Clinical ReviewContribution of sleep deprivation to suicidal behaviour: A systematic review
Introduction
Sleep disturbances are highly prevalent both in psychiatric and non–psychiatric populations. Insomnia alone affects between six and 18% of the general population [1]. Reduced quality or quantity of sleep, and abnormal sleep phenomena have a significant impact on functioning. High rates of comorbidity, poor quality of life and increased mortality have been associated with sleep disturbances [2], [3]. However, Sleep Medicine has been neglected by research in comparison to other medical disciplines [4], even though sleep problems have been linked with an increased risk of suicidal behaviour [5].
Up to a million people die from suicide every year worldwide, making it a leading cause of unnatural death [6]. Unlike other (preventable) public health issues, suicide prevention has been largely unsuccessful [7], which may have been due to suicidal behaviour being a complex multifactorial phenomenon that also remains poorly understood. .
One of the long–standing goals of suicide research has been to identify valid biomarkers of those at risk in order to focus prevention strategies on these high–risk individuals. This approach has yielded poor results so far [8].
Nevertheless, sleep, which can be easily assessed, may become a promising biomarker for suicidal behaviour, and has attracted research interest over the last few decades given its potential role in prevention as a therapeutics target [9], ∗[10]. The relationship between sleep disturbances and suicidal behaviour has been supported by a growing body of evidence. However, there are issues around the conceptualization of both phenomena, since they cannot be easily separated from other mental disorders, which has hampered research in this area [11], [12].
Several studies over the past few decades have examined the association between sleep disturbances and suicide risk, some of which have focused on the epidemiological basis of this association. Thus, in 2012, Pigeon et al. carried out an extensive meta–analysis on this topic [5], while two years later Malik et al. restricted the search to psychiatric populations [13]. However, only a few risk factors reviews focused on the mechanisms underlying this association, investigating certain explanatory factors, such as staying awake at night [14] or psychological factors [15].
The present review aims to explore the epidemiological evidence of the association between sleep disturbances and suicidality and to focus on the explanatory putative mechanisms underlying this association, including neurocognition, mental disorders, serotonin dysregulation, circadian rhythms and psychological factors. In particular, we hypothesised that the potential neurocognitive alterations caused by disordered sleep may lead to impulsive decisions and increase the risk of a suicide attempt. Finally, we will discuss the implications of these findings for suicidal behaviour prevention.
Section snippets
Methods
The Preferred Reporting Items for Systematic reviews and Meta–Analyses (PRISMA) guidelines were complied with as applicable [16].
Results
The initial search yielded 2586 results. Following initial screening of abstracts, full–text revision and selection process as appropriate, 65 articles were finally included in the review (see Fig. 1).
Discussion
We conducted a systematic review aimed to examine the relationship between sleep disturbances and suicidal behaviour with a focus on the mechanisms and contributory factors underlying such as association, from which several findings emerged, which may have relevant implications on clinical practice and future research, as detailed below.
Conflicts of interest
The authors declare they have no potential conflicts of interest.
Acknowledgements
This study has received financial support by: Carlos III (ISCIII PI16/01852), Delegación del Gobierno para el Plan Nacional de Drogas (20151073), American Foundation for Suicide Prevention (LSRG-1-005-16), Comunidad de Madrid (Actividades I + D en Biomedicina B2017/BMD-3740, AGES-CM 2CM) and Structural Funds of the European Union.
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The most important references are denoted by an asterisk.