Comorbid sleep disorders and suicide risk among children and adolescents with bipolar disorder
Introduction
Suicide is a leading cause of death among children and adolescents (Centers for Disease Control and Prevention [CDC], 2017). Robust evidence suggests that children and adolescents with bipolar disorder are at markedly increased risk for suicide (Brent et al., 1993, Brent and Mann, 2005, Geller et al., 2008, Geller et al., 2004, Goldstein et al., 2005, Hauser et al., 2013, Inder et al., 2016, Kochman et al., 2005). A recent systematic review of 14 studies examining suicidal thoughts and behaviors among youth with bipolar disorder found weighted mean averages of current suicide ideation and attempts in this population to be 50.4% and 25.5%, respectively (Hauser et al., 2013). These prevalence rates starkly contrast with past-year rates of suicide ideation (17.7%) and attempts (8.6%) found among the general youth population (Kann et al., 2016). Given these high rates of suicidal thoughts and behaviors among youth with bipolar disorder, as well as the devastating consequences of suicide for families (Cerel et al., 2008), increased efforts are needed to identify and understand the associated features of bipolar disorder that may elevate suicide risk.
One associated feature of bipolar disorder that may increase suicide risk is sleep disturbances (Bernert et al., 2015, Goldstein et al., 2008, Nadorff et al., 2013, Pigeon et al., 2012, Sjöström et al., 2007). Prominent examples of sleep disturbances include insomnia (i.e., difficulties falling and/or staying asleep, waking up too early) and nightmares (i.e., frightening dreams). Sleep disturbances are a core feature of bipolar disorder, present in both manic and depressive phases (Harvey et al., 2009). Parent-reported restless sleep and nightmares have also been found to be significantly more prevalent among youth with bipolar disorder than matched controls (Mehl et al., 2006). Though no study of which we are aware has examined sleep disturbances and suicide risk among individuals with bipolar disorder, among the general population, sleep disturbances appear to serve as a potent suicide risk factor (Bernert et al., 2015, Bernert and Joiner, 2007).
For example, Goldstein et al. (2008) examined the psychological autopsies of 140 adolescents who died by suicide and found higher rates of insomnia in the week prior to their death compared to community controls, even after controlling for the possible effects of a current affective disorder diagnosis (e.g., bipolar disorder). Regarding nightmares and suicide risk, few studies have examined samples of children and adolescents. A study of young adults found that nightmares were associated with suicidal ideation even after controlling for the effects of insomnia as well as symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression (Nadorff et al., 2011). The potent effects of nightmares on suicide risk have similarly been observed among adult psychiatric inpatient samples (Sjöström et al., 2007), and of particular concern, nightmares have also been shown to predict death by suicide (Tanskanen et al., 2001).
These findings converge with a meta-analysis of 39 studies, which found that insomnia (RR = 2.84, 95% CI = 2.44–3.31), nightmares (RR = 2.61, 95% CI = 2.03–3.36), and other sleep disturbances (RR = 2.72, 95% CI = 2.00–3.70) were significantly associated with increased risk for any suicide-related outcome (i.e., suicide ideation, attempts, or fatalities; Pigeon et al., 2012). Importantly, sleep disturbances have been shown to predict suicide risk independent of one another as well as of other risk factors, including depression and hopelessness (Bernert and Joiner, 2007, Bernert and Nadorff, 2015). Thus, insomnia and nightmares provide incremental information regarding suicide risk (Pigeon et al., 2012, Ribeiro et al., 2012). Together, findings suggest that both insomnia and nightmares are implicated in suicide risk, including among youth (Liu, 2004, Liu and Buysse, 2006).
Given that sleep disturbances are common among youth with bipolar disorder and are also independently implicated in suicide risk, comorbid sleep disorders may augment risk for suicide. Thus, utilizing a large sample of children and adolescents diagnosed with bipolar I disorder, manic or mixed phase, the purpose of this study is to examine the relationship between current and lifetime DSM-IV sleep disorders and current suicide risk. The specific comorbid DSM-IV sleep disorders examined were nightmare disorder, sleep terror disorder, and sleepwalking disorder. Due to the nature of the data collected for the larger study from which these data were obtained, we were unable to investigate other sleep disorders, such as insomnia, which also demonstrate strong associations with suicidal thoughts and behaviors (Bernert et al., 2015, Chu et al., 2016, Pigeon et al., 2012). Since sleep disturbances, such as nightmares, are common reactions to trauma (American Psychiatric Association, 1994) and also commonly co-occur with anxiety (Alfano et al., 2007), we additionally examined the relationship between sleep disturbances and suicide risk controlling for the possible confounding effects of trauma exposure and a comorbid generalized anxiety disorder (GAD) diagnosis. In exploratory analyses, we also examined models controlling for depression symptoms (see Rogers et al., 2016, for a discussion of issues inherent in controlling for depression symptoms when examining suicidality as the outcome variable).
Section snippets
Participants and procedures
Participants were individuals aged 6–15 years (mean ± SD = 10.2 ± 2.7 years) who participated in the baseline assessment for the Treatment of Early Age Mania (TEAM) study (53.8% female; 73.6% white, 17.9% black, and 8.5% other). The TEAM study was a controlled, randomized, 8-week parallel comparison of the efficacy and tolerability of three antimanic medications (i.e., risperidone, lithium carbonate, and divalproex sodium) as an initial treatment for bipolar I disorder, mixed or manic phase (
Results
Of the 379 children and adolescents with bipolar I disorder, 216 (57.0%) screened positive for elevated suicide risk. Regarding current sleep disorders, 96 (25.3%) met DSM-IV diagnostic criteria for nightmare disorder, 17 (4.5%) for sleep terror disorder, and 27 (7.1%) for sleepwalking disorder. Regarding lifetime sleep disorders, 136 (35.9%) met DSM-IV diagnostic criteria for nightmare disorder, 41 (10.8%) for sleep terror disorder, and 49 (12.9%) for sleepwalking disorder. Overall, 53 (14.0%)
Discussion
The present study found that among children and adolescents with bipolar I disorder, mixed or manic phase, the presence of a current or lifetime comorbid sleep disorder—namely, nightmare disorder—was associated with increased suicide risk. These effects were significant even after controlling for trauma exposure, a GAD diagnosis, and depression symptoms, suggesting that a nightmare disorder is uniquely associated with elevated suicide risk. In contrast, neither the presence of a co-occurring
Conclusions
Children and adolescents with bipolar I disorder, mixed or manic phase, are at increased risk for suicide. This risk may be augmented in the presence of a comorbid sleep disorder—namely, nightmare disorder. Clinicians assessing and treating suicide risk among youth with bipolar disorder should consider the presence of a co-occurring nightmare disorder.
Funding
The Treatment of Early Age Mania (TEAM) study was supported by National Institute of Mental Health grants U01 MH064846, U01 MH064850, U01 MH064851, U01 MH064868, U01 MH064869, U01 MH064887, U01 MH064911, and R01 MH051481. The opinions and assertions contained in this report are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of Health and Human Services, NIH, or NIMH.
Mr. Stanley and Dr. Joiner were supported in part by the
Disclosures/Conflicts of Interest
The following authors report no disclosures relevant to this article: Ian H. Stanley, M.S., Melanie A. Hom, M.S., and Thomas E. Joiner, Ph.D. Joan L. Luby, M.D., has received funding from the National Institute of Mental Health (NIMH) & Guilford Press. Paramjit T. Joshi, M.D., has no financial disclosures. She reports leadership roles with the American Board of Psychiatry and Neurology (ABPN) & Children's National Medical Center. Karen D. Wagner, M.D., Ph.D., has received honorarium from UBM
Acknowledgements:
The authors gratefully acknowledge the pivotal contributions of Barbara Geller, M.D., of Washington University, in designing and overseeing this project from its inception through to its publication.
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2020, Current Opinion in PsychologyCitation Excerpt :Among outpatients with mood disorders, suicidality and/or non-suicidal self-injury (n = 223 adolescents age 11–19), McGlinchey et al. [23] found past month late insomnia was associated with suicidal ideation; middle insomnia and circadian reversal were associated with lifetime suicide attempt; and severity of sleep complaints was associated with lifetime non-suicidal self-injury (after controlling for demographics variables). In a secondary analysis of data from the Treatment of Early Age Mania (TEAM) study of 379 youth age 6–15 years with bipolar disorder, Stanley et al. [24] found those who met criteria for current nightmare disorder were twice as likely to endorse lifetime suicide risk after controlling for depression, anxiety and trauma history. Studies among hospitalized adolescents offer the opportunity to gather data during a period of acute suicide risk.