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Original Research Focus on Suicide March 23, 2021

Insomnia, Suicidal Ideation, and Suicide Attempts in the Clinical Antipsychotic Trials of Intervention Effectiveness

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J Clin Psychiatry 2021;82(3):20m13338

ABSTRACT

Objective: Insomnia occurs frequently in the clinical course of schizophrenia. There is a robust association between insomnia and suicide in other psychiatric disorders. Several previous studies found associations between insomnia and suicidal ideation, suicide attempt, and psychopathology in schizophrenia. We explored these associations in a cross-sectional study of a large sample of patients with schizophrenia.

Methods: In February 2020, we investigated relationships between current insomnia, suicidal ideation over the past 2 weeks, suicide attempt in the past 6 months (assessed by either the Calgary Depression Scale for Schizophrenia or self-report), and current psychopathology for subjects with baseline data from the Clinical Antipsychotic Trials of Intervention Effectiveness (DSM-IV schizophrenia trial conducted 2001–2004) using regression models.

Results: After controlling for multiple potential confounding factors, terminal insomnia was associated with significant, 2.7-fold increased odds of current suicidal ideation (OR = 2.7, 95% CI = 2.0–3.6, P < .001). Initial/middle insomnia was associated with a significant, 5.5-fold increased odds of suicide attempt in the past 6 months (OR = 5.5, 95% CI = 1.4–21.1, P = .013). Terminal insomnia was also a significant indicator of higher Positive and Negative Syndrome Scale total (β = 0.12, P < .001), positive subscale (β = 0.11, P < .001), and general psychopathology subscale (β = 0.14, P < .001) scores. There were no other significant associations between insomnia, suicidal thinking or behavior, and psychopathology.

Conclusions: Insomnia is associated with suicidal ideation, recent suicide attempt, and greater psychopathology in schizophrenia. Findings provide additional evidence that formal assessment of insomnia is relevant to the clinical care of patients with schizophrenia as an indicator of suicidal ideation and behavior, as well as symptom severity.

Trial Registration: ClinicalTrials.gov identifier: NCT00014001

 

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  1. Batalla-Martín D, Belzunegui-Eraso A, Miralles Garijo E, et al. Insomnia in schizophrenia patients: prevalence and quality of life. Int J Environ Res Public Health. 2020;17(4):E1350. PubMed CrossRef NLM
  2. Hou CL, Li Y, Cai MY, et al. Prevalence of insomnia and clinical and quality of life correlates in chinese patients with schizophrenia treated in primary care. Perspect Psychiatr Care. 2017;53(2):80–86. PubMed CrossRef NLM
  3. Palmese LB, DeGeorge PC, Ratliff JC, et al. Insomnia is frequent in schizophrenia and associated with night eating and obesity. Schizophr Res. 2011;133(1–3):238–243. PubMed CrossRef NLM
  4. Monti JM, BaHammam AS, Pandi-Perumal SR, et al. Sleep and circadian rhythm dysregulation in schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry. 2013;43:209–216. PubMed CrossRef NLM
  5. Wulff K, Dijk DJ, Middleton B, et al. Sleep and circadian rhythm disruption in schizophrenia. Br J Psychiatry. 2012;200(4):308–316. PubMed CrossRef NLM
  6. Davies G, Haddock G, Yung AR, et al. A systematic review of the nature and correlates of sleep disturbance in early psychosis. Sleep Med Rev. 2017;31:25–38. PubMed CrossRef NLM
  7. Malik S, Kanwar A, Sim LA, et al. The association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses: a systematic review and meta-analysis. Syst Rev. 2014;3(1):18. PubMed CrossRef NLM
  8. McCall WV, Blocker JN, D’Agostino R Jr, et al. Insomnia severity is an indicator of suicidal ideation during a depression clinical trial. Sleep Med. 2010;11(9):822–827. PubMed CrossRef NLM
  9. Lu L, Dong M, Zhang L, et al. Prevalence of suicide attempts in individuals with schizophrenia: a meta-analysis of observational studies. Epidemiol Psychiatr Sci. 2019;29:e39. PubMed CrossRef NLM
  10. Hor K, Taylor M. Suicide and schizophrenia: a systematic review of rates and risk factors. J Psychopharmacol. 2010;24(4 suppl):81–90. PubMed CrossRef NLM
  11. Andriopoulos I, Ellul J, Skokou M, et al. Suicidality in the “prodromal” phase of schizophrenia. Compr Psychiatry. 2011;52(5):479–485. PubMed CrossRef NLM
  12. Freeman D, Bold E, Chadwick E, et al. Suicidal ideation and behaviour in patients with persecutory delusions: prevalence, symptom associations, and psychological correlates. Compr Psychiatry. 2019;93:41–47. PubMed CrossRef NLM
  13. Li SX, Lam SP, Zhang J, et al. Sleep disturbances and suicide risk in an 8-year longitudinal study of schizophrenia-spectrum disorders. Sleep. 2016;39(6):1275–1282. PubMed CrossRef NLM
  14. Miller BJ, Parker CB, Rapaport MH, et al. Insomnia and suicidal ideation in nonaffective psychosis. Sleep. 2019;42(2). PubMed CrossRef NLM
  15. Pompili M, Lester D, Grispini A, et al. Completed suicide in schizophrenia: evidence from a case-control study. Psychiatry Res. 2009;167(3):251–257. PubMed CrossRef NLM
  16. Hawton K, Sutton L, Haw C, et al. Schizophrenia and suicide: systematic review of risk factors. Br J Psychiatry. 2005;187(1):9–20. PubMed CrossRef NLM
  17. Pompili M, Innamorati M, Forte A, et al. Insomnia as a predictor of high-lethality suicide attempts. Int J Clin Pract. 2013;67(12):1311–1316. PubMed CrossRef NLM
  18. Reeve S, Nickless A, Sheaves B, et al. Insomnia, negative affect, and psychotic experiences: modelling pathways over time in a clinical observational study. Psychiatry Res. 2018;269:673–680. PubMed CrossRef NLM
  19. Cosgrave J, Haines R, van Heugten-van der Kloet D, et al. The interaction between subclinical psychotic experiences, insomnia and objective measures of sleep. Schizophr Res. 2018;193:204–208. PubMed CrossRef NLM
  20. Lee YJ, Cho SJ, Cho IH, et al. The relationship between psychotic-like experiences and sleep disturbances in adolescents. Sleep Med. 2012;13(8):1021–1027. PubMed CrossRef NLM
  21. Sheaves B, Bebbington PE, Goodwin GM, et al. Insomnia and hallucinations in the general population: findings from the 2000 and 2007 British Psychiatric Morbidity Surveys. Psychiatry Res. 2016;241:141–146. PubMed CrossRef NLM
  22. Reeve S, Emsley R, Sheaves B, et al. Disrupting sleep: the effects of sleep loss on psychotic experiences tested in an experimental study with mediation analysis. Schizophr Bull. 2018;44(3):662–671. PubMed NLM
  23. Goines KB, LoPilato AM, Addington J, et al. Sleep problems and attenuated psychotic symptoms in youth at clinical high-risk for psychosis. Psychiatry Res. 2019;282:112492. PubMed CrossRef NLM
  24. Li Y, Hou CL, Ma XR, et al. Quality of life in Chinese patients with schizophrenia treated in primary care. Psychiatry Res. 2017;254:80–84. PubMed CrossRef NLM
  25. Lieberman JA, Stroup TS, McEvoy JP, et al; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005;353(12):1209–1223. PubMed CrossRef NLM
  26. Cassidy RM, Yang F, Kapczinski F, et al. Risk factors for suicidality in patients with schizophrenia: a systematic review, meta-analysis, and meta-regression of 96 studies. Schizophr Bull. 2018;44(4):787–797. PubMed CrossRef NLM
  27. Pigeon WR, Pinquart M, Conner K. Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. J Clin Psychiatry. 2012;73(9):e1160–e1167. PubMed CrossRef NLM
  28. Kirkpatrick B, Buchanan RW, Ross DE, et al. A separate disease within the syndrome of schizophrenia. Arch Gen Psychiatry. 2001;58(2):165–171. PubMed CrossRef NLM
  29. McCall WV, Black CG. The link between suicide and insomnia: theoretical mechanisms. Curr Psychiatry Rep. 2013;15(9):389. PubMed CrossRef NLM
  30. Selvaraj S, Arnone D, Cappai A, et al. Alterations in the serotonin system in schizophrenia: a systematic review and meta-analysis of postmortem and molecular imaging studies. Neurosci Biobehav Rev. 2014;45:233–245. PubMed CrossRef NLM
  31. Bradley AJ, Dinan TG. A systematic review of hypothalamic-pituitary-adrenal axis function in schizophrenia: implications for mortality. J Psychopharmacol. 2010;24(suppl):91–118. PubMed CrossRef NLM
  32. Waite F, Myers E, Harvey AG, et al. Treating sleep problems in patients with schizophrenia. Behav Cogn Psychother. 2016;44(3):273–287. PubMed CrossRef NLM
  33. Castro J, Zanini M, Gonçalves BdaS, et al. Circadian rest-activity rhythm in individuals at risk for psychosis and bipolar disorder. Schizophr Res. 2015;168(1-2):50–55. PubMed CrossRef NLM
  34. Johansson AS, Owe-Larsson B, Hetta J, et al. Altered circadian clock gene expression in patients with schizophrenia. Schizophr Res. 2016;174(1-3):17–23. PubMed CrossRef NLM
  35. Agargun MY, Besiroglu L, Cilli AS, et al. Nightmares, suicide attempts, and melancholic features in patients with unipolar major depression. J Affect Disord. 2007;98(3):267–270. PubMed CrossRef NLM
  36. McGlinchey EL, Courtney-Seidler EA, German M, et al. The role of sleep disturbance in suicidal and nonsuicidal self-injurious behavior among adolescents. Suicide Life Threat Behav. 2017;47(1):103–111. PubMed CrossRef NLM
  37. Del-Monte J, Graziani P. Anticipatory, relief-oriented and permissive beliefs in patients with suicidal behaviors: an exploratory case-control study [published online March 23, 2020]. Arch Suicide Res. PubMed CrossRef NLM
  38. Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307. PubMed CrossRef NLM
  39. Horne JA, Ostberg O. A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. Int J Chronobiol. 1976;4(2):97–110. PubMed NLM
  40. McCall WV, Benca RM, Rosenquist PB, et al. Reducing Suicidal Ideation Through Insomnia Treatment (REST-IT): a randomized clinical trial. Am J Psychiatry. 2019;176(11):957–965. PubMed CrossRef NLM
  41. Gold PW. The organization of the stress system and its dysregulation in depressive illness. Mol Psychiatry. 2015;20(1):32–47. PubMed CrossRef NLM
  42. Stummer L, Markovic M, Maroney ME. Pharmacologic treatment options for insomnia in patients with schizophrenia. Medicines (Basel). 2018;5(3):88. PubMed CrossRef NLM
  43. Joober R, Cole K, Tabbane K, et al. An algorithmic approach to the management of insomnia in patients with schizophrenia. Ann Clin Psychiatry. 2017;29(2):133–144. PubMed NLM
  44. Cohrs S. Sleep disturbances in patients with schizophrenia: impact and effect of antipsychotics. CNS Drugs. 2008;22(11):939–962. PubMed CrossRef NLM
  45. Meng Q, Li R, Hou F, et al. Effects of chlorpromazine on sleep quality, clinical and emotional measures among patients with schizophrenia. Clin Neurol Neurosurg. 2018;165:134–138. PubMed CrossRef NLM
  46. Wirz-Justice A, Haug HJ, Cajochen C. Disturbed circadian rest-activity cycles in schizophrenia patients: an effect of drugs? Schizophr Bull. 2001;27(3):497–502. PubMed CrossRef NLM
  47. Meltzer HY, Alphs L, Green AI, et al; International Suicide Prevention Trial Study Group. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry. 2003;60(1):82–91. PubMed CrossRef NLM
  48. Pompili M. Adding suicide prevention to the triple advantages of injectable long-acting second-generation antipsychotics. Front Psychiatry. 2020;10:931. PubMed CrossRef NLM
  49. Chemerinski E, Ho BC, Flaum M, et al. Insomnia as a predictor for symptom worsening following antipsychotic withdrawal in schizophrenia. Compr Psychiatry. 2002;43(5):393–396. PubMed CrossRef NLM
  50. Freeman D, Waite F, Startup H, et al. Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial. Lancet Psychiatry. 2015;2(11):975–983. PubMed CrossRef NLM
  51. Waters F, Chiu VW, Janca A, et al. Preferences for different insomnia treatment options in people with schizophrenia and related psychoses: a qualitative study. Front Psychol. 2015;6:990. PubMed CrossRef NLM
  52. Chiu VW, Ree M, Janca A, et al. Sleep profiles and CBT-I response in schizophrenia and related psychoses. Psychiatry Res. 2018;268:279–287. PubMed CrossRef NLM
  53. Hwang DK, Nam M, Lee YG. The effect of cognitive behavioral therapy for insomnia in schizophrenia patients with sleep disturbance: a non-randomized, assessor-blind trial. Psychiatry Res. 2019;274:182–188. PubMed CrossRef NLM
  54. Tek C, Palmese LB, Krystal AD, et al. The impact of eszopiclone on sleep and cognition in patients with schizophrenia and insomnia: a double-blind, randomized, placebo-controlled trial. Schizophr Res. 2014;160(1–3):180–185. PubMed CrossRef NLM
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