Sleep and suicide: A systematic review and meta-analysis of longitudinal studies

Abstract

The current review provides a quantitative synthesis of the empirical literature on sleep disturbance as a risk factor for suicidal thoughts and behaviors (STBs). A systematic search of PsycINFO, MEDLINE, and the references of prior reviews resulted in 41 eligible studies included in this meta-analysis. Sleep disturbance, including insomnia, prospectively predicted STBs, yielding small-to-medium to medium effect sizes for these associations. Complicating interpretation of these findings however, is that few studies of suicidal ideation and suicide attempts, as well as none of suicide deaths, assessed short-term risk (i.e., employed follow-up assessments of under a month). Such studies are needed to evaluate current conceptualizations of sleep dysregulation as being involved in acute risk for suicidal behavior. This want of short-term risk studies also suggests that current clinical recommendations to monitor sleep as a potential warning sign of suicide risk has a relatively modest empirical basis, being largely driven by cross-sectional or retrospective research. The current review ends with recommendations for generating future research on short-term risk and greater differentiation between acute and chronic aspects of sleep disturbance, and by providing a model of how sleep disturbance may confer risk for STBs through neuroinflammatory and stress processes and associated impairments in executive control.

Keywords: Insomnia; Meta-analysis; Sleep; Suicidal ideation; Suicide.

Conflict of interest statement

Declaration of Competing Interest None.

Copyright © 2020 Elsevier Ltd. All rights reserved.

Figures

Fig. 1.

PRISMA flow chart of literature search.

Fig. 2.

Funnel plots for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall sleep disturbance and suicidal ideation. 2b. Overall sleep disturbance and suicide attempts. 2c. Overall sleep disturbance and suicide deaths. 2d. General insomnia and suicidal ideation. 2e. General insomnia and suicide attempts. 2f. General insomnia and suicide deaths.

Fig. 2.

Funnel plots for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall sleep disturbance and suicidal ideation. 2b. Overall sleep disturbance and suicide attempts. 2c. Overall sleep disturbance and suicide deaths. 2d. General insomnia and suicidal ideation. 2e. General insomnia and suicide attempts. 2f. General insomnia and suicide deaths.