Sleep in youth with repeated self-harm and high suicidality: Does sleep predict self-harm risk?

Nightmares and self-injurious thoughts among clinically acute adolescents: Examining negative affect as a potential mechanism

Nightmares, a specific sleep problem, have been associated with increased risk for suicidal and nonsuicidal self-injurious thoughts, yet mechanisms underlying this relationship remain poorly understood, particularly among adolescents. This study examined negative affect (NA) intensity as a potential mediator between nightmares and self-injurious thoughts in a clinically acute sample of adolescents. Adolescents (N = 86; Mage = 14.30; 48.8% white, 46.51% female) completed an ecological momentary assessment (EMA) study design for 28 days following discharge from acute psychiatric care for suicidal thoughts and behaviors. Daily sleep diaries were used to assess prior night nightmare presence and intensity. EMA was used to assess NA intensity, suicidal thought intensity, and nonsuicidal self-injurious thought intensity multiple times per day. Multilevel structural equation modeling revealed significant between-person mediation effects, whereby adolescents reporting more frequent and intense nightmares exhibited greater NA intensity, which, in turn, was associated with increased suicidal and nonsuicidal self-injurious thought intensity. Mediation effects were not observed at the within-person level, indicating that individual differences, rather than daily fluctuations in nightmares, accounted for these associations. Results identify NA intensity as a person-level mechanism linking nightmares and self-injurious thoughts. Future research should investigate additional mechanisms and employ temporally sensitive designs to clarify dynamic (within-person) processes underlying suicidal and nonsuicidal self-injurious thoughts in adolescents. This study underscores the clinical importance of addressing nightmares and NA intensity in clinically acute adolescents to inform suicide prevention efforts.

Mediating Effects of Sleep Problems and Emotional Symptoms in the Relationship Between Chronotype and Self-Harm Among Adolescents Aged 11-19 Years

Purpose

Self-harm is linked to numerous adverse health and social outcomes, including repetitive self-harm and an increased risk of suicide. This study aims to explore the influence of chronotype on self-harm among adolescents and further investigate the mediating role of sleep problems and emotional symptoms.

Participants and Methods

The study was conducted between April and June 2022, involving 13 junior and senior high schools in Tianjin. The participants were asked to complete online questionnaires assessing chronotype, sleep problems, depression, anxiety, and self-harm. The data were analyzed and processed using Spearman correlation and mediation effect analysis. Two mediation pathways were tested: Model 1 with sleep problems and depression as the mediators, and Model 2 with sleep problems and anxiety as the mediators.

Results

Participants comprised 13,374 Chinese middle school adolescents (6745 boys) aged 11-19 years. In Model 1, the independent mediation effects of sleep problems and depression were -0.216 (95% CI = [-0.263, -0.172]) and -0.101 (95% CI = [-0.121, -0.083]), accounting for 33.33% and 15.59% of the total effect, respectively. The chain mediation effect was -0.170 (95% CI = [-0.196, -0.146]), accounting for 26.23% of the total effect. In Model 2, the independent mediation effects of sleep problems and anxiety were -0.232 (95% CI = [-0.279, -0.189]) and -0.075 (95% CI = [-0.091, -0.059]), respectively accounting for 35.63% and 11.52% of the total effect. The chain mediation effect was -0.151 (95% CI = [-0.176, -0.128]), accounting for 23.20% of the total effect.

Conclusion

Chronotype is a significant predictor of self-harm, with a later chronotype associated with a higher risk. Both sleep problems and emotional symptoms independently and serially mediate the relationship between chronotype and self-harm. These findings highlight the complex pathways through which chronotype influences self-harm behavior and suggest potential targets for intervention.

Anhedonia Links Sleep Problems and Suicidal Thoughts: An Intensive Longitudinal Study in High-Risk Adolescents

Growing research indicates that sleep problems are a robust independent risk factor for suicidal thoughts and behaviors among youth. However, relatively little is known about how this risk is conferred. This study used an intensive longitudinal design to investigate anhedonia as a mechanism linking sleep problems and next-day suicidal thoughts in a clinically high-risk sample of adolescents. Adolescents (N = 48; Mage=14.96; 77.1% white, 64.6% female) completed an ecological momentary assessment (EMA) study design for 28 days following discharge from acute psychiatric care for suicide risk. Daily sleep diaries were used to assess prior night total sleep time and sleep onset latency. Ecological momentary assessment was used to assess anhedonia and suicidal thoughts up to six times per day. A series of multi-level structural equation models were used to examine facets of anhedonia as parallel mediators of the association between sleep problems and next-day suicidal thoughts. Significant direct effects were found between sleep problems and consummatory anhedonia, consummatory anhedonia and suicidal thoughts, and anticipatory anhedonia and suicidal thoughts. There were significant indirect (mediated) effects between sleep problems and next-day suicidal thoughts through consummatory anhedonia, but not anticipatory anhedonia. Findings provide initial evidence as to how sleep problems may confer risk for next-day suicidal thoughts- by increasing consummatory anhedonia. Future research is needed to replicate these findings in larger samples and investigate how modifying anhedonia may mitigate suicide risk in youth.

Adolescent campus bullying and non-suicide self-injury: chain mediating effect of negative affect and sleep quality

Aim

This study aimed to explore the chain mediating role of negative affect and sleep quality between campus bullying and non - suicidal self - injury (NSSI) among adolescents.

Methods

569 adolescents were selected through convenience sampling. Participants completed the Olweus Bully/Victim Questionnaire, Positive and Negative Affect Schedule, Pittsburgh Sleep Quality Index, and Adolescent Non - suicidal Self - injury Assessment Questionnaire.

Results

Our result showed significant positive correlations among campus bullying, negative affect, sleep quality and NSSI. Negative affect and sleep quality were identified as independent and sequential mediators in the relationship between campus bullying and NSSI.

Conclusion

These findings elucidate the mechanisms linking campus bullying to NSSI, providing a preliminary basis for exploring the causal relationships among these variables. this study offers theoretical support for future research and inform the development of targeted interventions to reduce NSSI and improve the overall mental health of adolescents in China.

Sleep trajectories and frequency of non-suicidal self-injury in adolescents: a person-oriented perspective over two years

Adolescent sleep quality and quantity is commonly linked to worse emotion regulation. One maladaptive emotion regulation strategy that is on the rise is non-suicidal self-injury (NSSI), which includes burning, hitting, or scratching one's own body tissue without suicidal intent. The aim of this study was to explore the frequency of NSSI among different longitudinal trajectories of insomnia symptoms and short sleep duration to identify at-risk adolescents. We used questionnaire data collected annually (3 time points over 2 years) from a sample of Swedish adolescents (N = 1,294; Mage = 13.2 [range: 12-15 years], SD = 0.4; 46.8% girls). Adolescents answered questions about their sleep duration, symptoms of insomnia, NSSI, depressive symptoms, and demographics. Adolescents who reported persistent or increasing sleep problems over time also reported more NSSI. A notable pattern was that adolescents whose insomnia symptoms were high and increasing reported the highest frequency of NSSI, also compared to adolescents who started at the same high level of insomnia symptoms but improved over time. Therefore, measuring NSSI may help identify a risk-group for persistent sleep problems and self-injury. Because sleep disturbances, especially insomnia, and NSSI go hand-in-hand for most adolescents, sleep interventions would benefit the treatment and prevention of self-injury.

The brain, rapid eye movement sleep, and major depressive disorder: A multimodal neuroimaging study

BACKGROUND

Evidence has established the prominent involvement of rapid eye movement (REM) sleep disturbance in major depressive disorder (MDD). However, the neural correlates of REM sleep in MDD and their clinical significance are less clear.

METHODS

Cross-sectional and longitudinal polysomnography and resting-state functional MRI data were collected from 131 MDD patients and 71 healthy controls to measure REM sleep and voxel-mirrored homotopic connectivity (VMHC). Correlation and mediation analyses were performed to examine the associations between REM sleep, VMHC, and clinical variables. Moreover, we conducted spatial correlations between the neural correlates of REM sleep and a multimodal collection of reference brain maps to facilitate genetic, structural and functional annotations.

RESULTS

MDD patients exhibited REM sleep abnormalities manifesting as higher REM sleep latency and lower REM sleep duration, which were correlated with decreased VMHC of the precentral gyrus and inferior parietal lobe and mediated their associations with more severe anxiety symptoms. Longitudinal data showed that VMHC increase of the inferior parietal lobe was related to improvement of depression symptoms in MDD patients. Spatial correlation analyses revealed that the neural correlates of REM sleep in MDD were linked to gene categories primarily involving cellular metabolic process, signal pathway, and ion channel activity as well as linked to cortical microstructure, metabolism, electrophysiology, and cannabinoid receptor.

CONCLUSION

These findings may add important context to the growing literature on the complex interplay between sleep and MDD, and more broadly may inform future treatment for depression via regulating sleep.

Prospectively predicting 6-month risk for non-suicidal self-injury among adolescents after psychiatric hospitalization based on a predictive model

Background

It is challenging to predict the occurrence of non-suicidal self-injury (NSSI) among adolescents over short periods. Moreover, the predictive value of indices for NSSI remains elusive. Thus, this study aimed to identify predictors of NSSI within 6 months among adolescents after psychiatric hospitalization by establishing a risk assessment model.

Methods

A total of 632 high-risk participants were included in this study. The distribution characteristics of adolescent NSSI were initially assessed through a cross-sectional survey, following which risk factors were identified using logistic regression analysis. The risk score method was then used to construct a 6-month risk assessment model for NSSI. Lastly, the predictive effect of the model was evaluated by indicators such as the area under the receiver operating characteristic (ROC) curve and the positive predictive value.

Results

After 6 months, 412 cases of NSSI were identified. According to the logistic regression model, the frequency of relapses, medication status, and NSSI history were identified as influencing factors. Higher scores on the Impulsive Behavior Scale and Pittsburgh Sleep Quality Index were associated with a higher risk of NSSI. Conversely, higher scores on the Pain and Belief Perception Scale were correlated with a lower risk of NSSI. Moreover, the area under the ROC curve for the predictive model was 0.9989, with a 95% confidence interval of (0.9979, 0.9999), highlighting its high predictive ability and accuracy. The predictive model was validated using 78 patients, yielding an area under the ROC curve of 0.9703 and a 95% confidence interval of (0.9167, 0.9999), demonstrating outstanding predictability.

Conclusion

These results collectively showed that the predictive model could accurately predict adolescent NSSI. Thus, the model's primary variables may be applied to predict the risk of NSSI in the clinical setting.

Role of sleep problem on suicidal behaviour and non-suicidal self-injury among adolescents in Pokhara, Nepal

INTRODUCTION

Sleep is a fundamental human requirement, considered one of the major contributing factors to physical and mental health, especially among adolescents. Poor quality sleep has many potential consequences including non-suicidal self-injury (NSSI), suicidal thoughts or behaviour and complete suicide. The NSSI and suicidal behaviour are increasing in Nepal. Thus, this study aimed to assess the role of sleep problem on suicidal behaviour and non-suicidal self-injury among adolescents in Pokhara metropolitan, Nepal.

METHODS

A cross-sectional analytical study was conducted among 673 adolescents using a multistage cluster sampling technique from private and public schools in Pokhara Metropolitan. Self-administered questionnaire was used for data collection. Collected data was entered and managed in EpiData (version 3.1) and analysed in IBM SPSS (version 23). Binary logistic regression was used to identify the association of sleep problem with NSSI and suicidal behaviour.

RESULTS

The study found that sleep problem (65.2%, 439), suicidal behaviour (18.6%, 125) and NSSI (57.9%, 390) were prevalent among adolescents in study setting. The presence of sleep problem significantly influenced the suicidal behavior (AOR = 3.88, 95% CI = 2.27-6.63) alongside the sex of student (AOR = 1.96, 95% CI = 1.28-3.00), adolescents from family having monthly income less than NPR 40,000 (AOR = 1.97 95% CI = 1.16-3.35) and private schools students (AOR = 2.99, 95% CI = 1.84-4.86). Likewise, sleep problem was also associated with non-suicidal self-injury (AOR = 3.24, 95% CI = 2.26-4.65), in addition to attending private school (AOR = 2.52, 95% CI = 1.71-3.72).

CONCLUSION

This study concludes that sleep problem is prevalent among the adolescents and increase the risk of NSSI and suicidal behaviour. Therefore, parents and teachers need to assess their conditions and help them maintain sound sleep. Additionally, suicide prevention strategies need to be adopted to mitigate further risk.

Self-Compassion as a Mediator Linking Sleep Disturbances with Non-Suicidal Self-Injury: A Four-Wave, Cross-Lagged Study

Objective

This longitudinal study examined the reciprocal relationship between sleep disturbances with non-suicidal self-injury and whether self-compassion mediates these associations.

Methods

A total of 5785 freshmen were sampled from a large-scale health-related cohort among Chinese college students at the baseline. This study spanned six waves with a six-month interval between each wave. Data from the last four waves were used because self-compassion or non-suicidal self-injury was not measured in the first two waves. The cross-lagged panel models were used to examine the longitudinal dynamic relationships between sleep disturbances, self-compassion, and non-suicidal self-injury.

Results

The results showed that all the auto-regressive paths were significant. For the cross-lagged paths, there was a reciprocal relation between sleep disturbances and self-compassion. Importantly, self-compassion played a longitudinal mediating role in the prediction from sleep disturbances to non-suicidal self-injury (indirect effect = 0.007 to 0.009, all p values < 0.001).

Conclusion

Psychological interventions targeting improved sleep quality and self-compassion may hold great promise for reducing the incidence of non-suicidal self-injury.

How to survive the long night? Longitudinal relationship between sleep problems and suicidal behavior among adolescents: The serial mediating roles of negative emotion, self-control, and nonsuicidal self-injury

OBJECTIVE

Sleep problems are a significant risk factor for identifying and preventing suicidal involvement among adolescents. However, there is limited evidence to assess the underlying mechanisms between them. This study investigated the longitudinal relationship between sleep problems and suicidal behavior and examined whether this relationship was moderated by negative emotions, low self-control, and nonsuicidal self-injury (NSSI).

METHODS

From December 2020 onward, we assessed 1214 Chinese secondary school adolescents (60.7% were boys, aged 13-19 years) three times, 6 months apart.

RESULTS

In the direct effects model, sleep problems were found to have a positive impact on adolescent suicidal behavior. In the indirect effects model, we observed that sleep problems were associated with an elevated risk of suicidal behavior through several pathways: one-mediator path of negative emotions, low self-control, and NSSI, respectively; two-mediator path of negative emotions via low self-control, negative emotions via NSSI, and low self-control via NSSI, and three-mediator path from negative emotions to NSSI via low self-control.

CONCLUSIONS

This longitudinal study provides evidence that sleep problems in adolescents may increase suicidal behavior by exacerbating negative emotions, weakening self-control, and promoting NSSI. The findings suggest sleep problems should be addressed in suicide prevention and intervention efforts for adolescents.

IL-6 predicts non-suicidal self-injury over 3 months in high-risk adolescents

BACKGROUND

Suicide is the second leading cause of death in 12- to 17-year-old adolescents in the USA. Research on biological mechanisms contributing to self-harm risk that could be targeted in treatment could help to prevent suicide and self-harm episodes.

AIMS

We aimed to evaluate whether markers of inflammation, interleukin-6 (IL-6) and C-reactive protein (CRP), predict self-harm over 3 months within a sample selected for elevated suicide/self-harm risk at project entry.

METHOD

Fifty-one adolescents aged 12-19 years selected for elevated suicide/self-harm risk completed three clinical interviews about suicide attempts and non-suicidal self-injury, 3 months apart. At baseline and 3 months, youth also provided blood samples, from which we assayed levels of IL-6 and CRP.

RESULTS

Using generalised mixed models, we found that greater levels of IL-6 predicted more self-harm episodes (odds ratio [OR] = 3.3, 95% CI: 1.1, 10.0) and specifically, non-suicidal self-injury (OR = 3.5, 95% CI: 1.1, 11.2), over 3 months.

CONCLUSIONS

The study findings increase our understanding of whether and how inflammation may be implicated in risk of self-harm. IL-6 may be a viable biological marker of short-term risk for self-harm.

Report from a randomized control trial: improved alignment between circadian biology and sleep-wake behavior as a mechanism of depression symptom improvement in evening-type adolescents with depressive symptoms

STUDY OBJECTIVES

An evening circadian preference is common among adolescents. It is characterized by a behavioral predilection for later sleep and wake timing and is associated with higher rates of Major Depressive Disorder (MDD). The present study aims to (a) test the effectiveness of a cognitive behavioral sleep intervention (Transdiagnostic Sleep and Circadian Intervention; TranS-C) in a sample of adolescents with an evening circadian preference and clinically significant depressive symptoms and (b) evaluate improved alignment between circadian biology and sleep-wake behavior as a potential mechanism in the relationship between sleep and depression symptom improvement.

METHODS

Adolescents with an evening circadian preference and clinically significant depressive symptoms were randomized to receive TranS-C (n = 24) or a psychoeducation condition (PE; n = 18). Alignment between circadian biology and sleep-wake behavior was measured using objective biological measurement. Measures of sleep and circadian rhythm were taken at pre- and posttreatment, and depression symptoms were measured at pre- and posttreatment and 6- and 12-month follow-up.

RESULTS

Mixed effects modeling revealed that compared with an active control condition, TranS-C resulted in a significant reduction in MDD severity at 12-month follow-up. A MacArthur mediation analysis conducted to explore alignment between circadian biology and sleep-wake behavior as a mediator of depression severity reduction through 12-month follow-up revealed a significant interaction between change in alignment between circadian biology and sleep-wake behavior and treatment arm, indicating that improved alignment between circadian biology and sleep-wake behavior at posttreatment was associated with improvements in depression outcomes at 12-month follow-up under the treatment condition.

CONCLUSIONS

These results provide novel evidence for improved alignment between circadian biology and sleep-wake behavior as a specific mechanism of depression improvement, provide key clues into the complex relationship between sleep and depression, and have significant clinical implications for adolescents with depression.

Machine learning-based prediction for self-harm and suicide attempts in adolescents

This study aimed to use machine learning (ML) models to predict the risk of self-harm and suicide attempts in adolescents. We conducted secondary analysis of cross-sectional data from the Longitudinal Study of Australian Children dataset. Several key variables at the age of 14-15 years were used to predict self-harm or suicide attempt at 16-17 years. Random forest classification models were used to select the optimal subset of predictors and subsequently make predictions. Among 2809 participants, 296 (10.54%) reported an act of self-harm and 145 (5.16%) reported attempting suicide at least once in the past 12 months. The area under the receiver operating curve was fair for self-harm (0.7397) and suicide attempt (0.7220), which outperformed the prediction strategy solely based on prior suicide or self-harm attempt (AUC: 0.6). The most important factors identified were similar, and included depressed feelings, strengths and difficulties questionnaire scores, perceptions of self, and school- and parent-related factors. The random forest classification algorithm, an ML technique, can effectively select the optimal subset of predictors from hundreds of variables to forecast the risks of suicide and self-harm among adolescents. Further research is needed to validate the utility and scalability of ML techniques in mental health research.

Reporting Ethical Procedures in Suicide Prevention Research: Current Status and Recommendations

OBJECTIVE

Ethical concerns frequently arise in suicide prevention research regarding participant safety and confidentiality. Despite a substantial literature on managing and navigating ethical concerns in suicide research, little attention has been paid to the reporting of ethical procedures. Furthermore, standard procedures for reporting ethical risk management procedures have not been developed.

METHOD

A review of the current literature was performed to examine the current state of reporting of ethical procedures within suicide research. Articles published in 2020 (N = 263) from three suicide-focused publications were screened and then coded (n = 131) to identify reporting of procedures for the ethical conduct of research and suicide risk management steps taken by the research teams.

RESULTS

The majority of articles reported ethical review or approval (84.7%) and reported the use of an informed consent process (77.9%). Only 28.2% included risk mitigation procedures. Of those 29.7% of those articles reported conducting risk evaluation, 66.7% reported resource dissemination, and 51.4% reported an intervention.

CONCLUSION

As empirical support for brief interventions accrues, suicide prevention researchers should consider establishing standards for the reporting of procedures to ensure the safety of participants with suicidal risk.HighlightsReporting suicide safety protocols helps ensure high ethical standards in research.Fewer than 1/3 of articles reviewed reported risk mitigation procedures in 2020.Standard procedures for reporting safety protocols in suicide research are needed.

Zero Suicide Quality Improvement: Developmental and Pandemic-Related Patterns in Youth at Risk for Suicide Attempts

The Zero Suicide (ZS) approach to health system quality improvement (QI) aspires to reduce/eliminate suicides through enhancing risk detection and suicide-prevention services. This first report from our randomized trial evaluating a stepped care for suicide prevention intervention within a health system conducting ZS-QI describes 1) our screening and case identification process, 2) variation among adolescents versus young adults; and 3) pandemic-related patterns during the first COVID-19 pandemic year. Between April 2017 and January 2021, youths aged 12-24 with elevated suicide risk were identified through an electronic health record (EHR) case-finding algorithm followed by direct assessment screening to confirm risk. Eligible/enrolled youth were evaluated for suicidality, self-harm, and risk/protective factors. Case finding, screening, and enrollment yielded 301 participants showing suicide risk-indicators: 97% past-year suicidal ideation, 83% past suicidal behavior; 90% past non-suicidal self-injury (NSSI). Compared to young adults, adolescents reported: more past-year suicide attempts (47% vs 21%, p<.001) and NSSI (past 6-months, 64% vs 39%, p<.001); less depression, anxiety, posttraumatic stress, and substance use; and greater social connectedness. Pandemic-onset was associated with lower participation of racial-ethnic minority youths (18% vs 33%, p<.015) and lower past-month suicidal ideation and behavior. Results support the value of EHR case-finding algorithms for identifying youths with potentially elevated risk who could benefit from suicide-prevention services, which merit adaptation for adolescents versus young adults. Lower racial-ethnic minority participation after the COVID-19 pandemic-onset underscores challenges for services to enhance health equity during a period with restricted in-person health care, social distancing, school closures, and diverse stresses.

The relationship between sleep disturbance and self-harming behaviours in high-risk clinical adolescents

Emerging research has identified sleep disturbance as an important risk factor for predicting self-harming behaviours. However, the temporality of this relationship, particularly in clinical adolescent samples remains poorly understood. This study examines the relationship between sleep disturbance and self-harming behaviours (namely nonsuicidal self-injury and suicide attempts) in clinical adolescents engaging in risk-taking and self-harming behaviours using secondary analyses from a clinical cohort study. Cross-lagged structural equation modelling was used to determine whether baseline sleep disturbance and self-harming behaviours were predictors of each other over a one-year follow-up period in a sample of adolescents (n = 238, 89.5% female) attending and receiving treatment from an outpatient clinic specializing in risk-taking and self-harming behaviours. When controlling for age, sex and depressive symptoms, greater sleep disturbance (p = 0.001) at baseline independently predicted higher numbers of suicide attempts at follow-up. No bidirectional relationship was found when sleep disturbance was modelled with the frequency of nonsuicidal self-injury. This study adds to the growing evidence that sleep disturbance may predict suicidal behaviours. Clinicians should thus regularly assess for sleep disturbances when evaluating suicidal behaviours in high-risk adolescents. Further research and clinical trials should investigate whether sleep-based interventions may be efficacious in reducing the prevalence of suicidal behaviours.

Association between Suicidal Behaviors in Adolescence and Negative Emotions, the Level of Stress, Stress Coping Strategies and the Quality of Sleep

Suicidal behaviors in adolescents stem from complex processes deeply rooted in various spheres of life and functioning. The study was aimed at assessing the relationship between selected negative emotions, the quality of sleep, the level of perceived stress as well as stress coping strategies and suicidal ideation and attempts among high school students. The examined group consisted of adolescents aged 16-18 recruited by social-media groups in Poland. The study was based on a diagnostic survey with the application of CAWI method. The other research tools applied in the study included: Hospital Anxiety and Depression Scale-Modified, Perceived Stress Scale-10, How do you cope?-Questionnaire, Athens Insomnia Scale as well as the authors' own questionnaire on suicidal ideation and suicide attempts. Anxiety, depression, aggression and insomnia as well as a high level of stress were statistically more common in girls than in boys (p < 0.001). The high level of negative emotions and insomnia, in turn, increased the risk of suicidal ideation (OR = 3.59, 95% CI: 2.13-6.06 and OR = 2.35, 95% CI: 1.60-3.46), as well as suicide attempts (OR = 6.29, 95% CI: 2.93-14.80 and OR = 3.29, 95% CI: 2.07-5.35). Additionally, high level of stress was associated with more than twice larger odds of suicidal ideation (OR = 2.26, 95% CI: 1.13-4.63). Significantly higher prevalence of suicidal ideation (p = 0.017) and suicide attempts (p = 0.016) was observed in girls. A high level of negative emotions and stress accompanied by a low quality of sleep are factors predisposing people to suicidal ideation and attempted suicide.

Recent advances in sleep and depression

PURPOSE OF REVIEW

There is increasing interest in the connection between sleep disturbances and mood disorders. The purpose of this review is to summarize and evaluate current research on the role of sleep disturbance in the development of depression, as well as to describe recent advances in treatments that improve both sleep and depression symptoms.

RECENT FINDINGS

Relevant publications included in this review cover a wide range of topics related to sleep and depression. Data from large longitudinal studies suggest that insomnia and evening circadian preference are unique risk factors for depression. Depression treatment studies indicate poorer outcomes for those with comorbid sleep disturbances. A few recent trials of cognitive behavioral therapy for insomnia and triple chronotherapy in unipolar depression have shown promising results.

SUMMARY

Sleep disturbance is a modifiable risk factor in the development and maintenance of depression. In the context of current depression, although the data is mixed, some evidence suggests treating sleep disturbance can improve overall outcomes. Recent evidence also suggests that treating sleep disturbance may prevent the future depressive episodes.

Stepped care for suicide prevention in teens and young adults: Design and methods of a randomized controlled trial

BACKGROUND

Suicide is the second‑leading cause of death among adolescents and young adults in the United States, with rates rising over much of the last decade. The design, testing, and implementation of interventions to prevent suicide in this population is a public health priority. This manuscript outlines the design and methods for a research study that compares two interventions aimed at reducing suicide and suicide attempts in youth.

METHODS

We will enroll 300 youth aged 12-24 at high risk for suicide in this randomized controlled parallel group superiority trial. Participants will be randomly assigned to one of two study arms: (1) Zero Suicide Quality Improvement (ZSQI) implemented within the Kaiser Permanente Northwest (KPNW) health system, or (2) ZSQI plus a stepped care intervention for suicide prevention (SC-SP), where the services offered (including care management and dialectical behavior therapy [DBT]) increase based on risk level. Outcomes will be assessed at baseline, as well as 3-, 6-, and 12-months post randomization. The study was conceptualized and designed collaboratively by investigators at UCLA and KPNW.

RESULTS

To be reported in future manuscripts.

CONCLUSION

The main objective of the study is to determine whether the SC-SP intervention is superior to ZSQI with regard to lowering rates of fatal and nonfatal suicide attempts. Interventions that incorporate the latest research need to be designed and tested under controlled conditions to make progress toward the goal of achieving zero suicide. The results from this trial will directly inform those efforts.

TRIAL REGISTRATION

CLINICALTRIALS

gov, NCT03092271, https://clinicaltrials.gov/ct2/show/NCT03092271https://clinicaltrials.gov/ct2/show/NCT01379027.

Patterns of sleep disturbances and associations with depressive symptoms in autistic young adults

Autistic individuals are at an increased risk for both sleep disturbances and depression. While studies in the general population and in autistic adults have drawn general links between sleep disturbances and mental health, few studies have examined the extent to which specific sleep problems may be implicated in the extremely high rates of depression among autistic adults. This study aimed to describe the patterns of sleep disturbances in autistic young adults, and their associations with depressive symptoms while controlling for relevant demographic factors. A sample of 304 legally independent adults (age 18-35 years old) with a childhood diagnosis of autism spectrum disorder self-reported on their average sleep behaviors during the past week and depressive symptoms on the Beck Depressive Inventory-II. A significant proportion (86.01%) of autistic young adults experienced at least one of the primary sleep disturbances of interest, including short total sleep time (39.59%), poor sleep efficiency (60.07%), and delayed sleep phase (36.18%). Additionally, lower sleep efficiency and delayed sleep phase were both associated with higher depressive symptoms. The associations between sleep and depressive symptoms identified in our study suggest that sleep treatments may hold potential for ameliorating depressive symptoms in autistic adults who also experience sleep problems. Further research using daily sleep diaries and objective measures of sleep behaviors, as well as longitudinal studies, are needed to understand how changes in sleep may relate to changes in depressive symptoms in autistic adults.

Trajectories of Treatment Response and Nonresponse in Youth at High Risk for Suicide

OBJECTIVE

To examine trajectories of treatment response in suicidal youth who participated in a randomized controlled trial comparing dialectical behavior therapy (DBT) and individual and group supportive therapy.

METHOD

Using latent class analysis across both treatment conditions, secondary analyses were conducted of data from a multisite randomized controlled trial comprising 173 youths ages 12-18 with repetitive self-harm (SH) (including ≥1 lifetime suicide attempts) and elevated suicidal ideation (SI). The sample was 95% female, 56.4% White, and 27.49% Latina. Participants received 6 months of DBT or individual and group supportive therapy and 6 months of follow-up. Primary outcomes were SH and SI.

RESULTS

Of the sample, 63% and 74% were members of latent classes that showed improvement in SI and SH, respectively; 13% were total nonresponders, with no improvement in SI or SH. SH nonresponse emerged at the midpoint of treatment (3 months), with nonresponders showing a sharp increase in SH over the remainder of treatment and follow-up. Youth receiving DBT were significantly more likely to be an SH responder vs nonresponder than youths in individual and group supportive therapy (ꭓ21 = 6.53, p = .01). An optimal threshold cut point using multivariate predictors of total nonresponse (White, externalizing symptoms, total SH, and SI) predicted total nonresponders to DBT with 100% accuracy.

CONCLUSION

This is the first study to identify trajectories of both SI and SH response to treatment in a sample of adolescents at risk of suicide. Results may inform personalized treatment approaches.

CLINICAL TRIAL REGISTRATION INFORMATION

Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www.

CLINICALTRIALS

gov/; NCT01528020.

Metabolomic biomarkers related to non-suicidal self-injury in patients with bipolar disorder

BACKGROUND

Non-suicidal self-injury (NSSI) is an important symptom of bipolar disorder (BD) and other mental disorders and has attracted the attention of researchers lately. It is of great significance to study the characteristic markers of NSSI. Metabolomics is a relatively new field that can provide complementary insights into data obtained from genomic, transcriptomic, and proteomic analyses of psychiatric disorders. The aim of this study was to identify the metabolic pathways associated with BD with NSSI and assess important diagnostic and predictive indices of NSSI in BD.

METHOD

Nuclear magnetic resonance spectrometry was performed to evaluate the serum metabolic profiles of patients with BD with NSSI (n = 31), patients with BD without NSSI (n = 46), and healthy controls (n = 10). Data were analyzed using an Orthogonal Partial Least Square Discriminant Analysis and a t-test. Differential metabolites were identified (VIP > 1 and p < 0.05), and further analyzed using Metabo Analyst 3.0 to identify associated metabolic pathways.

RESULTS

Eight metabolites in the serum and two important metabolic pathways, the urea and glutamate metabolism cycles, were found to distinguish patients with BD with NSSI from healthy controls. Eight metabolites in the serum, glycine and serine metabolism pathway, and the glucose-alanine cycle were found to distinguish patients with BD without NSSI from healthy controls. Five metabolites in the serum and the purine metabolism pathway were found to distinguish patients with BD with NSSI from those with BD without NSSI.

CONCLUSIONS

Abnormalities in the urea cycle, glutamate metabolism, and purine metabolism played important roles in the pathogenesis of BD with NSSI.

Sleep irregularity and nonsuicidal self-injurious urges and behaviors

STUDY OBJECTIVES

The objectives of this study were to examine the relationships between sleep regularity and nonsuicidal self-injury (NSSI), including lifetime NSSI history and daily NSSI urges.

METHODS

Undergraduate students (N = 119; 18-26 years), approximately half of whom endorsed a lifetime history of repetitive NSSI, completed a 10-day actigraphy and ecological momentary assessment (EMA) protocol. A Sleep Regularity Index was calculated for all participants using scored epoch by epoch data to capture rapid changes in sleep schedules. Participants responded to EMA prompts assessing NSSI urge severity and negative affect three times daily over the 10-day assessment period.

RESULTS

Results indicate that individuals with a repetitive NSSI history were more likely to experience sleep irregularity than those without a history of NSSI. Findings also suggest that sleep irregularity was associated with more intense urges to engage in NSSI on a daily basis, even after accounting for average daily sleep duration, sleep timing, negative affect, and NSSI history. Neither sleep duration nor sleep timing was associated with NSSI history nor daily NSSI urge intensity.

CONCLUSIONS

Findings suggest that sleep irregularity is linked with NSSI, including NSSI history and intensity of urges to engage in NSSI. The present study not only supports the growing evidence linking sleep disturbance with the risk for self-injury but also demonstrates this relationship using actigraphy and real-time assessments of NSSI urge severity. Findings highlight the importance of delineating the nuances in sleep irregularity that are proximally associated with NSSI risk and identifying targets for intervention.

Suicide Risk, Self-Injury, and Sleep: An Exploration of the Associations in a Sample of Juvenile Justice Involved Adolescents

Court-involved youth living in the community represent a vulnerable, yet understudied, group that is at risk for a variety of concerning outcomes including increased suicidal ideation, suicide attempts, and non-suicidal self-injury (NSSI). Additionally, sleep disruption, which has been associated with an increase in impulsive decision making, appears to be disproportionately high in this population. However, little is known about any connection between poor sleep and increased suicide risk and NSSI in a group of youth. This study explores the associations between sleep disruption, suicidal ideation, suicide attempts, and NSSI in a sample of court-involved youth in the community referred for mental health evaluation at a court based mental health clinic. Findings suggest that sleep disruption is related to NSSI in this population but not suicidal ideation and suicide attempts. Additional relationships were found between NSSI and being female, as well as having a lifetime history of trauma and marijuana use. Findings suggest that court clinics may wish to screen for sleep disruption as a risk factor for NSSI, and future studies may wish to explore improved sleep as a protective factor for CINI youth.

A Comprehensive Review of the Literature on Sleep Difficulties and Suicidality in Youth to Inform an Integrative Developmental Model and Future Directions

Purpose of Review

Suicide is currently the second leading cause of death among youth. Identification of modifiable near-term risk factors can inform suicide prevention strategies. One promising, readily assessed factor is sleep. We critically review the literature on sleep and suicidal thoughts and behaviors among youth.

Recent Findings

Most studies examining the youth sleep-suicidality relationship are from epidemiological samples in which both sleep problems and suicidality were assessed over variable timeframes using limited items from scales not designed to measure these constructs. Nonetheless, these data overwhelmingly support an association between suicidality and a range of sleep difficulties (e.g., insomnia, short/long sleep, weekend oversleep), above and beyond depressive symptoms. Limited studies include clinical samples or prospective designs. We review potential mechanisms and present a developmentally-informed integrative model.

Summary

Literature supports a clear association between sleep difficulties and youth suicidality. Future directions include prospective longitudinal studies and targeted prevention efforts.

Sleep problems predict next-day suicidal thinking among adolescents: A multimodal real-time monitoring study following discharge from acute psychiatric care

Suicidal thoughts and behaviors (STBs) are major public health concerns among adolescents, and research is needed to identify how risk is conferred over the short term (hours and days). Sleep problems may be associated with elevated risk for STBs, but less is known about this link in youth over short time periods. The current study utilized a multimodal real-time monitoring approach to examine the association between sleep problems (via daily sleep diary and actigraphy) and next-day suicidal thinking in 48 adolescents with a history of STBs during the month following discharge from acute psychiatric care. Results indicated that specific indices of sleep problems assessed via sleep diary (i.e., greater sleep onset latency, nightmares, ruminative thoughts before sleep) predicted next-day suicidal thinking. These effects were significant even when daily sadness and baseline depression were included in the models. Moreover, several associations between daily-level sleep problems and next-day suicidal thinking were moderated by person-level measures of the construct. In contrast, sleep indices assessed objectively (via actigraphy) were either not related to suicidal thinking or were related in the opposite direction from hypothesized. Together, these findings provide some support for sleep problems as a short-term risk factor for suicidal thinking in high-risk adolescents.

Prevalence and risk factors for depression, anxiety and suicidal ideation in youth with persistent post-concussive symptoms (PPCS)

Objectives: To assess the prevalence and risk factors for emotional distress in youth with persistent post-concussive symptoms (PPCS) greater than one month.Methods: We used baseline data from an intervention study for youth with PPCS, utilizing Poisson regression to examine factors associated with exceeding clinical cut-points on measures of depression, anxiety, self-harm and suicidal ideation. Predictors included: age, sex, socioeconomic status, mental health history, duration of concussion symptoms, history of prior concussion, trauma history and sleep quality.Results: The sample included 200 youth with PPCS, (mean 14.7 SD 1.7 years, 82% white, 62% female). Forty percent reported clinically significant depressive symptoms, 25% anxiety, 14% thoughts of self-harm and 8% thoughts of suicide. History of depression was associated with 3-fold higher risk for thoughts of self-harm (95% CI:1.82-6.99) and 6-fold higher risk for suicidal ideation (95% CI:1.74-24.46). Better sleep quality was associated with lower risk for all outcomes. History of prior concussion and duration of PPCS were not significantly associated with any outcomes.Conclusions: Suicidal thoughts are common post-concussion, and history of depression is a strong risk factor. Tailored interventions may be needed to address mental health in this population.

Repeat self-harm among Chinese adolescents: 1-year incidence and psychosocial predictors

PURPOSE

Self-harm in adolescents is prevalent and is the most significant predictor of future self-harm and suicide. Longitudinal data on the incidence and predictors of repeat self-harm in the general population of adolescents are limited. This study investigated 1-year incidence and psychosocial predictors of repeat self-harm in Chinese adolescents.

METHODS

Shandong Adolescent Behavior and Health Cohort is a longitudinal study of behavior and health in adolescents in Shandong Province, China. Of 7072 participants who were assessed in 2015 and again 1 year later in 2016, 1879 reported a history of self-harm at the baseline survey and were included for this analysis. A self-administered structured questionnaire was used to assess behavioral and emotional problems, sleep, life stress, previous history of self-harm and suicidal thought, and family factors at baseline and self-harm at 1-year follow-up.

RESULTS

Mean age of the sample was 14.86 (SD 1.36) years and 54.6% were female. At 1-year follow-up, 22.1% participants engaged in repeat self-harm. Multiple logistic regression analyses showed that female gender (OR 1.45, 95% CI 1.11-1.89), alcohol use (OR 1.95, 95% CI 1.48-2.57), frequent nightmares (OR 1.61, 95% CI 1.14-2.28), elevated depression score (OR 1.59, 95% CI 1.05-2.42), and prior suicidal thought (OR 1.79, 95% CI 1.37-2.34) were independently and significantly associated with an increased risk of repeat self-harm.

CONCLUSION

More than one in five Chinese adolescents who had a history of self-harm engaged in self-harm at 1-year follow-up. Multiple psychosocial factors including female gender, alcohol use, frequent nightmares, depression, and prior suicidal thought appeared to be significant predictors of repeat self-harm. Our findings highlight the importance of comprehensive psychosocial assessment and intervention of repeat self-harm in adolescents.

Nonlinear relationship between sleep duration and non-suicidal self-injurious behaviour among Chinese adolescents

BACKGROUND

Previous studies have shown a positive association between sleep deprivation and non-suicidal self-injury (NSSI) among adolescents, but few studies have described the effects of oversleeping and weekend catch-up sleep on NSSI. The present study aimed to explore the nonlinear relationship between sleep duration and NSSI among Chinese adolescents.

METHODS

Data from China's National Adolescent Health Surveillance for the years 2014 to 2015 were collected from 15,713 students located across four provinces in China. A self-report questionnaire was used to assess sleep duration and 12-month NSSI. Binomial logistic regression models were used to examine the association between NSSI and sleep duration. The locally estimated scatter plot smoothing (LOESS) method was used to explore the associations of total NSSI number with sleep duration, and binomial regression analysis was used to test this relationship.

RESULTS

About 68.5% of adolescents reported sleeping less than 8 h on weeknights, while 37.8% of adolescents slept more than 10 h per night during weekends. The 12-month prevalence rate of NSSI was 29.4%. Compared to adolescents who reported weekend catch-up sleep of 0-1 h, those who slept < 0 h (adjusted odds ratio [aOR] = 1.38, 95% Confidence Interval [95% CI]: 1.16-1.64) had a higher risk of NSSI. Males who reported ≥3 h of weekend catch-up sleep had significantly increased odds of NSSI (aOR = 1.20, 95%CI: 1.01-1.42). Notably, a positive U-shaped association was observed between the sleep duration and the total NSSI number.

CONCLUSIONS

The findings reveal a nonlinear relationship between sleep duration and NSSI among Chinese adolescents. Therefore, it is necessary to be vigilant and screen for sleep duration among adolescents in NSSI treatment or prevention.

A Rhesus Monkey Model of Non-suicidal Self-Injury

Non-suicidal self-injury (NSSI) is a type of behavioral pathology seen not only in a variety of clinical conditions but also among non-clinical populations, particularly adolescents and young adults. With the exception of rare genetic conditions that give rise to self-harming behaviors, the etiology of NSSI and the events that trigger specific episodes of this behavior remain poorly understood. This review presents the features of an important, extensively studied animal model of NSSI, namely spontaneously occurring self-injurious behavior (SIB) in rhesus macaque monkeys. We compare and contrast rhesus monkey SIB with NSSI with respect to form, prevalence rates, environmental and biological risk factors, behavioral correlates, proposed functions, and treatment modalities. Many parallels between rhesus monkey SIB and NSSI are demonstrated, which supports the validity of this animal model across several domains. Determining the etiology of spontaneously occurring SIB in monkeys, its underlying biological mechanisms, and which pharmacological agents are most effective for treating the disorder may aid in identifying potential risk factors for the occurrence of NSSI in humans and developing medications for severe cases that are resistant to conventional psychotherapeutic approaches.

Sleep and Mood Disorders Among Youth

This article reviews the literature on mood disorders and sleep disorders among children and adolescents. Research suggests that sleep plays an important role in the development, progression, and maintenance of mood disorder symptoms among children and adolescents. Sleep problems as early as maternal perinatal insomnia may predict and predate depression among youth. Children and adolescents who develop comorbid mood disorders and sleep problems represent a particularly high-risk group with more severe mood episode symptoms, higher rates of self-harm and suicidality, and less responsivity to treatment. Treatment research supports the idea that sleep problems can be improved through behavioral interventions.