Sleep problems, suicidal ideation, and self-harm behaviors in adolescence

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Abstract

Objective

Previous research has found an association between sleep problems and suicidal behavior. However, it is still unclear whether the association can be largely explained by depression. In this study, we prospectively examined relationships between sleep problems when participants were 12–14 years old and subsequent suicidal thoughts and self-harm behaviors—including suicide attempts—at ages 15–17 while controlling for depressive symptoms at baseline.

Methods

Study participants were 280 boys and 112 girls from a community sample of high-risk alcoholic families and controls in an ongoing longitudinal study.

Results

Controlling for gender, parental alcoholism and parental suicidal thoughts, and prior suicidal thoughts or self-harm behaviors when participants were 12–14 years old, having trouble sleeping at 12–14 significantly predicted suicidal thoughts and self-harm behaviors at ages 15–17. Depressive symptoms, nightmares, aggressive behavior, and substance-related problems at ages 12–14 were not significant predictors when other variables were in the model.

Conclusions

Having trouble sleeping was a strong predictor of subsequent suicidal thoughts and self-harm behaviors in adolescence. Sleep problems may be an early and important marker for suicidal behavior in adolescence. Parents and primary care physicians are encouraged to be vigilant and screen for sleep problems in young adolescents. Future research should determine if early intervention with sleep disturbances reduces the risk for suicidality in adolescents.

Introduction

In 2002, the Institute of Medicine report on Reducing Suicide recommended that prospective studies of populations at high risk for the onset of suicidal behavior were needed (Goldsmith et al., 2002). Of particular concern are adolescents, because suicide is the third leading cause of death in the 15–24-year old age group (Cash and Bridge, 2009). Although the Institute of Medicine report did not mention sleep disturbances as a risk factor for suicidality, a consistent and strong association between sleep disturbances and suicidality has been reported in both adults (Agargun et al., 2007, Chellappa and Araujo, 2007, McGirr et al., 2007, Sjostrom et al., 2007, Turvey et al., 2002, Wallander et al., 2007, Wojnar et al., 2009) and adolescents (Bailly et al., 2004, Barbe et al., 2005, Choquet et al., 1993, Choquet and Menke, 1990, Goldstein et al., 2008, Liu, 2004, Nrugham et al., 2008).

Among adolescents, insomnia has been linked to suicidal thoughts (Bailly et al., 2004, Barbe et al., 2005, Choquet and Menke, 1990), attempts (Bailly et al., 2004, Nrugham et al., 2008), and completed suicides (Goldstein et al., 2008). Similarly, nightmares have been linked to both suicidal thoughts (Choquet and Menke, 1990, Liu, 2004) and suicide attempts (Liu, 2004). These relationships have been reported in both general student populations (Liu, 2004, Nrugham et al., 2008) and clinical samples (Barbe et al., 2005). With one exception (Nrugham et al., 2008), however, most of these studies were cross-sectional in design. In the one prospective study already present in the literature, Nrugham et al. (2008) followed 265 students in Norway for 5 years, starting when they were approximately 15 years of age. Bivariate analyses demonstrated that insomnia at age 15 predicted suicide attempts during the next 5 years. In multivariate analyses that controlled for depressive symptoms, however, insomnia was no longer predictive. This is probably due to the well-established association between depression and suicide attempts in adolescents (Kovacs et al., 1993, Lewinsohn et al., 1994, Liu and Buysse, 2006). The results of this study illustrate the importance of controlling for depressive symptoms. Nevertheless, the authors cautioned that a 70% follow-up rate and a small number of boys (N = 61) in the sample may have biased the results. More prospective studies are clearly needed to address the possible relationships between sleep problems and suicidal behavior.

Children of alcoholics (COAs) are another high-risk group for numerous adverse outcomes including substance use disorders, internalizing disorders, and externalizing disorders—all of which can increase the risk for suicidality (Lieberman, 2000, Zucker et al., 2008). Recent work also suggests that COAs may differ from other children by objectively measured sleep disturbance (Dahl et al., 2003, Tarokh and Carskadon, 2009). Therefore, the relationship between sleep disturbances and suicidality in COAs warrants study.

Here, we report to our knowledge the first prospective study of high-risk adolescents to investigate a potential link between sleep disturbances and subsequent suicidal thoughts and either self-harm behaviors or suicide attempts (self-harm/suicidal behaviors). We hypothesized that (1) COAs would have higher rates of sleep disturbance than non-COAs; (2) COAs would have higher rates of suicidal thoughts and self-harm/suicidal behaviors than non-COAs; and (3) sleep disturbances would prospectively predict the development of suicidal thoughts and self-harm/suicidal behaviors after controlling for depressive symptoms, COA status, and other potentially confounding variables. We used the terms “sleep disturbances,” “poor sleep,” “insomnia,” and “sleep problems” interchangeably in this paper.

Section snippets

Participants

The present study is part of the Michigan Longitudinal Study, an ongoing longitudinal family study on the development of risk for alcohol and other substance use disorders (Zucker and Fitzgerald, 1991, Zucker et al., 2000). The larger study recruited a population-based sample of alcoholic men, their partners (whose substance use disorder was free to vary), and controls, as well as their initially 3–5-year-old sons (N = 311 families). The 3–11-year-old daughters in the families were also invited

Descriptive statistics

At ages 15–17, 7.6% reported having suicidal thoughts and 5% reported that they had tried to harm or kill themselves in the last six months. The figures were similar when participants were at ages 12–14 at which time 4.1% had suicidal thoughts and 3.3% had actually engaged in self-harm/suicidal behavior. There was no completed suicide at either wave. However, there was one complete suicide when participants were 18–20 years old. Regarding sleep disturbances at ages 12–14, over one-quarter of

Discussion

The main finding of this study is that self-reported trouble sleeping between the ages of 12 and 14 was significantly associated with suicidal thoughts and self-harm/suicidal behaviors at ages 15–17, while adjusting for age, gender, prior suicidality, depressive symptoms, aggressive behavior, substance-related problems, COA status, and parental suicidal thoughts. This is to our knowledge the first prospective study of this relationship performed in the U.S. with a high-risk sample of

Role of funding source

This work was supported in part by grants from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) awarded to M.M. Wong (R21 AA016851), K.J. Brower (2K24 AA00304-10) and R.A. Zucker (R37 AA07065 and R01 AA12217).

The NIAAA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Contributors

The present study is a part of the Michigan Longitudinal Study. Dr. Zucker designed the Michigan Longitudinal Study. All authors contributed to the design of this study. Drs. Brower and Wong managed the literature searches. Drs. Brower and Wong wrote the first draft of the manuscript. Dr. Wong conducted the statistical analyses for the study. All authors contributed to and have approved the final manuscript.

Conflict of interest

All three authors have no conflict of interests.

Acknowledgements

We are grateful to all participating families for their willingness to engage in the study. We thank Ms. Susan Refior, Director of Field Operations in the Michigan Longitudinal Study, for her commitment and skill in maintaining the study’s viability over a long time. We also thank Dr. Leon Puttler for his comments on the paper.

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