April 12, 2021

Insomnia, Sleep Medicines, and Suicide – it’s complicated!

To further our understanding of the role of sleep disturbance in suicidal behaviors, below we present a sleep researcher’s explanation of a recent study addressing insomnia, sleep medications, and suicide. The researcher, Andrew Tubbs, and his collaborators from the University of Arizona have just published data that indicate the particular type of sleep medicine may not be as big of a factor in suicide risk as the underlying sleep disturbance itself.  In this From the Scientist piece below Andrew summarizes his findings for us.  Moreover, Andrew and his colleagues were kind enough to provide JKBF with additional insight into the landscape of insomnia/suicide research and open questions at this time.

We learned that while there is an established correlation between suicide and insomnia, we don’t actually know the cause of this association. Possibilities might include that suicidal ideation and distress promote insomnia, or that individuals with insomnia develop suicidal ideation because of a lack of sleep, or that the usefulness of medications for insomnia is insufficient or variable across individuals or over time. From a research standpoint, insomnia itself has not been shown to increase the risk of suicide. Rather, the number of suicidal thoughts and behaviors tends to be higher in individuals with insomnia, which means insomnia is most accurately described as a suicide risk marker, not a suicide risk factor.

Research has also shown that sleep medications might offer a very valuable approach to treating short-term sleep difficulties arising from acute emotional trauma, and yet offer only marginal sleep induction/maintenance benefits after several weeks of use. Medicine is more an art than a science, and how we use sleep medicines matters. Furthermore, as this recent advice from the British Medical Journal outlines, there is support for a role for Cognitive Behavioral Therapy as a primary (first line) treatment modality due to effectiveness and safety.

A primary hurdle for establishing insomnia as a cause would be a longitudinal study showing that insomnia precedes suicidal thoughts or behaviors. While the field has some long-term data supporting this using sleep as a predictor of suicidal ideation or attempts a year or more later, prospective exploration of whether “incident insomnia” (e.g. acute sleeplessness as a result of a disruptive event) leads to suicidal thinking/behavior weeks or days later still needs to be done.

More convincing evidence would be a study that explored whether treatment of insomnia reduces the incidence or likelihood of suicidal ideation/attempts. To date, there are only two randomized clinical trials of insomnia treatment to reduce suicidality: one showed reduced ideation in those with severe insomnia when sleep medication was paired with SSRIs, and a pilot trial of brief behavioral therapy showed effect in primary care patients. Clinical trials like this are hard to conduct, expensive, and require large samples and long-term follow up.

In sum, more studies need to be done to determine causality as well as the potential for treatment of sleep as an intervention for suicidal behaviors and JKBF supports a call for this line of research. As Franklin et al have established, 50 years of research and the currently accepted risk factors are still insufficient in predicting suicidal behaviors —  having deeper knowledge of a role for chronic or acute insomnia or sleep disturbance might provide meaningful improvements for those assessing, treating, and experiencing suicidal thoughts and behaviors.

From the Scientist:

Summary of “Prescription medications for insomnia are associated with suicidal thoughts and behaviors in two nationally representative samples”

By Andrew Tubbs, BSC

Research has shown that individuals with insomnia are at a higher risk of suicidal thinking, suicidal actions, and dying by suicide. Our study in the Journal of Clinical Sleep Medicine is attempting to address this correlation, and specifically to help tease apart the relationship between insomnia medication and suicidal ideation.

In the United States, an estimated 3 percent of adults receive a prescription medication for insomnia, which means this is a fairly common problem. However, the medications used for insomnia are associated with suicidal thoughts and behaviors; in one study, individuals using a Z-drug (Ambien, Lunesta, or Sonata) were 2- to 3-fold more likely to report suicidal thinking than those not using a Z-drug. The trouble is that these studies cannot establish causality – we cannot prove that Z-drugs cause suicidal thinking. In fact, one way to read the finding above is that individuals whose insomnia is so bad that they went to the doctor to get a medication to sleep are more likely to think about suicide. Thus, the issue may not be the medication, but rather the underlying severity of the insomnia. Interestingly, a study of healthcare data from South Korea found that among individuals with depression, the risk of a suicide attempt peaked just prior to starting a prescription for insomnia, and that the risk decreased thereafter. This seems to support the idea that the severity of insomnia, not the medication itself, is responsible for suicidal thinking and attempts.

If this is the case, and medication is just a proxy for insomnia severity, then this association should be consistent across medications used for insomnia, even if they work in different ways. Z-drugs, benzodiazepines, and the antidepressant trazodone are all used for insomnia, but they do not all work in the exact same way. Thus, our study compared how Z-drugs, benzodiazepines, and trazodone were related to suicidal thoughts and behaviors using 2 nationally representative datasets. While all 3 medication groups were linked to more suicidal thinking and suicide attempts, the strength of these associations did not differ across medications; they all had roughly the same connection with suicidality. We believe these findings support our hypothesis that underlying insomnia, not use of a prescription sedative, increases risk for suicidality.