The rates of death by suicide have been on the rise in the United States, up 33% between 1999 and 2017. The annual suicide rate is 15 deaths per 100,000 and it is the second leading cause of death for those under the age of 35. Clearly, suicide is a serious public health threat.
One independent risk factor for suicidal ideation, suicidal attempts, and suicide deaths is insomnia. Understanding the connection between sleep disruption and suicide is imporant because there are several viable options for treating sleep disturbances. However, up until a few years ago, there had been no randomized clinical trials to examine whether treating insomnia could reduce the risk of suicide.
In this article, we look at one study seeking to determine whether taking a sleeping pill at bedtime would reduce suicidal thoughts in depressed patients taking selective serotonin reuptake inhibitors (SSRIs). Although the results of the study do not support prescription of sleep medication for all depressed patients with insomnia, sleeping pills as an add on with an antidepressant appear to be beneficial, especially in patients with severe insomnia.
Scientists have yet to establish that improving sleep in and of itself reduces suicide. However, one large study of veterans with previous suicide attempts found that treatment of sleep disturbances, including insomnia, nightmares, and sleep apnea, was a protective factor against additional suicide attempts.
Here is what we know about the science:
What does this mean for clinicians hoping to address the connection between sleep disturbance and suicide? It is crucial for clinicians to screen patients for sleep disturbances, and any complaints of insomnia among depressed individuals may indicate that more direct questioning about suicide is needed.
To better understand the connection between insomnia and suicide, one group of researchers conducted the first randomized clinical trial to determine whether use of sleep medication to treat insomnia would reduce the risk of suicide. The study was called Reducing Suicidal Ideation Through Insomnia Treatment (REST-IT). Their hypothesis was that the addition of zolpidem-CR (Ambien) would result in greater reduction of suicide risk when compared with a placebo group. Let’s now look more closely at the details of the study.
Participants were outpatients 18-65 years of age, who were diagnosed with major depressive disorder (MDD) and who complained of insomnia. Patients diagnosed with bipolar depression, schizophrenia, substance abuse, or sleep disorders other than insomnia were excluded from the study.
The primary variable tracked during the study was suicidal ideation. During each visit, researchers administered the Scale for Suicide Ideation, a self-rated scale consisting of 19 items that evaluate suicidal desire and planning. They also administered an observer-rated test called C-SSRS, which rates the “intensity” of suicidal thoughts.
In addition, the study tracked several secondary variables: sleep metrics, depression severity, hopelessness, health-related quality of life, overall status and treatment response, antidepressant treatment response, and adverse effects.
Participants who took zolpidem-CR (Ambien) immediately showed improvement in their insomnia compared with the placebo group, which was not surprising, and the greatest change was seen in those with severe insomnia. Likewise, while there was no significant effect on suicidal ideation among those with mild insomnia, those with severe insomnia experienced a greater reduction in suicidal ideation (measured by the C-SSRS scale) when taking zolpidem-CR.
In addition, the improvements in suicidality and insomnia continued after the discontinuation of the sleep medication as confirmed during a telephone follow-up two weeks after the clinical phase of the trial.
Points of Interest
There are a number of points of interest worth noting about the REST-IT study from a clinical perspective. First, like the STAR-D study, which we’ve discussed in previous blog articles, REST-IT expands the population of study participants in a significant way.
The REST-IT study proves that it is possible to selectively recruit and safely manage suicidal outpatients with MDD in a randomized clinical trial. Additionally, the researchers detected no worsening of suicidal ideation or emergence of new suicidal behavior during the controlled trial.
In most psychiatric clinical trials, those with histories of suicide attempts or suicidal thoughts are excluded, and REST-IT shows that there are no reasons to systematically exclude these patients from future trials. As a result, the study paves the way for carrying out double-blind randomized trials for other types of treatment for suicidality in outpatients.
Second, although this study did not compare sleep medication with cognitive-behavioral therapy for insomnia (CBT-I), another study has shown that CBT-I can also effectively reduce suicidal ideation in depressed patients with insomnia. This means patients have options. However, the researchers point out that the treatment effect of CBT-I is likely to be slower than taking a sleeping pill and this may be an important consideration for patients and their doctors.
For patients with major depressive disorder (MDD) and insomnia, the REST-IT study provides hope. When we treat a patient’s insomnia with a sleep medication, they experience fewer suicidal thoughts, but because treatment with anti-depressants also improves both insomnia and suicidality, routine prescription of sleep medication is not necessary for all patients with MDD. Still, results suggest that for patients with the most severe insomnia, relief of insomnia can provide a more rapid reduction of suicidal ideation without any undue risks.