Patient concerns about insomnia warrant attention. Although not always a main complaint, data suggest that prevalence of this condition is rising, and as many as half of all patients seen by family practitioners struggle with impaired sleep.

According to the DSM-5, insomnia disorder involves poor/inadequate sleep for 3 or more months, along with worsened daytime functioning. Insomnia can exert debilitating effects on health, quality of life, work, and driving.

Recent research has gone so far as establishing causality between insomnia and suicidal behavior. The gravity of insomnia among patients should be enough to give any physician pause. Fortunately, there are ways to curb its impact.

 

Independent risk

Results of a population-based study published in BMC Psychiatry established insomnia as an independent risk factor for suicide.

Lin H-T, Lai C-H, Perng H-J, et al. Insomnia as an independent predictor of suicide attempts: a nationwide populationbased retrospective cohort study. BMC Psychiatry. 2018;18(1):117.

 

In insomnia patients aged between 25 and 44 years, the risk of suicide was 5.546-fold higher (adjusted HR = 5. 54; P < 0.001) compared with controls. This risk was even higher (18.322-fold) in insomnia patients with mental illness versus controls.

Researchers found that in addition to insomnia and mental illness, low income and drug dependency were additional risk factors for suicide, with these variables synergizing.

Clinicians should pay attention to the mental status and income level of insomnia patients and implement early suicide prevention intervention.

“If members of the general public have friends who suffer from insomnia, they should pay attention to the mental and financial status of their friends in order to reduce the probability of suicide,” the authors added.

 

Causality

In a two-sample Mendelian randomization study, Harvard researchers found that not only is the relationship between insomnia and suicide independently correlated—it could also be causal.

Nassan M, Daghlas I, Winkelman JW, et al. Genetic evidence for a potential causal relationship between insomnia symptoms and suicidal behavior: a Mendelian randomization study. Neuropsychopharmacology. 2022; Online ahead of print.

 

However, restless leg syndrome, which often accompanies insomnia, is not linked to any of these psychiatric outcomes. In other words, restless leg syndrome is not to blame for the suicidal effects of insomnia.

As for underlying mechanisms, the authors offered the “stress-accumulation” hypothesis, which suggests that insomnia is linked to insufficient dissolution of emotional distress secondary to REM sleep dysfunction and fragmentation.

This pathologic process could result in emotional distress accumulation. Furthermore, insomnia could also impair emotional regulation at the level of the frontal cortex, thus leading to disinhibited behavior.

Collectively, insomnia-induced stress accumulation and behavioral disinhibition might be part of how insomnia causes suicidal behavior.

The authors hypothesized that the hyperarousal state in insomnia could be a biomarker for suicide, with irritability, hypervigilance, and agitation all serving as intermediaries between insomnia and suicidal behavior.

 

Clinician role

When confronted with an insomnia diagnosis, clinicians may initially prescribe medications to treat it. Medications do play a role in treatment, according to a study published in the American Journal of Psychiatry.

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.

 

In the study, 103 participants with major depressive disorder, insomnia, and suicidal ideation were administered either zolpidem-CR or placebo.

Researchers found that combining zolpidem-CR with an SSRI outperformed placebo in decreasing insomnia symptoms in suicidal patients with depression.

They also found that cessation of suicidal ideation varied with the insomnia treatment. Adding zolpidem-CR to treatment regimens resulted in a greater decrease in suicidality versus placebo.

Of note, SSRIs on their own were linked to some improvement in insomnia and suicidality. Therefore, hypnotics may not be necessary if SSRIs are initiated in the setting of managing major depression.

The authors suggested “with proper safety procedures, it is possible to provide short-term relief of insomnia and more rapid reduction of suicidal ideation by time-limited prescribing of small quantities of hypnotics, without incurring major risk of emergent suicidal ideation, especially in those suicidal outpatients with major depression with the most severe insomnia.”

In a review published in BMC Primary Care, the authors noted that while more than 80% of patients who were taking a sleep medication preferred non-pharmacologic treatment, many of them weren’t presented with alternatives.

Ogeil RP, Ogeil RP, Chakraborty SP, et al. Clinician and patient barriers to the recognition of insomnia in family practice: a narrative summary of reported literature analysed using the theoretical domains framework. BMC Primary Care. 2020;21(1):1.

 

Cognitive behavioral therapy (CBT) options included a simplified sleep restriction intervention or a shortened five-session CBT trial.

The authors recommended that physicians heighten their awareness of insomnia issues with patients, which can mean chart reminders, as well as more education and training on the topic. Furthermore, patients can be provided with specific brochures on insomnia.