Kenneth R. Conner

Meta-Analysis of Sleep Disturbance and Suicidal Thoughts and Behaviors

OBJECTIVE The potential association of various sleep disturbances to suicidal thoughts and behaviors is the subject of several reviews. The current meta-analysis was conducted to estimate the size of the association generally as well as between more specific relationships. DATA SOURCES Electronic databases for years 1966-2011 were searched to identify candidate studies using PubMed search terms suicide and sleep or sleep initiation/maintenance disorders or dreams or nightmares or sleep disorders/psychology or sleep disorders/epidemiology as well as Ovid search terms suicide and sleep or insomnia or nightmares. The search was supplemented by cross-referencing from identified articles and reviews. STUDY SELECTION Original studies reporting both sleep disturbance and suicide outcomes were identified with 39 of 98 studies (40%) comprising 147,753 subjects selected for inclusion. DATA EXTRACTION Data were extracted by multiple independent observers and verified by a study author. The meta-analysis was performed using random-effects models. The size of associations was calculated for all types of sleep disturbances and suicide outcomes combined and for more specific categories including nightmares, insomnia, and insomnia subtypes and suicidal ideation, suicide attempts, and suicide. Moderator effects were evaluated. RESULTS Overall, sleep disturbance was significantly associated with an increased relative risk for suicidal ideation, suicide attempt, and suicide ranging from 1.95 (95% CI, 1.41-2.69) to a relative risk of 2.95 (95% CI, 2.48-3.50) in unadjusted studies. Associations were smaller, but remained highly significant among adjusted studies. Depression did not moderate the association between sleep and suicide variables. CONCLUSIONS This meta-analysis supports an association between sleep disturbance and suicidal thoughts and behaviors. Sleep disturbances in general, as well as insomnia and nightmares individually, appear to represent a risk factor for suicidal thoughts and behavior. This proposition is further bolstered by the result that depression did not show risk moderation.

Suicide at 50 years of age and older: perceived physical illness, family discord and financial strain

BACKGROUND Mental disorders amplify suicide risk across the lifecourse, but most people with mental disorder do not take their own lives. Few controlled studies have examined the contribution of stressors to suicide risk. METHOD A case-control design was used to compare 86 suicides and 86 controls aged 50 years and older, matched on age, gender, race and county of residence. Structured interviews were conducted with proxy respondents for suicides and controls. RESULTS Perceived physical illness, family discord and employment change amplified suicide risk after controlling for sociodemographic covariates and mental disorders that developed > or = 1 year prior to death/interview. Only the effect of physical illness (OR 6.24, 95% CI 1.28-51.284) persisted after controlling for all active mental disorders. CONCLUSIONS Interventions to decrease the likelihood of financial stress and to help families manage discord and severe physical illness may effectively reduce suicides among middle-aged and older adults.

Poor social integration and suicide: fact or artifact? A case-control study

BACKGROUND Sociological studies have shown that poor social integration confers suicide risk. It is not known whether poor integration amplifies risk after adjusting statistically for the effects of mental disorders and employment status. METHOD A case-control design was used to compare 86 suicides and 86 living controls 50 years of age and older, matched on age, gender, race, and county of residence. Structured interviews were conducted with proxy respondents for suicides and controls. Social integration was defined in reference to two broad levels of analysis: family (e.g. sibship status, childrearing status) and social/ community (e.g. social interaction, religious participation, community involvement). RESULTS Bivariate analyses showed that suicides were less likely to be married, have children, or live with family. They were less likely to engage in religious practice or community activities and they had lower levels of social interaction. A trimmed logistic regression model showed that marital status, social interaction and religious involvement were all associated with suicide even after statistical adjusting for the effects of affective disorder and employment status. Adding substance abuse to the model eliminated the effects of religious involvement. CONCLUSIONS The association between family and social/community indicators of poor social integration and suicide is robust and largely independent of the presence of mental disorders. Findings could be used to enhance screening instruments and identify problem behaviors, such as low levels of social interaction, which could be targeted for intervention.

Meta-analysis of depression and substance use among individuals with alcohol use disorders.

The relationships of depression with alcohol and drug use and impairment were examined. Additional analyses were conducted to examine moderators of these associations. Empirical reports on adults with alcohol abuse or dependence published in English in peer-reviewed journals since 1986 that contained data on depression and substance use variable(s) were obtained using a systematic search. The search yielded 74 studies including 58 reports from clinical venues, 10 that were community based, and 6 with subjects from both settings. As hypothesized, the analyses showed that depression is associated with concurrent alcohol use and impairment and drug use and impairment. Effect sizes were small. Depression was also related to future alcohol use and impairment, an earlier age of onset of an alcohol use disorder, and higher treatment participation. Age moderated the association between depression and alcohol use and impairment such that the association was stronger in older samples.

Predisposing and Precipitating Factors for Suicide Among Alcoholics: Empirical Review and Conceptual Integration

Alcohol dependence is a potent risk factor for suicide. Accordingly, alcoholics should be targeted in suicide prevention efforts. This article reviews the literature on suicide among alcoholics and provides a model that may inform research, clinical work, and prevention efforts. In this model, we propose that aggression/impulsivity, severe alcoholism, negative affect, and hopelessness are key predisposing factors for suicide among alcoholics. We propose that major depressive episodes and stressful life events, particularly interpersonal difficulties, are key precipitating factors. We also integrate these constructs in a model that proposes that many acts of suicide among alcoholics may be viewed as acts of reactive aggression executed in the midst of distress over a lost or threatened relationship. Empirical evidence for the model is discussed along with its limitations. The next generation of research on alcoholism and suicide should include a focus on the interpersonal anlage of suicide in this population.

Reactive aggression and suicide: Theory and evidence

Abstract Aggression confers risk for suicide. However, “aggression” is a heterogeneous construct, and it is likely that subgroups of individuals with particular types of aggression are at higher risk. We postulate that a subtype of aggression, reactive aggression, underlies the link with suicide with implications for suicide risk-recognition and prevention. The theoretical rationale and empirical evidence for the role of reactive aggression in suicide is presented from the perspectives of neurobiology, psychopathology, and overt violent behavior. It is hypothesized that partner–relationship disruptions amplify risk for suicide in the near term among reactive aggressive individuals, particularly those with psychiatric disorders, and preliminary evidence in support of this hypothesis is reviewed. We also discuss being jailed as a potential precipitant of suicide in reactive aggressive individuals. Recommendations are made to advance the study of reactive aggression and suicide, including methodological innovations and a greater focus on research of women and older adults.

The validity of proxy‐based data in suicide research: a study of patients 50 years of age and older who attempted suicide. I. Psychiatric diagnoses

Objective: To investigate the validity of best‐estimate methodology for making psychiatric diagnoses among individuals who attempted suicide.

The validity of proxy-based data in suicide research: a study of patients 50 years of age and older who attempted suicide. II. Life events, social support and suicidal behavior.

Objective: To investigate the validity of proxy respondent reports of stressful life events, social support and suicidal behavior among individuals who attempted suicide.

Low-planned suicides in China

BACKGROUND Acts of suicide differ widely in the amount of planning preceding the act. Correlates of completed suicide in China identified in a previous investigation were re-examined to identify those that may be especially relevant to low-planned (impulsive) and high-planned suicidal behavior. The association of planning and method in completed suicide was also assessed. METHOD A psychological autopsy study of 505 suicide decedents aged > or = 18 years sampled to be representative of suicides in China was conducted. Multinomial regression analyses compared three levels of suicide planning (low, intermediate, high). RESULTS Women and younger individuals were more likely to carry out low-planned and intermediate-planned than high-planned acts of suicide. Greater acute stress distinguished low-planned from high-planned suicides. Ingestion of pesticides stored in the home was a more commonly employed method in low-planned than high-planned suicides. CONCLUSIONS Low-planned suicides are more common in women, in younger individuals, and among those who are experiencing acute stress. Prevention strategies targeted at restricting access to pesticides may preferentially lower the rate of low-planned suicides.

Health status and suicide in the second half of life

To examine the associations of suicide in the second half of life with medical and psychiatric illness, functional limitations, and reported use of inpatient, ambulatory, and home health care services.