مشکلات خواب، افکار خودکشی و رفتارهای خودآسیبی در دوران نوجوانی

Abstract Objective Previous research has found an association between sleep problems and suicidal behavior. However, it is still unclear whether the association can be largely explained by depression. In this study, we prospectively examined relationships between sleep problems when participants were 12–14 years old and subsequent suicidal thoughts and self-harm behaviors—including suicide attempts—at ages 15–17 while controlling for depressive symptoms at baseline. Methods Study participants were 280 boys and 112 girls from a community sample of high-risk alcoholic families and controls in an ongoing longitudinal study.

. Introduction In 2002, the Institute of Medicine report on Reducing Suicide recommended that prospective studies of populations at high risk for the onset of suicidal behavior were needed ( Goldsmith et al., 2002). Of particular concern are adolescents, because suicide is the third leading cause of death in the 15–24-year old age group ( Cash and Bridge, 2009). Although the Institute of Medicine report did not mention sleep disturbances as a risk factor for suicidality, a consistent and strong association between sleep disturbances and suicidality has been reported in both adults ( Agargun et al., 2007, Chellappa and Araujo, 2007, McGirr et al., 2007, Sjostrom et al., 2007, Turvey et al., 2002, Wallander et al., 2007 and Wojnar et al., 2009) and adolescents ( Bailly et al., 2004, Barbe et al., 2005, Choquet et al., 1993, Choquet and Menke, 1990, Goldstein et al., 2008, Liu, 2004 and Nrugham et al., 2008). Among adolescents, insomnia has been linked to suicidal thoughts (Bailly et al., 2004, Barbe et al., 2005 and Choquet and Menke, 1990), attempts (Bailly et al., 2004 and Nrugham et al., 2008), and completed suicides (Goldstein et al., 2008). Similarly, nightmares have been linked to both suicidal thoughts (Choquet and Menke, 1990 and Liu, 2004) and suicide attempts (Liu, 2004). These relationships have been reported in both general student populations (Liu, 2004 and Nrugham et al., 2008) and clinical samples (Barbe et al., 2005). With one exception (Nrugham et al., 2008), however, most of these studies were cross-sectional in design. In the one prospective study already present in the literature, Nrugham et al. (2008) followed 265 students in Norway for 5 years, starting when they were approximately 15 years of age. Bivariate analyses demonstrated that insomnia at age 15 predicted suicide attempts during the next 5 years. In multivariate analyses that controlled for depressive symptoms, however, insomnia was no longer predictive. This is probably due to the well-established association between depression and suicide attempts in adolescents (Kovacs et al., 1993, Lewinsohn et al., 1994 and Liu and Buysse, 2006). The results of this study illustrate the importance of controlling for depressive symptoms. Nevertheless, the authors cautioned that a 70% follow-up rate and a small number of boys (N = 61) in the sample may have biased the results. More prospective studies are clearly needed to address the possible relationships between sleep problems and suicidal behavior. Children of alcoholics (COAs) are another high-risk group for numerous adverse outcomes including substance use disorders, internalizing disorders, and externalizing disorders—all of which can increase the risk for suicidality (Lieberman, 2000 and Zucker et al., 2008). Recent work also suggests that COAs may differ from other children by objectively measured sleep disturbance (Dahl et al., 2003 and Tarokh and Carskadon, 2009). Therefore, the relationship between sleep disturbances and suicidality in COAs warrants study. Here, we report to our knowledge the first prospective study of high-risk adolescents to investigate a potential link between sleep disturbances and subsequent suicidal thoughts and either self-harm behaviors or suicide attempts (self-harm/suicidal behaviors). We hypothesized that (1) COAs would have higher rates of sleep disturbance than non-COAs; (2) COAs would have higher rates of suicidal thoughts and self-harm/suicidal behaviors than non-COAs; and (3) sleep disturbances would prospectively predict the development of suicidal thoughts and self-harm/suicidal behaviors after controlling for depressive symptoms, COA status, and other potentially confounding variables. We used the terms “sleep disturbances,” “poor sleep,” “insomnia,” and “sleep problems” interchangeably in this paper.

3. Results 3.1. Descriptive statistics At ages 15–17, 7.6% reported having suicidal thoughts and 5% reported that they had tried to harm or kill themselves in the last six months. The figures were similar when participants were at ages 12–14 at which time 4.1% had suicidal thoughts and 3.3% had actually engaged in self-harm/suicidal behavior. There was no completed suicide at either wave. However, there was one complete suicide when participants were 18–20 years old. Regarding sleep disturbances at ages 12–14, over one-quarter of participants (27.5%) reported trouble sleeping and more than one-third endorsed feeling overtired (35.3%) or having nightmares (40.8%) (Table 1). Table 1. Descriptive statistics on all variables (N = 392). % Yes Mean SD Range Suicidal thoughts at ages 12–14 4.1% – – 0 (no) −1 (yes) Suicidal thoughts at ages 15–17 7.6% – – 0 (no) −1 (yes) Self-harm/suicidal behavior at ages 12–14 3.3% – – 0 (no) −1 (yes) Self-harm/suicidal behavior at ages 15–17 5.0% – – 0 (no) −1 (yes) Sleep problems at ages 12–14 Trouble sleeping 27.5% – – 0 (no) −1 (yes) Overtired 35.3% – – 0 (no) −1 (yes) Nightmares 40.8% – – 0 (no) −1 (yes) Depressive symptoms at ages 12–14 (excluding sleep problems and suicidal behavior) – 0.31 0.27 Aggressive behavior at ages 12–14 – 7.93 5.31 Presence of alcohol or drug-related problems 9.4% – – 0 (no) −1 (yes) Gender 71.4% Male – – 0 (female) −1 (male) Age at Time 5 – 16.53 0.93 14.72–18.84a Paternal alcoholism 71.7% Alcoholic – – 0 (no) −1 (yes) Maternal alcoholism 29.6% Alcoholic – – 0 (no) −1 (yes) Paternal suicidal ideation or attempts 27.0% – – 0 (no) −1 (yes) Maternal suicidal ideation or attempts 28.1% – – 0 (no) −1 (yes) a Note: In this paper, we analyzed the data from the Michigan Longitudinal Study at Time 4 (12–14 years old) and Time 5 (15–17 years old). Due to delay in scheduling, about 5% of the participants were 18 years old at Time 5. Table options A higher percentage of girls (11.4%) than boys (5.1%) reported having suicidal thoughts at 12–14 years old (χ2 (1) = 4.62, p < 0.05). There were no gender differences in suicidal thoughts at 15–17 years old (girls: 7.9%; boys: 7.4%; χ2 (1) = 0.03, p = 0.87). Similarly, no gender differences in self-harm/suicidal behaviors were found at either age period (ages 12–14: girls: 2.6%; boys: 3.5%;χ2 (1) = 0.21, p = 0.65; ages 15–17: girls: 5.3%; boys: 4.9%; χ2 (1) = 0.02, p = 0.90). A larger percentage of girls (43%) reported being overtired than boys (32.2%) at ages 12–14 (χ2 (1) = 4.17, p < .05). There were no gender differences for having nightmares (girls: 48.2%; boys: 37.82%; χ2 (1) = 3.66, p = 0.06) or trouble sleeping (girls: 28.1%; boys: 27.2%; χ2(1) = 0.03, p = 0.86). There was a significant relationship between having trouble sleeping at ages 12–14 and suicidal thoughts at ages 15–17 (χ2 (1) = 5.95, p < 0.05, Fig. 1). Among adolescents who had no suicidal thoughts at ages 15–17, 26% had trouble sleeping at ages 12–14. However, among adolescents who had suicidal thoughts at ages 15–17, almost half (46.7%) had trouble sleeping at an earlier age. There was also a significant relationship between having trouble sleeping at ages 12–14 and self-harm/suicidal attempts at ages 15–17 (χ2 (1) = 11.12, p = 0.001, Fig. 2). About a quarter (25.8%) of 15–17-year-old adolescents who did not engage in self-harm or suicidal behavior had trouble sleeping at ages 12–14. In contrast, 60% of adolescents who engage in self-harm or suicidal behavior had trouble sleeping. There were no significant associations between the two other sleep variables (having nightmares and overtiredness) and suicidal thoughts (nightmares: χ2 (1) = 1.43, p = 0.23; overtiredness: χ2 (1) = 0.88, p = 0.35) or self-harm/suicidal behavior (nightmares: χ2 (1) = 0.00, p = 0.98; overtiredness: χ2 (1) = 0.84, p = 0.36). Relationship between having trouble sleeping at ages 12–14 and suicidal thoughts ... Fig. 1. Relationship between having trouble sleeping at ages 12–14 and suicidal thoughts at ages 15–17. Figure options Relationship between having trouble sleeping at ages 12–14 and ... Fig. 2. Relationship between having trouble sleeping at ages 12–14 and self-harm/suicidal behavior at ages 15–17. Note. The association between “having trouble sleeping” and self-harm/suicidal attempts was statistically significant. Figure options 3.2. The relationships among parental alcoholism, sleep problems, and suicidality Having an alcoholic parent had no significant association with self-reported sleep problems. COAs did not report more sleep problems than non-COAs (trouble sleeping: χ2 (1) = 0.07, p = 0.80; overtiredness: χ2 (1) = 0.91, p = 0.34; nightmares: χ2 (1) = 0.10, p = 0.75). Having an alcoholic parent was also not associated with suicidal thoughts (ages 12–14: χ2 (1) = 0.01, p = 0.93; ages 15–17: χ2(1) = 0.10, p = .76) or self-harm/suicidal behaviors in adolescence (ages 12-14: χ2 (1) = 0.05, p = 0.83; ages 15–17: χ2 (1) = 0.36, p = 0.55). 3.3. The relationship between sleep problems and suicidal thoughts We used parental alcoholism and history of suicidal thoughts or attempts, gender and age of the adolescent participants, and the following variables at ages 12–14 (suicidal thoughts, depressive symptoms, aggressive behaviors, substance-related problems, overtiredness, nightmares, and having trouble sleeping) to predict suicidal thoughts at ages 15–17 in a direct logistic regression model (Table 2). The analysis showed that controlling for all variables in the model, having trouble sleeping at ages 12–14 significantly predicted suicidal thoughts at ages 15–17. Those who had trouble sleeping in early adolescence were more than two times as likely than those without trouble sleeping to think about killing oneself in late adolescence (Odds ratio: 2.41, p < 0.05). None of the other variables significantly predicted adolescent suicidal thoughts. Results of the sequential regression model were essentially the same ( Table 2). Entering sleep variables in the last block did not change the results. Table 2. Odds ratio for suicidal thoughts at ages 15–17. Direct logistic regressiona Odds Ratio 95% CI p Value Thoughts about killing oneself (ages 12–14) 1.90 0.46–7.79 0.37 Gender 0.88 0.37–2.08 0.77 Age 0.99 0.65–1.51 0.95 Paternal alcoholism 1.07 0.41–2.76 0.89 Maternal alcoholism 1.17 0.50–2.77 0.72 Paternal suicidal ideation or attempts 2.11 0.94–4.72 0.07 Maternal suicidal ideation or attempts 1.36 0.60–3.10 0.46 Depressive symptoms (ages 12–14) 0.91 0.12–6.67 0.88 Aggressive behavior (ages 1–14) 0.98 0.91–1.09 0.10 Alcohol or drug use related problems (ages 12–14) 1.19 0.33–4.30 0.79 Trouble sleeping (ages 12–14) 2.44 1.03–5.75 0.04* Overtired (ages 12–14) 1.09 0.43–2.74 0.86 Nightmares (ages 12–14) 0.48 0.20–1.17 0.11 Sequential logistic regression Block 1 Thoughts about killing oneself (ages 12–14) 2.17 0.69–6.81 0.18 Gender 0.98 0.43–2.24 0.98 Age 1.07 0.71–1.59 0.76 Block 2 Paternal alcoholism 1.08 0.46–2.86 0.87 Maternal alcoholism 1.14 0.48–2.55 0.78 Paternal suicidal ideation or attempts 2.14 0.99–4.62 0.05* Maternal suicidal ideation or attempts 1.42 0.63–3.16 0.40 Block 3 Depressive symptoms (ages 12–14) 0.91 0.12–6.67 0.88 Aggressive behavior (ages 12–14) 0.98 0.91–1.09 0.10 Alcohol or drug use related problems (ages 12–14) 1.19 0.33–4.30 0.79 Trouble sleeping (ages 12–14) 2.44 1.03–5.75 0.04* Overtired (ages 12–14) 1.09 0.43–2.74 0.86 Nightmares (ages 12–14) 0.48 0.20–1.17 0.11 a Note: All variables were entered simultaneously in the analyses. *p < .05. Table options 3.4. The relationship between sleep problems and self-harm/suicidal behaviors Results from the direct logistic regression model showed that self-harm/suicidal behaviors at ages 15–17 were not significantly related to demographic variables, parental alcoholism, parental history of suicidal ideation or attempts, adolescents’ own previous self-harm/suicidal behaviors, overtiredness, or having nightmares (Table 3). Controlling for these other variables in the model, the only significant predictor was trouble sleeping at ages 12–14. Participants who had trouble sleeping in early adolescence were four times more likely to deliberately harm themselves or attempt suicide in late adolescence (Odds ratio: 4.1, p < 0.01). Results of the sequential regression model were consistent with that of the direct logistic regression model ( Table 3). Table 3. Oddsratio for self-harm/suicidal behavior at ages 15–17. Direct logistic regressiona Odds Ratio 95% CI p Value Deliberately try to hurt or kill oneself (ages 12-14) 3.79 0.53–26.88 0.18 Gender 0.81 0.28–2.36 0.71 Age 1.23 0.73–2.08 0.43 Paternal alcoholism 1.10 0.35–3.47 0.87 Maternal alcoholism 1.02 0.36–2.90 0.98 Paternal suicidal ideation or attempts 1.35 0.48–3.82 0.57 Maternal suicidal ideation or attempts 2.65 1.01–6.95 0.05* Depressive symptoms (ages 12–14) 1.64 0.18–15.06 0.66 Aggressive behavior (ages 12–14) 0.94 0.84–1.06 0.31 Alcohol or drug use related problems (ages 12–14) 1.97 0.48–7.89 0.34 Trouble sleeping (ages 12–14) 4.06 1.42–11.62 0.01** Overtired (ages 12–14) 1.19 0.38–3.66 0.77 Nightmares (ages 12–14) 0.78 0.27–2.24 0.64 Sequential logistic regression Block 1 Deliberately try to hurt or kill oneself (ages 12–14) 3.51 0.71–17.28 0.12 Gender 0.87 0.32–2.35 0.78 Age 1.36 0.84–2.21 0.21 Block 2 Paternal alcoholism 1.05 0.35–3.17 0.93 Maternal alcoholism 1.05 0.38–2.90 0.93 Paternal suicidal ideation or attempts 1.44 0.55–3.80 0.46 Maternal suicidal ideation or attempts 2.64 1.05–6.68 0.04* Block 3 Depressive symptoms (ages 12–14) 1.64 0.18–15.06 0.66 Aggressive behavior (ages 12–14) 0.94 0.84–1.06 0.31 Alcohol or drug use related problems (ages 12–14) 1.97 0.48–7.89 0.34 Trouble sleeping (ages 12–14) 4.06 1.42–11.62 0.01** Overtired (ages 12–14) 1.19 0.38–3.66 0.77 Nightmares (ages 12–14) 0.78 0.27–2.24 0.64 a Note. All variables were entered simultaneously in the analyses. *p < .05. **p < .01.