive Medicine, Mayo Clinic
(2)
Fairview Clinics
(3)
University of Wisconsin-Madison
(4)
Department of Psychiatry & Psychology, Mayo Clinic
(5)
Mayo Clinic Libraries, Mayo Clinic
(6)
Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic
(7)
Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
(8)
Knowledge and Evaluation Research Unit, Mayo Clinic

References

  1. Fawcett J, Scheftner WA, Fogg L, Clark DC, Young MA, Hedeker D, Gibbons R: Time-related predictors of suicide in major affective disorder. Am J Psychiatry. 1990, 147: 1189-1194.View ArticlePubMedGoogle Scholar
  2. Mann JJ, Waternaux C, Haas GL, Malone KM: Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry. 1999, 156: 181-189.PubMedGoogle Scholar
  3. Goldstein RB, Black DW, Nasrallah A, Winokur G: The prediction of suicide. Sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders. Arch Gen Psychiatry. 1991, 48: 418-422. 10.1001/archpsyc.1991.01810290030004.View ArticlePubMedGoogle Scholar
  4. Breslau N, Roth T, Rosenthal L, Andreski P: Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry. 1996, 39: 411-418. 10.1016/0006-3223(95)00188-3.View ArticlePubMedGoogle Scholar
  5. Ford DE, Kamerow DB: Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention?. JAMA. 1989, 262: 1479-1484. 10.1001/jama.1989.03430110069030.View ArticlePubMedGoogle Scholar
  6. Pigeon WR, Pinquart M, Conner K: Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. J Clin Psychiatry. 2012, 73: e1160-e1167. 10.4088/JCP.11r07586.View ArticlePubMedGoogle Scholar
  7. Agargun MY, Kara H, Solmaz M: Sleep disturbances and suicidal behavior in patients with major depression. J Clin Psychiatry. 1997, 58: 249-251. 10.4088/JCP.v58n0602.View ArticlePubMedGoogle Scholar
  8. Li SX, Lam SP, Yu MW, Zhang J, Wing YK: Nocturnal sleep disturbances as a predictor of suicide attempts among psychiatric outpatients: a clinical, epidemiologic, prospective study. J Clin Psychiatry. 2010, 71: 1440-1446. 10.4088/JCP.09m05661gry.View ArticlePubMedGoogle Scholar
  9. Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009, 151: 264-269. 10.7326/0003-4819-151-4-200908180-00135. W264View ArticlePubMedGoogle Scholar
  10. Borenstein M, Cooper H, Hedges L, Valentine J: Effect sizes for continuous data. The Handbook of Research Synthesis and Meta-Analysis. Edited by: Cooper H, Hedges LV, Valentine JC. 2009, New York, NY: Russell Sage, 221-235.Google Scholar
  11. DerSimonian R, Laird N: Meta-analysis in clinical trials. Control Clin Trials. 1986, 7: 177-188. 10.1016/0197-2456(86)90046-2.View ArticlePubMedGoogle Scholar
  12. 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: 203-209. 10.1016/j.jad.2006.06.016.View ArticlePubMedGoogle Scholar
  13. 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: 83-93. 10.1016/j.jad.2008.02.010.View ArticlePubMedGoogle Scholar
  14. Paffenbarger RS, Lee IM, Leung R: Physical activity and personal characteristics associated with depression and suicide in American college men. Acta Psychiatr Scand Suppl. 1994, 377: 16-22.View ArticlePubMedGoogle Scholar
  15. Pompili M, Lester D, Grispini A, Innamorati M, Calandro F, Iliceto P, De Pisa E, Tatarelli R, Girardi P: Completed suicide in schizophrenia: evidence from a case–control study. Psychiatry Res. 2009, 167: 251-257. 10.1016/j.psychres.2008.03.018.View ArticlePubMedGoogle Scholar
  16. Sjostrom N, Hetta J, Waern M: Persistent nightmares are associated with repeat suicide attempt: a prospective study. Psychiatry Res. 2009, 170: 208-211. 10.1016/j.psychres.2008.09.006.View ArticlePubMedGoogle Scholar
  17. Agargun MY, Kara H, Solmaz M: Subjective sleep quality and suicidality in patients with major depression. J Psychiatr Res. 1997, 31: 377-381. 10.1016/S0022-3956(96)00037-4.View ArticlePubMedGoogle Scholar
  18. Agargun MY, Cilli AS, Kara H, Tarhan N, Kincir F, Oz H: Repetitive and frightening dreams and suicidal behavior in patients with major depression. Compr Psychiatry. 1998, 39: 198-202. 10.1016/S0010-440X(98)90060-8.View ArticlePubMedGoogle Scholar
  19. Agargun MY, Kara H: Recurrent sleep panic, insomnia, and suicidal behavior in patients with panic disorder. Compr Psychiatry. 1998, 39: 149-151. 10.1016/S0010-440X(98)90074-8.View ArticlePubMedGoogle Scholar
  20. Agargun MY, Cartwright R: REM sleep, dream variables and suicidality in depressed patients. Psychiatry Res. 2003, 119: 33-39. 10.1016/S0165-1781(03)00111-2.View ArticlePubMedGoogle Scholar
  21. Chellappa SL, Araujo JF: Sleep disorders and suicidal ideation in patients with depressive disorder. Psychiatry Res. 2007, 153: 131-136. 10.1016/j.psychres.2006.05.007.View ArticlePubMedGoogle Scholar
  22. Krakow B, Artar A, Warner TD, Melendrez D, Johnston L, Hollifield M, Germain A, Koss M: Sleep disorder, depression, and suicidality in female sexual assault survivors. Crisis. 2000, 21: 163-170.View ArticlePubMedGoogle Scholar
  23. 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: 267-270. 10.1016/j.jad.2006.08.005.View ArticlePubMedGoogle Scholar
  24. 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 and Biological Rhythms. 2006, 4: 137-143. 10.1111/j.1479-8425.2006.00209.x.View ArticleGoogle Scholar
  25. Bjorngaard JH, Bjerkeset O, Romundstad P, Gunnell D: Sleeping problems and suicide in 75,000 Norwegian adults: a 20 year follow-up of the HUNT I study. Sleep. 2011, 34: 1155-1159.PubMedPubMed CentralGoogle Scholar
  26. Li SX, Lam SP, Chan JWY, Yu MWM, Wing Y-K: Residual sleep disturbances in patients remitted from major depressive disorder: a 4-year naturalistic follow-up study. Sleep. 2012, 35: 1153-1161.PubMedPubMed CentralGoogle Scholar
  27. Krakow B, Ribeiro JD, Ulibarri VA, Krakow J, Joiner TE: Sleep disturbances and suicidal ideation in sleep medical center patients. J Affect Disord. 2011, 131: 422-427. 10.1016/j.jad.2010.12.001.View ArticlePubMedGoogle Scholar
  28. Higgins JP, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in meta-analyses. BMJ. 2003, 327: 557-560. 10.1136/bmj.327.7414.557.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Anderson C, Platten CR: Sleep deprivation lowers inhibition and enhances impulsivity to negative stimuli. Behav Brain Res. 2011, 217: 463-466. 10.1016/j.bbr.2010.09.020.View ArticlePubMedGoogle Scholar
  30. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ: The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989, 28: 193-213. 10.1016/0165-1781(89)90047-4.View ArticlePubMedGoogle Scholar
  31. Morin CM, Culbert JP, Schwartz SM: Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry. 1994, 151: 1172-1180.View ArticlePubMedGoogle Scholar
  32. Manber R, Edinger JD, Gress JL, San Pedro-Salcedo MG, Kuo TF, Kalista T: Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep. 2008, 31: 489-495.PubMedPubMed CentralGoogle Scholar
  33. Chesson AL, Anderson WM, Littner M, Davila D, Hartse K, Johnson S, Wise M, Rafecas J: Practice parameters for the nonpharmacologic treatment of chronic insomnia, An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 1999, 22: 1128-1133.PubMedGoogle Scholar
  34. Allgulander C, Ljungberg L, Fisher LD: Long-term prognosis in addiction on sedative and hypnotic drugs analyzed with the Cox regression model. Acta Psychiatr Scand. 1987, 75: 521-531. 10.1111/j.1600-0447.1987.tb02828.x.View ArticlePubMedGoogle Scholar
  35. Carlsten A, Waern M: Are sedatives and hypnotics associated with increased suicide risk of suicide in the elderly?. BMC Geriatr. 2009, 9: 20-10.1186/1471-2318-9-20.View ArticlePubMedPubMed CentralGoogle Scholar
  36. Rod NH, Vahtera J, Westerlund H, Kivimaki M, Zins M, Goldberg M, Lange T: Sleep disturbances and cause-specific mortality: results from the GAZEL cohort study. Am J Epidemiol. 2011, 173: 300-309. 10.1093/aje/kwq371.View ArticlePubMedGoogle Scholar
  37. Belleville G: Mortality hazard associated with anxiolytic and hypnotic drug use in the National Population Health Survey. Can J Psychiatry. 2010, 55: 558-567.PubMedGoogle Scholar
  38. Kripke DF, Langer RD, Kline LE: Hypnotics’ association with mortality or cancer: a matched cohort study. BMJ Open. 2012, 2: e000850-View ArticlePubMedPubMed CentralGoogle Scholar
  39. Balshem H, Helfand M, Schunemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris S, Guyatt GH: GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011, 64: 401-406. 10.1016/j.jclinepi.2010.07.015.View ArticlePubMedGoogle Scholar

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© Malik et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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