If you are having thoughts of suicide, you are not alone. If you or someone you know needs help, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text 741-741 for the Crisis Text Line. If you are in danger of acting on suicidal thoughts, call 911.
Many of us having been talking a lot about suicide lately. The recent deaths of designer Kate Spade and chef/television host Anthony Bourdain brought the topic to the top of the news. That same week, the Centers for Disease Control released a report with some startling, alarming news: between 1999-2016, suicide rates in the United States rose by nearly 30 percent.
The CDC found an almost shocking degree of consistency in the increase of suicide around the country. Between 1999-2016, suicide rates rose in almost every state in the nation. (The only state where they didn’t rise, Nevada, itself has a consistently high rate of suicide.) They rose:
- Among both men and women
- Among all ethnic and racial groups
- In both rural and urban populations
- In all age groups, under age 75
According to the report, suicide is one of only three leading causes of death that are increasing. In 2016, suicide was the cause of death for 45,000 American adults and children over the age of 10.
With these deeply troubling numbers came a call for a comprehensive public-health approach to suicide prevention. That kind of attention is overdue. Suicide has long been a serious public health problem that’s been deeply overlooked, in funding for large-scale research and in attention from public-health efforts.
Sleep needs to be included in that public health approach. Problems with sleep—specifically, sleeping too little or too much– are among the warning signs of suicidal behavior.
Poor sleep is a major factor in depression and other mental health conditions that significantly escalate risk for suicide and suicidal thoughts. And there is a growing body of research indicating that disturbed sleep may raise risk for suicidal behavior, independent of depression or other mental health problems.
Let’s take a closer look at what we know about the connections between sleep and suicide.
Sleep, depression and suicide risk
You’ve heard me talk often about the impact of sleep on mental and emotional health, and of disordered sleep’s role as both a key symptom and a significant contributor to depression and anxiety. Sleeping poorly, and not getting enough high-quality sleep, can raise risks for depression and anxiety and make these conditions much more difficult to treat.
As many as 75 percent or more of people with depression also suffer symptoms of insomnia. Among younger adults with depression, an estimated 40 percent experience hypersomnia, a sleep disorder characterized by sleeping too much. Hypersomnia also occurs in older adults with depression, but it appears much more frequently in adults with depression under 30.
A great deal of the scientific research that explores the role of sleep as a factor in suicide has looked at sleep alongside depression. A strong body of research conducted over the past three decades shows that among people with depression, the presence of sleep problems increases both the likelihood and the intensity of suicidal thoughts and actions. These studies show:
- Poor sleep quality is linked to suicidal behavior in people with depression
- Both insomnia and hypersomnia significantly raise the risk for suicide in people with depression
- Nightmares are more common in people with depression who are also suicidal. As the frequency of nightmares increases in people with depression, the risk of suicide also increases
Depression isn’t the only mental health condition where sleep plays an important role, and where suicide is a heightened risk. Anxiety, substance use disorders, and other conditions such as PTSD and schizophrenia are all affected by sleep, and put people at greater risk for suicide. In people with mental health conditions, changes to sleep patterns, or increased complaints about sleep problems, must be taken seriously and addressed as part of treatment, and considered a signal of an elevated risk for suicide.
Sleep as an independent risk factor for suicide
Diagnosed mental health conditions are often a contributing factor to suicide. But not always. The new CDC study looked at the prevalence of mental health conditions among the suicide deaths it tracked, and found 54 percent of people who died from suicide did not have a known mental health condition. Some of those people likely had an undiagnosed mental health issue. But it’s important to know that suicide does not only occur among people with mental illness.
One of the challenges in understanding sleep’s relationship to suicidal behavior comes in separating depression from the equation. Is the influence of sleep over suicide a reflection of the close relationship between sleep problems and depression? Or is there a more specific and direct link between disrupted sleep and suicide risk? Over the past decade, several studies have tried to answer that question. Increasingly, there is evidence showing that disrupted sleep may have a direct influence over suicidal behavior and the risk of suicide, apart from its connection to depression.
Research shows that sleep disturbances—specifically insomnia and nightmares—increase risks for suicidal thoughts and actions, and that those risks are not attributable to depression. (That doesn’t mean depression doesn’t affect suicide risk. It does. But these studies show that even when scientists factor out the impact of depression on suicide, sleep problems on their own elevate the risk.)
Nightmares appear to have a particularly strong connection to suicidal behavior. Research has shown that nightmares are common among people who are contemplating suicide, and that there is a strong association between nightmares and greater risk of severe suicidal behavior—even after taking into account psychiatric conditions. The longer sleep problems like nightmares and insomnia go on, the greater the risk that suicidal behavior may develop, according to research.
One particularly noteworthy recent study looked at the relationship between sleep quality and suicide risk among older adults. (Suicide rates are highest among people over the age of 65.) The study specifically looked at sleep quality as an independent risk factor for suicide, controlling for depression in their analysis. Among a group of older adults, scientists found that poor sleep quality was linked to a higher risk of suicide over a 10-year follow-up period. Trouble falling asleep and experiencing un-refreshing sleep were also linked to higher suicide risk.
Insomnia and nightmares are two of the sleep problems most frequently linked to increased risk for suicidal behavior. But there’s emerging evidence that other sleep problems and sleep disorders, including obstructive sleep apnea, may also contribute to elevating suicide risk. There’s an urgent need for more research into the independent effects of sleep on suicide.
NOTE: Occasional nightmares are not uncommon, and many millions of people suffer from sleep disorders such as insomnia and sleep apnea, or struggle with periods of poor sleep quality. Not everyone who experiences these sleep problems is at high risk for suicide. Persistent nightmares, and chronic sleep troubles, especially in combination with depression, anxiety, and other mental health conditions, ought to be considered as one of several warning signs of potentially increased risk for suicidal thoughts or action. And all sleep troubles deserve attention.
How can we explain what increasingly looks like a direct effect of sleep on suicidal behavior? There are no clear, certain answers. We simply haven’t seen enough rigorous, large-scale and long-term research to know. But there are several likely ways sleep problems may make people more vulnerable to suicidal thoughts and actions, beyond the close relationship between disturbed sleep and depression.
Poor quality sleep and lack of sleep, especially when chronic, can have profoundly negative effects on our ability to process emotions, to make judgments and problem solve, and to think clearly. Sleep problems can also deeply affect how we perceive the world around us, and how we function and feel within relationships. Sleeping poorly can make us:
- More emotionally reactive
- More inclined toward negative emotions about ourselves and others
- More vulnerable to stress and its physical and mental effects
- In a near-constant state of arousal and hyper-vigilance, contributing to agitation, restlessness and fatigue
- Less able to execute good judgment, and employ necessary coping skills
- Less physically and mentally resilient
- Less trusting of and connected to the people around us
Looking at this list, it’s not hard to wonder at how sleep might join other factors in contributing to the hopelessness, depletion of energy, and emotional exhaustion that are often present in people who are the greatest risk for suicide.
What to watch for in yourself and others
We all need to be aware of the warning signs of suicide. Be alert to these changes in yourself and in others:
- Mood swings, including excessive sadness and anxiety, as well as anger, despondency, hopelessness and desire for revenge
- Talk of mental, emotional, or physical pain and anguish, a lack of purpose in life, or of being a burden to others
- Withdrawal from relationships with friends and family, and from social activities
- Experience of trauma, loss, and crisis, including deaths of loved ones, financial loss and stress, major life changes including job loss and divorce or separation from partners
- A lack of concern for one’s appearance
- Increased alcohol and drug use
- Risky behaviors including with alcohol and drugs, reckless driving, and sexual behavior
- Signs of preparation, including giving away possessions, tying up loose ends with friends and family, drawing up a will
- Sudden calmness, after a period of emotional upheaval or mood swings
Not all people who are suicidal will speak about it, or make threats. Any talk or threat of suicide should always be taken extremely seriously, and given immediate professional, emergency and medical attention.
Changes to sleep are another important warning sign for suicide. Not all sleep problems are indications of suicidal behavior. But all sleep problems should be taken seriously, as they can be indicators of mental and physical health problems, and can interfere with your ability to function well and cope with challenges. Along with the other warning signs above, pay attention to sleep issues, including:
- Changes to sleep patterns, including erratic and irregular sleep habits
- Sleeping too much (particularly among younger adults and teens)
- Sleeping too little
- Restless, fragmented sleep that’s unrefreshing
- Increased complaints about sleep
- Anxiety or hopelessness about an ability to sleep
Suicide is not typically the result of a single issue, but rather arises from a complex combination of factors in any individual’s life. Sleep reaches out to affect every aspect of life, health, and our ability to function and cope with challenge and adversity. As we move forward with greater commitment to address the underlying factors that contribute to suicide, and work to treat them, I hope sleep will be part of the conversation.
Michael J. Breus, PhD, DABSM
The Sleep Doctor™