sleep and suicide girish dhorajia, md pg y iii med-psych resident etsu
DESCRIPTION
Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU. Introduction. Suicide is a major preventable public health problem. In 2007, it was the tenth leading cause of death in the U.S., accounting for 34,598 deaths. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/1.jpg)
Sleep and Suicide
Girish Dhorajia, MDPG Y III Med-Psych Resident
ETSU
![Page 2: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/2.jpg)
INTRODUCTION
Suicide is a major preventable public health problem.
In 2007, it was the tenth leading cause of death in the U.S., accounting for 34,598 deaths.
The overall rate was 11.3 suicide deaths per 100,000 people. An estimated 11 attempted suicides occur per every suicide death.
![Page 3: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/3.jpg)
GLOBAL SUICIDE RATE
![Page 4: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/4.jpg)
GLOBAL SUICIDE RATE
![Page 5: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/5.jpg)
NATIONAL SUICIDE RATE MAP
![Page 6: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/6.jpg)
USA EPIDEMIOLOGY Children ages 10 to 14 — 0.9 per 100,000
Adolescents ages 15 to 19 — 6.9 per 100,000
Young adults ages 20 to 24 — 12.7 per 100,000
Ages 65 and older, 14.3 died by suicide of every 100,000 people in 2007. This figure is higher than the national average of 11.3 suicides per 100,000 people in the general population.
![Page 7: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/7.jpg)
USA EPIDEMIOLOGY
Non-Hispanic white men age 85 or older had an even higher rate, with 47 suicide deaths per 100,000.
Suicide was the seventh leading cause of death for males and the fifteenth leading cause of death for females in 2007.
Almost four times as many males as females die by suicide.
![Page 8: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/8.jpg)
USA EPIDEMIOLOGY
Firearms, suffocation, and poisoning(overdose) are by far the most common methods of suicide, overall. However, men and women differ in the method used, as shown below.
Suicide By Male Female
Firearms 56 30
Suffocation 24 21
Poisoning 13 40
![Page 9: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/9.jpg)
ETHNIC GROUPS
Highest rates: – American Indian and Alaska Natives — 14.3 per
100,000– Non-Hispanic Whites — 13.5 per 100,000
Lowest rates: – Non-Hispanic Blacks — 5.1 per 100,000– Hispanics — 6.0 per 100,000– Asian and Pacific Islanders — 6.2 per 100,000
![Page 10: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/10.jpg)
NUMBER OF SUICIDES 2007 USA
![Page 11: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/11.jpg)
SUICIDE RATES 2007 IN USA
![Page 12: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/12.jpg)
NO OF SUICIDE IN INDIA
![Page 13: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/13.jpg)
RATE OF SUICIDE IN INDIA
![Page 14: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/14.jpg)
1999-2007 SUICIDE RATE TRENDS USA
![Page 15: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/15.jpg)
SUICIDE RISK FACTORS
Non Modifiable Risk Factors: Advancing age Male gender Caucasian/American Indian ethnicity Previous suicide attempt History of trauma or abuse Family history of suicide Family history of mental disorder or
substance abuse Some major physical illnesses Local epidemics of suicide
![Page 16: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/16.jpg)
SUICIDE RISK FACTORS
Modifiable risk factors: Mental disorders, particularly mood
disorders, schizophrenia, anxiety disorders and certain personality disorders
Alcohol and other substance use disorders Hopelessness Impulsive and/or aggressive tendencies Easy access to lethal means Environmental Risk Factors: Job or financial
loss, Relational or social loss,
![Page 17: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/17.jpg)
WHAT ABOUT INSOMNIA ?
Insomnia is another symptom/condition which has been relatively under recognized as a marker for vulnerability for suicide.
Several Textbooks like APA psychiatry textbook and APA geriatric psychiatry textbooks has listed insomnia as one of the risk factor for suicide.
Some of the literature suggests sleep disturbance has prognostic significance in patients with affective disturbance.
![Page 18: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/18.jpg)
SLEEP AND SUICIDE Increasing evidence suggests that disturbances in
sleep are associated with an elevated risk for suicidal behaviors.
Several cross-sectional investigations indicate a unique association between nightmares and suicidal ideation.
Identification of insomnia as a risk factors for suicidal behaviors may enhance our ability to intervene and prevent suicide.
![Page 19: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/19.jpg)
SLEEP AND SUICIDE
90% people who commit suicide suffers from mental health issues.
Insomnia is a frequent symptom of mental health issues as well as last symptom to improve.
Prevalence of insomnia ranges from 6% to 30%.
Due to its chronicity, insomnia is associated with substantial impairments in an individual's quality of life.
![Page 20: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/20.jpg)
DSM IV TR CRITERIA FOR INSOMNIA A. The predominant complaint is difficulty initiating or
maintaining sleep, or nonrestorative sleep, for at least 1 month.
B. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-Related Sleep disorder, Circadian Rhythm Sleep Disorder, or a parasomnias.
D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, a Delirium).
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
![Page 21: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/21.jpg)
WHAT IS SLEEP ?
Sleep is a complex biological process that is influenced by many neuroendocrine parameters.
Sleep plays an important role in reparative and integrative process of the brain and body.
![Page 22: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/22.jpg)
SLEEP
The stages of sleep were first described in 1937 by Alfred Lee Loomis and his coworkers, who separated the different electroencephalography (EEG) features of sleep into five levels from wakefulness to deep sleep.
In 1953, REM sleep was discovered as distinct phase of sleep, and thus sleep was reclassified into four NREM stages and REM.
The staging criteria were standardized in 1968 by Allan Rechtschaffen and Anthony Kales in the "R&K sleep scoring manual.
![Page 23: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/23.jpg)
AMERICAN ACADEMY OF SLEEP MEDICINE (AASM)
In 2004, the AASM commissioned the AASM Visual Scoring Task Force to review the R&K scoring system.
The American Academy of Sleep Medicine (AASM) further divides NREM into three stages: N1, N2, and N3, the last of which is also called delta sleep or slow-wave sleep (SWS).
![Page 24: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/24.jpg)
NON-RAPID EYE MOVEMENT (NREM) SLEEP
Stage N1: Transition of the brain from alpha waves having
a frequency of 8–13 Hz (common in the awake state) to theta waves having a frequency of 4–7 Hz.
Sudden twitches and hypnic jerks are common during this phase.
Loss of some muscle tone.
Also referred as somnolence or drowsy sleep.
![Page 25: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/25.jpg)
NON-RAPID EYE MOVEMENT (NREM) SLEEP
Stage N2 EEG shows sleep spindles ranging from 11 to
16 Hz (most commonly 12–14 Hz) and K-complexes.
Muscular activity further decreases, and conscious awareness of the external environment disappears.
This stage occupies 45–55% of total sleep in adults.
![Page 26: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/26.jpg)
NON-RAPID EYE MOVEMENT (NREM) SLEEP
Stage N3 Also known as deep or slow-wave sleep) due to
the presence of a minimum of 20% delta waves ranging from 0.5–2Hz.
Parasomnias such as night terrors, nocturnal enuresis, sleepwalking and somniloquy occur.
Many illustrations and descriptions still show a stage N3 with 20–50% delta waves and a stage N4 with greater than 50% delta waves; these have been combined as stage N3.
![Page 27: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/27.jpg)
RAPID EYE MOVEMENT (REM) SLEEP
REM sleep (paradoxical sleep), accounts for 20–25% of total sleep time and four to six periods of REM sleep in most human adults.
Shorter at the beginning of the night and longer toward the end.
REM sleep normally occurs close to morning.
Most memorable dreaming occurs in this stage.
![Page 28: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/28.jpg)
HYPNOGRAM
![Page 29: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/29.jpg)
CLINICAL AND EPIDEMIOLOGICAL INVESTIGATIONS
Fawcett and colleagues(1990) conducted one of the first studies to prospectively examine sleep, depression, and suicide.
They recruited 954 patients with major affective disorders starting from 1978 and observed for 10yrs.
Results showed association of 6 clinical features including Global insomnia as a risk factor for committing suicide in next 1year.
![Page 30: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/30.jpg)
RETROSPECTIVE STUDY
Agargun et al (1997a): Recruited 113 patients with major depression. 17 item HAM-D, SADS(Schedule for affective disorder and schizophrenia) and SADS suicide subscale was used to rate depression, sleep and suicide.
Study demonstrated depressed subjects suffering from either hypersomnia or insomnia showed significantly higher scores on measures of suicidality.
![Page 31: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/31.jpg)
CLINICAL AND EPIDEMIOLOGICAL INVESTIGATIONS
Turvey et al (2002): 1. Community based prospective study recruited 14456 elderly participants and 21 committed suicide over the 10years observation period.
2. Study showed an association between
poor sleep quality and completed suicide in this prospective study population more than 65yrs old.
![Page 32: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/32.jpg)
POLYSOMNOGRAPHIC STUDIES
Sabo et al: Retrospectively studied the electroencephalography (EEG) of major depressives patients with and without a history of suicide attempts.
Suicide attempters had longer sleep latency, lower sleep efficiency, and fewer late-night delta wave counts than normal controls.
Non-attempters, compared to attempters, had less rapid eye movement (REM) time and activity in period 2, but more delta wave counts in non-REM period 4.
![Page 33: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/33.jpg)
PROBLEMS WITH ABOVE STUDIES
Although sleep disturbances are linked to suicidality, this relationship may largely be explained by higher depression ratings.
In all of these studies, depression was not accounted for when examining the association between sleep and completed suicide.
Only a few studies have examined the connection between suicide and sleep complaints beyond that explained by depression.
![Page 34: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/34.jpg)
POLYSOMNOGRAPHIC STUDIES
Keshavan et al (1994) examined REM sleep in psychotic patients with and without a history of suicide attempts or ideation.
Patients with a history of suicidal behavior showed more REM activity, and REM sleep parameters were not correlated with depression scores.
![Page 35: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/35.jpg)
RECENT STUDY
Study done at Army Medical center was published in J. of Affective disorder.
Study recruited 311 individuals with different psychiatric diagnosis.
Insomnia symptoms were assessed by Beck Depression Inventory items 16 & 17.
![Page 36: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/36.jpg)
CONT,,,,,,,
Suicidal ideations were assessed through Suicide Probability Scale and Modified Scale for Suicidal ideation.
This study suggested insomnia is a unique predictor assessed cross sectionally for suicidal ideation in comparison to other risk factors.
![Page 37: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/37.jpg)
Do we know enough about this association between Sleep and Suicide?
What can be the possible explanation of association?
QUESTIONS
![Page 38: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/38.jpg)
ROLE OF SEROTONIN
Serotonin has also been documented to play an important role in onset and maintenance of slow wave sleep.
Serotonergic function has been found to be low in patients who attempted and/or completed suicide, particularly those who used violent methods.
Levels of 5-Hydroxyindoleacetic acid(5-HIAA) is low in patients with insomnia as well as in patients who commit/attempt suicides.
5HT2 receptor antagonists helps to improve slow wave sleep.
![Page 39: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/39.jpg)
POSSIBLE EXPLANATION
Serotonergic dysregulation play a key role in underlying mechanisms of the association with suicidal tendency and sleep disturbance.
![Page 40: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/40.jpg)
ALSO…..
Other possible reason by which it can be explained is that poor sleep is a stressor that may independently increase the risk of suicide by
Impairing judgment Impulse control Fatigue Hopelessness Frustration
![Page 41: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/41.jpg)
WHAT ABOUT MODIFYING THIS RISK FACTOR?
Needs assessment of insomnia
Need to find appropriate strategies to improve sleep.
Non-pharmacological Sleep Hygiene. Stimulus control therapy.
![Page 42: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/42.jpg)
CONT,,,,,,,
Pharmacological : Benzodiazepines: Decrease sleep latency,
increases total sleep time and decreases slow wave sleep.
TCA: Reduce REM sleep percentage and increase REM sleep latency. Inconsistent activity on NREM Stage 3/4. TCA do not worsen sleep apnea and may have a small beneficial effect.
Zolpidem: Very mild effect on REM sleep and does not affect stage 3/4 NREM sleep. Tend to perverse the sleep architecture.
![Page 43: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/43.jpg)
CONT,,,,,
Trazodone: Little effect on REM sleep & increase in NREM Stage 3/4. Rebound insomnia can occur.
Antihistaminics: Improvement in sleep latency, decrease nocturnal awakenings and sleep quality.
Mirtazepine: Decreases sleep latency and awakenings. Some evidence suggest increases Stage 3/4 NREM sleep.
![Page 44: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/44.jpg)
IN SUMMARY,,,,,,,,,
Sparse research in this area shows there is an association between insomnia and suicide.
But we definitely need more research in this area.
Is it the time we need to start screening patients for insomnia as a part of suicide risk assessment?
![Page 45: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/45.jpg)
IN SUMMARY,,,,,,,,,
Would identifying insomnia as risk factor for suicide improve our ability to intervene and prevent suicide significantly in comparison to other risk factors?
We need to find better drugs to treat insomnia (particularly sleep maintenance insomnia) without having potential of abuse, dependence or lethal effects on overdose.
![Page 46: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/46.jpg)
EVIDENCED BASED SUICIDE MODIFIERS
CBT reduced the rate of repeated suicide attempts by 50 percent during a year of follow-up.
Clozapine is approved by the Food and Drug Administration for suicide prevention in people with schizophrenia.
Dialectical behavior therapy reduced suicide attempts by half in people with borderline personality disorder.
Lithium and ECT have strong evidence for a specific anti-suicide effect in mood disorders.
![Page 47: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/47.jpg)
WHAT THE FUTURE HOLDS ?
5 HT₂ₐ antagonist helps maintaining slow wave sleep and seems promising future treatment for insomnia(Sleep maintenance insomnia).
![Page 48: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/48.jpg)
![Page 49: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/49.jpg)
![Page 50: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/50.jpg)
REFERENCE
1. Fawcett J;Scheftner WA;Fogg L;Clark DC;Young MA;Hedeker D;Gi, Time-related predictors of suicide in major affective disorder, Am J Psychiatry 1990 Sep;147(9):1189-94
2. Ribeiro J;Pease J;Gutierrez P;Silva C;Bernert R;Rudd M;Joine, Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. J Affect Disord 2012 Feb;136(3):743-50.
3. Agargun M, Kara H, Solmaz M. Subjective Sleep Quality and Suicidality in Patients with Major Depression. J Psychiat Res 1997;31:377–381.
4. Agargun MY, Kara H, Solmaz M. Sleep disturbances and suicidal behavior in patients with major depression. J Clin Psychiatry 1997;58:249–251.
5. Agargun M, Cilli A, Kara H, et al. Repetitive and Frightening Dreams and Suicidal Behavior in Patients with Major Depression. Comprehensive Psychiatry 1998;39:198–202.
![Page 51: Sleep and Suicide Girish Dhorajia, MD PG Y III Med-Psych Resident ETSU](https://reader036.vdocument.in/reader036/viewer/2022062518/568148a4550346895db5b7b9/html5/thumbnails/51.jpg)
REFERENCE
6. Ann Clin Psychiatry, Sleep and suicide in psychiatric patients. 2001 Jun;13(2):93-101.
7. Sabo E, Reynolds CF 3rd, Kupfer DJ, Berman SR, Sleep, depression, and suicide. Psychiatry Res.1991 Mar;36(3):265-77.
8. Keshavan MS, Reynolds CF, Montrose D, Miewald J, Downs C, Sabo EM. Sleep and suicidality in psychotic patients.
9. Tanskanen A, Tuomilehto J, Vinamaki H, et al. Nightmares as Predictors of Suicide. Sleep 2001;24:844–847.
10. Turvey CL, Conwell Y, Jones MP, et al. Risk factors for late-life suicide: a prospective, community based study. Am J Geriatr Psychiatry 2002;10:398–406.