Novel Suicide-Prevention Treatment Targets Poor Sleep
More than 60 epidemiologic studies show that poor sleep raises the risk of suicide, but sleep-focused treatment may lower that risk.
Improving disturbed sleep may curb suicide risk in people with depression and other psychiatric disorders, said speakers at a symposium at the annual meeting of the American Academy of Sleep Medicine and Sleep Research Society in Minneapolis.
In June, San Francisco’s Golden Gate Bridge board of directors approved a $76 million, 20-foot-wide steel net to deter potential jumpers. Rebecca Bernert, Ph.D., who directs the Suicide Prevention Research Laboratory at Stanford University School of Medicine, is a member of the board of the Bridge Rail Foundation, which has long advocated for the suicide barrier.
Norbert von der Groeben/Stanford School of Medicine
Trouble falling asleep and staying asleep and poor-quality sleep predict increased risk for suicidal thoughts and behaviors, said Rebecca Bernert, Ph.D., symposium chair and director of the Suicide Prevention Research Laboratory at Stanford University School of Medicine. Unlike many other suicide risk factors, sleep complaints are amenable to treatment, said Bernert, an instructor in psychiatry and behavioral sciences at Stanford.
At the symposium, Bernert and others described what she said are the first outpatient suicide-prevention trials to focus on sleep as a therapeutic target and to use suicide risk as a primary outcome measure.
Developing an infrastructure to support an outpatient suicide-prevention trial poses many challenges, Bernert said. Researchers must show institutional review boards they have devised procedures to assure informed consent, confidentiality, and patient safety; will provide 24-hour on-call clinical coverage; and can manage possible emergencies.
The sensitive nature of suicidal symptoms, and the stigma surrounding them, present obstacles to subject recruitment, Bernert said. Researchers need a large population sample to study behaviors that occur rarely, she noted, and typically screen far more people than they enroll. The transient nature of a suicidal crisis adds complexity to both treatment and assessment.
Bernert and her colleagues at Stanford developed a manualized behavioral insomnia trial for suicide prevention. For an open-label feasibility study now in progress, they use clinic-based referrals, community flyers, and print advertising to recruit subjects with depressive symptoms, including suicidal ideation. Treatment consists of five weekly individual sessions that focus on insomnia symptoms and poor sleep quality.
Preliminary findings look promising, Bernert said. The researchers have found significant posttreatment reduction in suicidal ideation and insomnia, with treatment gains maintained at one-month and three-month follow-up. Subject recruitment will continue through 2014.
Study Targets Veterans With Depression
Brief behavioral sleep interventions may help depressed veterans with insomnia and suicidal ideation, according to another symposium speaker, Wilfred Pigeon, Ph.D., research director of the Center of Excellence for Suicide Prevention at the Canandaigua Veterans Affairs (VA) Medical Center in New York.
His team provided either cognitive-behavioral treatment for insomnia (CBT-I) or basic sleep education to veterans in a primary care setting. Therapists saw veterans in the CBT-I group individually for two 30- to 40-minute sessions and spoke with them by phone in two 15- to 20-minute sessions. Veterans in the control group received one in-person and one phone session focusing on healthy sleep habits.
While both approaches proved helpful, the number of participants was too small to show significant differences, Pigeon said. The study aimed mainly to assess feasibility of brief sleep interventions in a VA primary care setting. Upcoming studies will focus specifically on reduction of suicidal risk.
Pharmacotherapy Used in Other Studies
A four-year, randomized, controlled clinical trial using the hypnotic medication zolpidem to treat suicidal, depressed outpatients with insomnia is under way, W. Vaughn McCall, M.D., M.S., Case Distinguished University Chair of Psychiatry and Health Behavior at the Medical College of Georgia at Georgia Regents University, reported at the symposium.
McCall, who is the study’s principal investigator, and colleagues at the medical schools of Duke University, the University of Wisconsin, and Wake Forest University debated the level of severity of suicidal ideation to include. People who are overwhelmingly suicidal need to be in a hospital, McCall told Psychiatric News. The researchers did not, however, want to exclude people who potentially could benefit from the planned treatment.
They eventually included in their recruitment criteria scores on the Columbia Suicide Severity Rating Scale, which incorporates clinical judgment. They accept people with varying degrees of suicidal severity, but exclude those with imminent suicide intent. While defining inclusion/exclusion criteria is not a trivial task, McCall stressed, studies like this can be done without putting participants at undue risk.
By June 1, the research team had screened more than 525 people by phone, selecting about 1 in 15 for randomization into the study.
The researchers had planned to use a 12.5 mg dose of zolpidem as the hypnotic. In January 2013, just as the study was about to begin, however, the Food and Drug Administration (FDA) reduced the recommended starting dose of zolpidem to 6.25 mg, while allowing an increase to 12.5 mg if the lower dose is ineffective. The FDA’s action improved the study, McCall said, enabling the researchers to assess the impact of flexible dosing.
All study participants receive an open-label serotonin reuptake inhibitor and also take zolpidem-CR 6.25 mg or 12.5 mg or a placebo in tablet form at night 15 minutes before going to bed for eight weeks, wearing a wrist activity monitor throughout the study. Among the initial 35 patients followed for eight weeks, McCall said, suicidal ideation fell, and no patients made a suicide attempt or had to leave the study to be hospitalized. The study is scheduled to run through 2016. ■
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Published online: 26 September 2014
Published in print: September 20, 2014 – October 3, 2014
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