Sleep and adolescent suicidal behavior

STUDY OBJECTIVES: Suicide risk begins to increase during adolescence. Adolescents do not get enough sleep and are also at risk for many sleep disturbances. This study examined the association between sleep patterns and sleep problems and adolescent suicidal behavior. DESIGN AND SETTING: A questionnaire survey of adolescents attending school was conducted in one prefecture of Shandong Province, People's Republic of China. PARTICIPANTS: A total of 1,362 adolescents attending school (mean age 14.6 years, 60% males) participated in the survey. MEASUREMENTS: Respondents completed a self-administered questionnaire that asked about sleep patterns, sleep problems, suicidal behavior, depressive symptoms, and demographic characteristics of the family and adolescent. RESULTS: Overall, 19.3% of the sample reported having suicidal ideation, 10.5% having suicide attempts in the past 6 months, 16.9% having insomnia symptoms, 2.3% having taken hypnotic medication, and 48.9% having experience of nightmares in the past month. Mean night sleep duration was 7.6 hours (SD = 0.8). Logistic regression analyses showed that sleeping less than 8 hours at night (OR = 2.89, 95% confidence interval [CI] = 1.07-7.81) and frequent nightmares (OR = 2.43, 95% CI = 1.76-3.35) were significantly associated with increased risk for suicide attempts after adjustment for age, sex, father's occupation, and depressive symptoms and that nightmares (OR = 1.69, 95% CI = 1.20-2.38) were also significantly related to suicidal ideation. CONCLUSION: These findings demonstrate the association between short sleep duration and nightmares and suicidal behavior and highlight the potential role of sleep intervention in the prevention of adolescent suicide.     

Nightmares, suicide attempts, and melancholic features in patients with unipolar major depression

OBJECTIVES: Recently, there has been a growing interest in the relationship between sleep disturbances and suicidality in major depression. Sleep disturbances are one of the 'modifiable risks' for suicide in major depression. The present study examines whether there is a relationship among nightmares, suicide attempts, and melancholic features in unipolar major depressed patients. METHODS: One hundred (49 males and 51 females) depressed patients with melancholic features and 49 (23 males and 26 females) patients without melancholic features were included in the study. All patients were classified as those who attempted suicide at least once during current depressive episode and as those who never attempted. RESULTS: Melancholic attempters had higher rates of nightmares, middle, and terminal insomnia than melancholic non-attempters. There was no significant difference between non-melancholic patients with and without suicidal attempts in terms of the frequency of all types of insomnia and nightmares. Limitations: This study does not have polysomnographic records for sleep variables. CONCLUSIONS: Feeling worse in the morning than later in the day may be related to the intervening dream content and affect and predict suicidal tendency. Melancholia may be associated with increased risk of suicide attempts due to repetitive and frightening dreams.     

Understanding the link between anxiety symptoms and suicidal ideation and behaviors in outpatients with bipolar disorder

BACKGROUND: Prior studies suggest an association between anxiety comorbidity and suicidal ideation and behaviors in bipolar disorder. However, the nature of this association remains unclear. METHODS: We examined a range of anxiety symptoms, including panic, phobic avoidance, anxiety sensitivity, worry and fear of negative evaluation, in 98 patients with bipolar disorder. We predicted that each anxiety dimension would be linked to greater suicidal ideation and behavior as measured by Linehan's Suicide Behaviors Questionnaire (SBQ), greater depressive rumination, and poorer emotional processing and expression. RESULTS: Each anxiety dimension except fear of negative evaluation was associated with greater SBQ score, greater rumination, and lower levels of emotional processing in univariate analyses. Depressive rumination was a significant predictor of higher SBQ scores in a stepwise multivariate model controlling for age, gender, bipolar subtype, and bipolar recovery status; the association between the anxiety symptom dimensions and SBQ score was found to be redundant with depressive rumination. Emotional processing emerged as protective against suicidal ideation and behaviors in men only, while emotional expression was a significant predictor of lower SBQ scores for women and for the full sample; however, emotional expression was not significantly correlated with anxiety symptoms. Confirmatory analyses examining only those in recovery or recovered (n=68) indicated that the link between rumination and suicidality was not explained by depression. LIMITATIONS: Interpretation is limited by the cross-sectional study design. CONCLUSIONS: These findings indicate that increased ruminations may mediate the association between anxiety and suicidal ideation/behavior. In men, lower emotional processing may also play a role in this relationship.     

Nightmares and sleep disturbances in relation to suicidality in suicide attempters

STUDY OBJECTIVES: To study the prevalence of specific sleep disturbances in suicide attempters and to examine the association between specific sleep disturbances and suicidality. DESIGN AND SETTING: A cross-sectional study in suicide attempters during the period October 1, 2001, to June 30, 2004. PARTICIPANTS: One hundred sixty-five patients aged 18 to 68 years who were admitted to medical units or psychiatric wards at Sahlgrenska University Hospital after a suicide attempt. INTERVENTIONS: N/A. MEASUREMENTS: The face-to-face interview included Structured Clinical Interview for DSM-IV-IV and the Suicide Assessment Scale. Two self-report instruments were employed, the Uppsala Sleep Inventory and Comprehensive Psychopathological Self-rating Scale for Affective Syndromes. The latter assessed symptom burden. Using multiple logistic regression analyses, we examined associations between sleep complaints and suicidality. RESULTS: Eighty-nine percent of subjects reported some kind of sleep disturbance. The most common complaint was difficulties initiating sleep (73%). Other complaints included difficulties maintaining sleep (69%), nightmares (66%) and early morning awakening (58%). Nightmares were associated with a 5-fold increase in risk for high suicidality. This relationship remained after adjustment for psychiatric diagnosis and psychiatric symptom intensity. CONCLUSIONS: Sleep disturbances are common among suicide attempters. Nightmares are associated with suicidality. Our findings suggest that questions concerning sleep disturbance and nightmares should be addressed in the clinical assessment of suicidal patients.     

Correlates of suicidal ideation in dysphoric mania

BACKGROUND: Previous investigations have reported that suicidal ideation and behavior are more prevalent during mixed than pure mania. Uncertainties exist about whether suicidality in mania arises from multiple concurrent depressive symptoms, or rather, as a categorical phenomenon, reflecting dysphoria without necessarily a full major depression. To elucidate the relationship between suicidal ideation and dysphoric mania, we analyzed clinical and demographic features associated with suicidal versus nonsuicidal dysphoric manic inpatients. METHODS: Records were reviewed for 100 DSM-III-R bipolar I manic inpatients at the Payne Whitney Clinic of New York Hospital from 1991-1995. All had > or = 2 concomitant depressive symptoms (other than suicidality). Affective and psychotic symptoms, past suicide attempts, prior illness, and related clinical/demographic variables were assessed by a standardized protocol. RESULTS: Suicidal ideation was significantly more common among dysphoric manics who were caucasian, took antidepressant medications in the week prior to admission, had histories of alcohol abuse/dependence, and made past suicide attempts. Suicidal ideation was evident for nearly half of dysphoric manic patients with < or = 3 depressive symptoms who did not meet DSM criteria for a mixed state. No individual manic or depressive symptoms other than dysphoric mood were more common among suicidal than nonsuicidal patients. LIMITATIONS: Findings from this retrospective study require confirmation using a prospective assessment. Treatments were naturalistic and may have differentially influenced hospital course and illness characteristics. Factors related to suicide attempts (rare in this cohort) or completions (not a focus of this study) may differ from those related only to suicidal ideation. CONCLUSIONS: Caucasian dysphoric manic patients with past suicide attempts and substance abuse may have a significantly elevated risk for suicidality, even when full major depression does not accompany mania. Suicidality is a clinically important consideration in a majority of dysphoric manic patients.     

Suicidality in early pregnancy among antepartum mothers in urban India

This study assessed the prevalence and predictors of suicidality among 462 pregnant women in South India. Women in early pregnancy (<20 weeks) attending an urban public hospital antenatal center were assessed for suicidality using a modified version of the Suicide Behaviors Questionnaire–Revised (SBQR) and a single-item (item 10) from the Edinburgh Postnatal Depression Scale (EPDS). Severity of depressive symptoms, family violence, and perceived social support were also measured. The prevalence of suicidality in pregnancy was 7.6 % (35/462). Eleven women (2.4 %) reported having had suicidal plans, and 8 (1.7 %) had made a suicidal attempt during the current pregnancy. Younger age, belonging to a middle socioeconomic status, poor perceived support, domestic violence, depressive symptoms, and having a past history of suicidality predicted suicidal ideation during the current pregnancy. Multivariate analysis revealed depression severity and a life time history of suicidal ideation as being the strongest predictors. The findings underscore the need for assessment of psychiatric and psychosocial factors that confer risk among women in this vulnerable period. The results of the study however may be specific to low-income urban women from this geographical location limiting the external validity of our findings.     

Insomnia Symptoms,Depressive Symptoms,and Suicide Ideation in Japanese White-Collar Employees

Background

Although poor sleep quality is the most common subjective complaint of workers and is a risk factor for depressive symptoms and suicide, researchers have not yet provided definitive links between insomnia symptoms, depressive symptoms, and suicide.

Purpose

In our mediation model, we hypothesized relationships among insomnia symptoms, depressive symptoms, and suicide ideation. The purpose here was to use structural equation modeling (SEM) to test our mediation model.

Method

Three hundred forty-three Japanese full-time white-collar workers completed the measures to assess insomnia symptoms, depressive symptoms, and suicide ideation over an approximately 3-month period.

Results

A SEM analysis revealed that insomnia symptoms were positively and significantly associated with depressive symptoms, and depressive symptoms were positively and significantly associated with suicide ideation. Two tests showed a significant indirect effect of insomnia symptoms on suicide ideation through depressive symptoms. Thus, these results supported our mediation model.

Conclusion

We conclude that insomnia symptoms were positively associated with suicidal ideation, though this relation was accounted for by depressive symptoms in Japanese white-collar workers.     

The effect of childhood maltreatment on suicidal ideation through cognitive emotion regulation strategies and specific obsessive–compulsive symptoms in obsessive–compulsive disorder

Childhood maltreatment is thought to be associated with suicidality in patients with obsessive–compulsive disorder (OCD). Although the underlying mechanism of this relationship is not clear, cognitive emotion regulation strategies (CERSs) and the specific OC symptoms including unacceptable obsessional thoughts (UOTs) and responsibility for harm (RFH) may underlie this link. Accordingly, the study aimed to assess the effect of childhood maltreatment on suicidal ideation through UOTs, RFH and adaptive and maladaptive CERSs in OCD patients. Three hundred patients meeting a DSM-5 diagnosis of OCD were selected and completed the scales measuring childhood maltreatment, OCD, suicidality and depressive symptoms. After controlling for depressive symptoms and OCD severity, childhood maltreatment was shown to affect suicidal ideation directly. Also, the indirect effect of childhood maltreatment on suicidal ideation was mediated by adaptive CERSs, UOTs and RFH. The findings show that OCD patients with a history of childhood maltreatment, less use of adaptive CERSs and the experiences of UOTs and RFH should be carefully considered regarding suicidal risk.     

Agitated "unipolar" depression re-conceptualized as a depressive mixed state: implications for the antidepressant-suicide controversy

BACKGROUND: The nosologic status of agitated depression is unresolved. Are they unipolar (UP) or bipolar (BP)? Are they mixed states? Even more controversial is the notion that antidepressants might play some role in the suicidality of such patients (Akiskal and Mallya, 1987) [Akiskal, H.S., Mallya, G., 1987. Criteria for the "soft" bipolar spectrum: treatment implications. Psychopharmacol Bull. 23, 68-73]. METHODS: After excluding all patients with history of hypomanic episodes occurring outside the frame of a major depressive episode (MDE), even those with a shorter duration of hypomanic symptoms than stipulated in DSM-IV, the remaining consecutive 254 unipolar major depressive disorder (MDD) private adult (> 21 years old) outpatients were interviewed (off psychoactive drugs for 2 weeks) with the Structured Clinical Interview for DSM-IV (SCID-CV), the Hypomania Interview Guide (HIGH-C), and the Family History Screen. Intra-MDE hypomanic symptoms were systematically assessed, with > or = 3 such symptoms required for a diagnosis of depressive mixed state (DMX). Agitated depression was defined as an MDE with HIGH-C psychomotor agitation score > or = 2. Logistic regression was used to study associations and control for confounding variables. RESULTS: In this strictly defined unipolar sample, agitated depression was present in 19.7%. Compared with its non-agitated counterpart, it had significantly fewer recurrences, less chronicity, higher rate of family history for bipolar disorder, and DMX; and, among the intra-depressive non-euphoric hypomanic symptoms (in decreasing order of frequency), distractibility, racing/crowded thoughts, irritable mood, talkativeness, and risky behavior. The most striking finding was the robust association between agitated depression and DMX (OR = 36.9). Furthermore, patients with psychomotor agitation had significantly higher rate of weight loss and suicidal ideation. Of DMX symptoms, we found an association between suicidal ideation, psychomotor activation, and racing thoughts. Agitated depression was tested by forward stepwise logistic regression versus all variables significantly different in the pairwise comparisons, yielding DMX, talkativeness, and suicidal ideation as the independent significant positive predictors. LIMITATIONS: No suicidal ideation scale was used. CONCLUSIONS: Agitated depression emerges as a distinct affective syndrome with weight loss, pressure of speech, racing thoughts and suicidal ideation. Psychomotor activation and racing thoughts during MDD independently predicted suicidal ideation. In this "unipolar" MDD sample, agitated depression had a strong clustering of intra-episode non-euphoric hypomanic symptoms (i.e. DMX) which, coupled with its association with bipolar family history, support its link with the bipolar spectrum. Agitated depression is therefore best regarded as "pseudo-unipolar." These findings overall accord with classical German concepts of agitated depression as a mixed state. Given that these patients are typically activated along the lines of risk-taking behavior, Kraepelin's rubric of "excited (mixed) depression" appears to us the preferred terminology over "agitated depression". CLINICAL IMPLICATIONS: The data reported herein, placed in the setting of the literature reviewed in the discussion suggest that the reports of increased risk of suicidal ideation and/or behavior in some depressed patients treated by antidepressant monotherapy or combinations thereof might be attributed to baseline psychomotor activation/agitation as part of an unrecognized bipolar mixed state. Whether antidepressants induce de novo suicidality in MDD cannot be answered without adequately powered prospective double-blind studies, unlikely to be conducted because of ethical constraints. Nonetheless, we submit that agitated, activated, or otherwise excited depressions (which we consider as depressive mixed states) overlap considerably with the so-called antidepressant "activation syndrome." Furthermore, the rare occurrence of suicidality on antidepressants should not obscure the fact that the advent of the new antidepressants is associated with worldwide decline in suicide rates. We finally wish to point out that our formal nosology (i.e. DSM-IV and ICD-10), in its failure to recognize the bipolar nature of depressive mixed states, thereby fails to shield pseudo-unipolar patients from antidepressant monotherapy, which is inappropriate for such patients.     

Association of Overweight with the Prevalence of Lifetime Psychiatric Disorders and Suicidality: General Population-based Study in Korea

Many epidemiological studies suggest that overweight is associated with an elevated risk of psychiatric disorders and suicidal tendency. However, findings vary across studies, and some have contradictory results. We investigated the relationship of overweight with a range of psychiatric disorders and suicidality in the Korean general population. A multistage cluster sampling design was adopted. A total of 6,022 participants aged 18–74 years completed face-to-face interviews (response rate: 78.7%) including assessment of psychiatric disorders, suicidality, and height and weight. Overweight (defined as body mass index of ≥ 25) was associated with an increase in the lifetime prevalence of depressive disorders (adjusted odds ratio [AOR] 1.38; 95% confidence interval [CI], 1.07–1.77), suicidal ideation (AOR, 1.42; 95% CI, 1.20–1.68), and suicidal plans (AOR, 1.44; 95% CI, 1.02–2.03), controlling for sociodemographic variables. Subgroup analysis found that the association between overweight and depressive disorders exists only in women aged 18–44 years (AOR, 1.75; 95% CI, 1.07–2.89) while the association of overweight with suicidal ideation (AOR, 2.08; 95% CI, 1.53–2.82) and suicide plans (AOR, 2.59; 95% CI, 1.25–5.37) existed only in men aged 18–44 years. Overweight was associated with increased odds of nicotine use disorders in women aged 18–44 years (AOR, 2.35; 95% CI, 1.02–5.43), but the association was in the opposite direction in men aged 45–74 years (AOR, 0.64; 95% CI, 0.43–0.94). In conclusion, overweight is related to various psychiatric disorders and suicidality in Korea. Policy makers and clinicians should pay more attention to the mental health of overweight individuals.     

Nightmare complaints in treatment-seeking patients in clinical sleep medicine settings: diagnostic and treatment implications

STUDY OBJECTIVES: To develop clinical guideposts to identify patients with salient nightmare conditions. DESIGN: Prevalence data from a retrospective chart review on a consecutive series of sleep patients to assess how or whether those with nightmares (1) rank nightmare complaints compared to other sleep complaints, (2) link nightmares to disrupted sleep, (3) report worse sleep symptoms and health outcomes compared to other sleep patients, and (4) endorse criteria for a salient nightmare condition on the Disturbing Dream and Nightmare Severity Index. SETTING: Two community sleep facilities: private sleep medical center and a hospital-based sleep lab. PATIENTS: Seven hundred eighteen patients presenting at intake: sleep center (n = 620); sleep lab (n = 98). MEASUREMENTS AND RESULTS: Standard sleep parameters and various health outcomes were assessed with self-report measures. Of 718 sleep patients, 186 ranked a nightmare complaint among their sleep problems, of whom 117 linked their bad dreams to disrupted sleep, suggesting a potential salient nightmare condition. Compared to all other sleep patients, these 117 cases demonstrated consistent significant patterns of worse or more prevalent problems with self-reported sleep indexes, insomnia, sleep quality, sleep-fragmentation factors, sleep-related daytime impairment, psychiatric history, medical comorbidity, and parasomnias. The Disturbing Dream and Nightmare Severity Index identified those with salient nightmare complaints and correlated with worse sleep and health outcomes. CONCLUSIONS: At 2 sleep medical facilities, 16% of patients presented with an apparent salient nightmare condition, and these patients were identified with simple clinical guideposts, which could be incorporated at intake in various sleep medicine settings.     

Recurrence of suicidal ideation across depressive episodes

BACKGROUND: In recent years it has become clear that depression is a recurrent disorder, with the risk of recurrence in those with two or more episodes being as high as 90%. This has prompted interest in the consistency of individual depressive symptoms across consecutive episodes, an issue that is important for symptoms such as suicidal ideation, where a past history may give important indicators of future behaviour. METHODS: We prospectively examined 69 individuals with a history of Major Depression, over 12 months, 38 of whom experienced a recurrence of major depression during the follow-up period. RESULTS: Spearman's rank order correlations between severity ratings of each symptom of major depression during a previous episode and severity ratings at recurrence showed significant associations for suicidality, guilt or worthlessness and thinking difficulties only. Weighted kappa coefficients indicated relatively low levels of agreement across episodes for most diagnostic symptoms, with suicidality showing the strongest relationship. Using a broad definition of suicidality-- any reporting of thoughts of death or suicide during episode-- a much higher level of agreement (kappa = .64) was found, with 83% of individuals falling into the same category (suicidal/non-suicidal) at both episodes. LIMITATIONS: This study was based on a relatively small sample and examines re-emergence of suicidal ideation in the absence of suicidal behaviour. CONCLUSIONS: This study provides preliminary evidence of cross-episode consistency in the recurrence of suicidal ideation, in line with the differential activation theory of suicidality in depression.     

住院抑郁症患者自杀相关问题

目的 :探讨住院抑郁症患者自杀相关问题。方法 :调查 2 0 0 0年连续住院抑郁症患者 3 0 9例 ,记录自杀相关问题及相应临床资料。结果 :住院抑郁症患者出现自杀意念、自杀意图、自杀行为的比例相当高。女性病人自杀行为明显多于男性 ,而男性自杀行为的后果较女性更为严重。精神疾病家族史、自杀家族史均与自杀行为关系密切。终身自杀次数与病程、住院次数、总住院时间相关。结论 :住院抑郁症患者存在较多的自杀问题 ,特别对病程长、多次住院、具有精神疾病或自杀家族史者 ,更是自杀预防的重点人群     

Are body dissatisfaction, eating disturbance, and body mass index predictors of suicidal behavior in adolescents? A longitudinal study

Disordered eating, body dissatisfaction, and obesity have been associated cross sectionally with suicidal behavior in adolescents. To determine the extent to which these variables predicted suicidal ideation and attempts, the authors examined these relationships in a longitudinal design. The study population included 2,516 older adolescents and young adults who completed surveys for Project EAT-II (Time 2), a 5-year follow-up study of adolescents who had taken part in Project EAT (Time 1). Odds ratios for suicidal behaviors at Time 2 were estimated with multiple logistic regression. Predictor variables included Time 1 extreme and unhealthy weight control behaviors (EWCB and UWCB), body dissatisfaction, and body mass index percentile. Suicidal ideation was reported by 15.2% of young men and 21.6% of young women, and suicide attempts were reported by 3.5% of young men and 8.7% of young women. For young women, suicidal ideation at Time 2 was predicted by Time 1 EWCB. The odds ratio for suicide attempts was similarly elevated in young women who had reported EWCB at Time 1. These odds ratios for both suicidal ideation and suicide attempts remained elevated even after controlling for Time 2 depressive symptoms. In young men, EWCB was not associated with suicidal ideation or suicide attempts 5 years later. Body mass index and body dissatisfaction did not predict suicidal ideation or suicide attempts in young men or young women. These results emphasize the importance of EWCB.     

Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy

Objectives

Posttraumatic stress disorder (PTSD) is associated with sleep disturbances including insomnia and nightmares. This study compared cognitive behavioral therapy for insomnia (CBT-I) with CBT-I combined with imagery rehearsal therapy (IRT) for nightmares to evaluate if the combined treatment led to greater reductions in trauma-related sleep disturbances in Australian veterans.

Methods

Veterans with diagnosed PTSD, high insomnia symptom severity, and nightmares (N = 31) were randomized to eight group CBT-I sessions or eight group CBT-I + IRT sessions. Self-reported sleep, nightmare, and psychological measures (primary outcome: Pittsburgh Sleep Quality Index), and objective actigraphy data were collected; the effect of obstructive sleep apnea (OSA) risk on treatment outcomes was also examined.

Results

No treatment condition effects were detected for the combined treatment compared to CBT-I alone, and no moderating effect of OSA risk was detected. On average, participants from both groups improved on various self-report measures over time (baseline to 3 months posttreatment). Despite the improvements, mean scores for sleep-specific measures remained indicative of poor sleep quality. There were also no significant differences between the groups on the actigraphy indices.

Conclusions

The findings indicate that there is potential to optimize both treatments for veterans with trauma-related sleep disturbances.     

Physiological-emotional reactivity to nightmare-related imagery in trauma-exposed persons with chronic nightmares

Script-driven imagery was used to assess nightmare imagery-evoked physiological-emotional reactivity (heart rate, skin conductance, facial electromyogram, subjective ratings) in trauma-exposed persons suffering from chronic nightmares. Goals were to determine the efficacy of nightmare imagery to evoke physiological-emotional reactivity, correlates (mental health, nightmare characteristics) of reactivity, and consequences (sleep and health problems) of reactivity. Nightmare imagery resulted in significant reactivity relative to control imagery. No mental health variable (posttraumatic stress disorder status, depressive symptoms, dissociation) or nightmare characteristic (months experienced, frequency, similarity to trauma) was associated with reactivity level. However, nightmare imagery-evoked autonomic responses were associated with greater sleep disturbance and reported health symptoms, even when nightmare frequency was controlled. These results suggest nightmare-related autonomic reactions may contribute to sleep and health disturbance.     

In severely suicidal young adults, hopelessness, depressive symptoms, and suicidal ideation constitute a single syndrome

BACKGROUND: Despite voluminous research on the role of hopelessness and depression in suicidality, a systematic examination of various causal models pertaining to these variables is conspicuous in its absence. METHOD: The directions of relationships between the three variables were examined by means of a prospective-longitudinal, cross-lagged, three-wave design in a severely suicidal young adults. RESULTS: Structural Equation Modeling (SEM) analyses revealed synchronous, but not longitudinal, associations between hopelessness, depressive symptoms, and suicidal ideation. CONCLUSIONS: In severely suicidal young adults, the three clinical constructs appear to constitute a single depressive syndrome.     

Nightmare prevalence, nightmare distress, and self-reported psychological disturbance

STUDY OBJECTIVES: The relationship between nightmare prevalence, nightmare distress, and self-reported psychological disturbance was assessed prospectively. DESIGN: Differences in self-reported psychological disturbance as a function of nightmare prevalence was investigated by MANCOVA's with non-nightmare dreams as the covariate as well as Pearson correlations. The relative contribution of nightmare prevalence and distress to the prediction of psychological disturbance was investigated through multiple regression analyses. SETTING: N/A. PARTICIPANTS: 116 participants (mean age = 20 years) completed self-report indices of depression, anxiety, dissociation, psychosis-proneness, and a psychiatric symptom checklist and kept a nightmare log for 21 consecutive nights. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Frequent nightmares were associated with higher levels of psychological disturbance. Individuals who reported 3 or more nightmares across the 3 weeks reported more dissociation, psychosis-proneness and psychiatric symptoms than participants reporting 2 nightmares or less. However, nightmare prevalence and distress were not significantly correlated and differentially predicted to different types of waking psychological disturbance. Multiple regressions further indicated that nightmare distress accounted for much of the unique explanatory variance in predicting clinical states associated with high negative affect (anxiety and depression). Last, there was no evidence for a specific relationship between nightmares and psychosis-proneness. CONCLUSIONS: The findings suggest that it is not the incidence of nightmares which is associated with poorer waking psychological functioning, especially anxiety and depression states, but the reported distress associated with the nightmare experience which is the critical variable in predicting higher psychological disturbance.     

Gender-related differences in symptoms of patients with suspected breathing disorders in sleep: a clinical population study using the sleep disorders questionnaire

BACKGROUND: Gender-related differences in the symptom profile of patients with suspected sleep disordered breathing (SDB) may be one explanation of the clinical underrecognition of SDB in women. STUDY OBJECTIVES: The aim of this study was to prospectively assess gender-related differences in presenting symptoms in a clinical sample of patients with suspected sleep disordered breathing. DESIGN: Administration of the Sleep Disorders Questionnaire prior to clinical and polysomnographic evaluation. Responses obtained from the questionnaire were used to construct 4 independent symptom scales: sleep apnea (SA), periodic limb movement syndrome (PLM), psychiatric sleep disorder (PSY), and narcolepsy (NAR). Analyses of variance were used to examine the effect of gender, AHI, and age on the symptom scales. Associations between gender and each diagnostic scale of the questionnaire were determined by multiple analyses of covariance. SETTING: Tertiary pulmonary referral center. PARTICIPANTS: 2739 men and 782 women with suspected SDB. All patients who were referred to the sleep laboratory underwent full-night polysomnography, irrespective of the likelihood of SDB. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Overall, men scored significantly higher on items related to worsening of snoring/breathing with alcohol (P < 0.001) and smoking history (P < 0.01) than women. Complaints such as witnessed apneas (P < 0.001) and worsening of snoring in supine position (P < 0.05), however, were more frequently reported by men with an apnea-hypopnea index (AHI) < 5/hr, compared with AHI-matched women. There were no significant differences in these items in patients with an AHI > 15/hr. In contrast, women complained significantly more often of insomnia, restless legs, depression, nightmares, palpitations at night, and hallucinations than men. As a result, women had significantly higher scores on the PLM, PSY, and NAR scales of the Sleep Disorders Questionnaire (P < 0.001, for all). After adjustments for age, body mass index, AHI, arousal index, oxygen saturation data, and smoking history, by means of multiple analyses of covariances, gender differences remained significant (P < 0.001, for all scales). CONCLUSIONS: We observed significant gender-related differences in presenting symptoms of patients with sleep disordered breathing at a tertiary level. These differences should be taken into consideration in clinical evaluation of women with suspected sleep disordered breathing.     

Insomnia and hypersomnia associated with depressive phenomenology and comorbidity in childhood depression

STUDY OBJECTIVES: To examine sleep disturbance (insomnia and hypersomnia) and associated clinical profiles among depressed children and adolescents in terms of illness history, depressive severity, depressive phenomenology, and psychiatric comorbid disorders. DESIGN: Clinical profiles from standardized clinical evaluations were compared. SETTING: Twenty-three mental health facilities in Hungary between April 2000 and December 2004. PATIENTS AND MEASUREMENTS: Five hundred fifty-three children with a current episode of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depressive disorder: 55% were boys, mean age was 11.7 years (SD = 2.0, range = 7.3-14.9), and 94% were Caucasian. Sleep and depressive symptoms were assessed with the Interview Schedule for Children and Adolescents-Diagnostic Version. INTERVENTIONS: N/A. RESULTS: Of the total sample, 72.7% had sleep disturbance: 53.5% had insomnia alone, 9.0% had hypersomnia alone, and 10.1% had both disturbances. Depressed girls were more likely to have sleep disturbance than boys (77.0% vs 69.2%, p < .05), but age had no significant effects. Compared with children without sleep disturbance, sleep-disturbed children were more severely depressed and had more depressive symptoms and comorbid anxiety disorders. Across sleep-disturbed children, those with both insomnia and hypersomnia had a longer history of illness, were more severely depressed, and were more likely to have anhedonia, weight loss, psychomotor retardation, and fatigue than were those with either insomnia or hypersomnia. CONCLUSION: Clinical profiles differ between depressed children without and with sleep disturbance, with those presenting insomnia plus hypersomnia being most severely depressed. Differentiating depressed children with different sleep disturbances may have important implications for research efforts on the etiology and therapeutics of child depression.