Co prescription of hypnotic controls suicidal thoughts in depressed patients with insomnia: REST-IT Study

Co prescription of hypnotic controls suicidal thoughts in depressed patients with insomnia finds REST-IT Study.

A recent study has found that prescribing sleeping pills during the initiation of antidepressants in depressed patients with insomnia may reduce suicidal thoughts by addressing their sleep problems.

Results of the study, published in The American Journal of Psychiatry, however, do not support the routine prescription of hypnotic medication for mitigating suicidal ideation in all depressed patients with insomnia.

Many previous studies have linked insomnia to suicidal thoughts or actions however suicide risk and prevention are largely overlooked in insomnia treatment. In REST-IT -- Reducing Suicidal Ideation Through Insomnia Treatment -- study, William V. McCall, chair of the Department of Psychiatry and Health Behavior at the Medical College of Georgia at Augusta University, and colleagues sought to determine whether targeted treatment of insomnia with controlled-release zolpidem (zolpidem-CR) in suicidal adults with insomnia would provide a reduction in suicidal ideation superior to placebo.

"If you have a patient who complains that their sleep has taken a turn for the worse then there is a reason to open the door to a question about suicide," says Dr. McCall. "If your patient says their sleep problem is really bad and they have had thoughts of killing themselves, maybe they should have a targeted treatment for their insomnia."

"While the results do not argue for the routine prescription of hypnotics for mitigating suicidal ideation in all depressed outpatients with insomnia, they suggest that co presciption of a hypnotic during initiation of an antidepressant may be beneficial in suicidal outpatients, especially in patients with severe insomnia," wrote the authors.

The study involved 103 participants (aged 18 to 65) with major depressive disorder, insomnia and suicidal thoughts. Thirty percent had a prior suicide attempt, however, individuals with an active and imminent plan to commit suicide were excluded out of concern for their safety since it was an outpatient study.

All participants took an antidepressant for the eight-week duration of the trial and half also took the sedative-hypnotic zolpidem at bedtime.

Participants completed regular self-reports of the severity of their insomnia and completed a daily sleep diary during their treatment that included details like how many times they woke up during the night and how long they actually slept.

Investigators also measured distorted thoughts about sleep, like participants thinking they would never again have a good night's sleep, something McCall has previously shown is itself a risk factor for suicide. The frequency and intensity of disturbing dreams or nightmares, also a factor in insomnia-associated suicide also were measured. Patients wore a wrist device to keep up with rest/activity cycles. Depression severity was measured by psychiatry staff at each study visit and participants also completed the Beck Hopelessness Scale, which measures pessimism and negative expectations and is considered a predictor of suicidal behaviour in adults and adolescents.

Also Read: Suicide : Second leading cause of death among young people: WHO

Key findings include:

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  Those taking the sleep aid showed both significant immediate and longer-term improvement in their reported insomnia severity.

  
  


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  While both groups reported significant improvement in their feelings about hopelessness, quality of life, nightmares and dysfunctional beliefs about sleep, as well as related insomnia and suicidality, the group taking the sleep aid, had a greater reduction in suicidal thinking.

  
  


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  Sleep aid was most effective in reducing suicidal thoughts in patients with the most severe insomnia.

  
  


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  There were no deaths or suicide attempts by participants during the course of the study.

  
  

Also Read: Suicide risk triples in patients with restless legs syndrome: JAMA Study

Hypnotics, like the drug they used for the study, are a common means to commit suicide, and there are also concerns about becoming dependent on them. To address these concerns, participants only received a week's supply of sleep aid until their suicidal thoughts began to abate, and the sleep aid was stopped after eight weeks. Afterwards, their condition remained the same or continued to improve, McCall says. Eight weeks is the timeframe McCall uses in prescribing the drug in his practice.

Two weeks after the study concluded both study groups -- including those not taking the sleep aid -- appeared to have maintained progress with reduced depression scores and suicidal thoughts. A possible reason all participants benefitted could be the extra attention they received over the course of the study, McCall notes.

Now he wants to understand more about why insomnia is a risk for suicide and how treating it reduces that risk.

Insomnia dramatically increases the risk of depression and vice versa and both increase suicide risk, McCall says. Depression studies often exclude those with strong suicidality, he says.

To read the complete study log on to https://doi.org/10.1176/appi.ajp.2019.19030267