Barry Krakow, MD

More than 30,000 individuals die by suicide each year in the United States. For every death by suicide, there are 10 to 25 nonlethal attempts. Lifetime prevalence indicates 5% of the population reports a suicide attempt, 4% a plan, and 14% ideation. Although suicide is the 11th leading cause of death in the United States, recent research reveals a number of risk factors that may be targeted to prevent fatalities.1

In our field of sleep medicine, research points to sleep disturbances as significant risk factors for suicidal ideation and behaviors. Severity of global insomnia has been identified as a significant—and, importantly, modifiable—short-term risk factor for suicide.2 Hypersomnia and poor sleep quality have both been predictive of eventual death by suicide.3 Suicidal individuals report significantly higher rates of nightmares, especially when the patient is suffering from depression.4 Other sleep disturbances have been implicated as potential suicide risk factors, including lower sleep efficiency, longer sleep latency, and sleep-disordered breathing.5-7

The knowledge that sleep problems may provoke or worsen suicidal thoughts creates a clinically important opportunity for sleep physicians, because patients with both sleep problems and suicidal ideation may seek treatment at sleep centers, particularly if their experiences with psychiatrists or other therapists have not fully resolved their mental health concerns. In such circumstances, mental health patients may suffer from lingering insomnia or nonrestorative sleep due to ineffective psychotherapy or psychotropic medications. If insomnia persists, they may turn their attention toward solving their sleep problems by seeking help from a sleep specialist. And sleep centers and providers would then have the chance to detect and provide early intervention for these patients before their suicidal ideation progresses to suicidal behaviors or completed suicides.

Until recently, research had not been conducted on the prevalence of suicidal ideation in patients seeking treatment at sleep medical centers. In 2010, we collaborated with experts in the field of suicide research at Florida State University (Drs Thomas Joiner and Jessica Ribeiro) to evaluate a large database of sleep patients who sought treatment at Maimonides Sleep Arts & Sciences, a community-based sleep center that specializes in the treatment of mental health patients with sleep disorders. Our results were published in the Journal of Affective Disorders in January 2011.1

From our database of 1,584 patients, we discovered that 13% (n = 211) of the entire sample reported suicidal ideation; and more than a third of these patients or 4.5% of the total sample reported a degree of suicidal ideation consistent with apparent clinical risk.

Statistically, a very large number of common sleep factors were associated significantly with suicidal ideation including:

  • Poor sleep quality
  • Lighter sleep
  • Insomnia severity
  • Awakenings at night
  • Sleep onset latency
  • Prolonged time in bed
  • Wake time after sleep onset
  • Lower sleep efficiency
  • Daytime fatigue and sleepiness

Additional interesting associations were parasomnias such as nightmares, acting out dreams, and disruptive sleep behaviors. Also, psychophysiological conditioning such as excessive time monitoring behavior or “losing sleep over losing sleep” was associated with the severity of suicidal ideation. Even something as simple as a poor sleep environment was associated with suicidal ideation.

To further analyze all these factors, we then controlled for depressive symptoms in our sample, because suicidal ideation is so strongly linked to depression. With this analysis, a number of sleep factors still correlated significantly with suicidal ideation or showed a trend toward significance, including greater chronicity of sleep problems, poor sleep quality, daytime fatigue, lighter sleep, prolonged time in bed, and nightmares. So, even though the effects of depressive symptoms were removed from the analysis, these sleep symptoms remained in association with suicidal ideation.

Now, this type of research cannot prove these sleep factors cause suicidal ideation or lead to completed suicides. However, the pervasiveness of these associations strongly suggests that intervention research is needed to learn whether treatment of these sleep problems would result in a decrease in suicidal ideation. Research programs are currently in the proposal stages to the Military Suicide Research Consortium to investigate whether sleep treatments such as cognitive-behavioral therapy for insomnia (CBT-I) or imagery rehearsal therapy (IRT) for nightmares can be effectively administered to military personnel who suffer from suicidal ideation.

At Maimonides Sleep Arts & Sciences, we use Dr Joiner’s DSI-SS scale (Depression Severity Index—Suicide Subscale) of four brief questions on suicidal thoughts and behaviors.8 If patients are identified with elevated scores, we contact them to find out whether they are currently undergoing counseling. If not, we help them make arrangements to begin work with a therapist. In rare instances in the clinic, we have also helped suicidal patients initiate preliminary actions (eg, removal of a gun from the home; third-party monitoring of medications) in conjunction with their therapists. Most importantly, we aggressively treat their sleep problems in the belief that enhanced sleep quality will improve mental health symptoms.

In summary, suicidal ideation appears to be fairly common in treatment-seeking sleep patients. Prevalence rates will likely vary depending on the type of sleep medical center and the population it serves. It seems plausible that evidence-based treatments of sleep disorders would lower suicidal risks, mostly in the area of decreased suicidal ideation. In fact, a recent case study showed that auto-CPAP treatment in an elderly sleep apnea patient dramatically eliminated suicidal ideation.9 Thus, the sleep center may prove to be an important research venue or early intervention site for this deadly and common mental health problem.

Barry Krakow, MD, is the author of Sound Sleep, Sound Mind, principal investigator at Sleep & Human Health Institute, and medical director at Maimonides Sleep Arts & Sciences Ltd (, and blogs at He can be reached at [email protected].


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