SLEEP, Vol. 30, No. 1, 2007
NIGHTMARES AND SUICIDE
THERE IS EVIDENCE THAT SLEEP DISTURBANCE
INCREASES SUICIDE RISK. MOST STUDIES HAVE
FOCUSED ON PATIENTS WITH AFFECTIVE DISORDER.
Global insomnia has been shown to predict suicide during the year
after hospitalisation for depression.1 Ağargün and colleagues exam-
ined sleep disturbance and suicidal behavior in patients with major
depression and found that patients with hypersomnia and insom-
nia scored higher on the suicide subscale of the Schedule for Af-
fective Disorders and Schizophrenia than did those without these
sleep disturbances.2 Singareddy and Balon reviewed the literature
on sleep and suicide and noted that sleep disturbance appears to be
more common among psychiatric patients with suicidal behavior
than among those without.3 In one study focusing specifically on
suicide attempters, Hall and colleagues found that global or partial
insomnia predicted suicidal behavior.4 However, the authors did
not examine the contribution of specific sleep difficulties. Because
an association between nightmares and suicide has been reported
in a general population study,5 we were interested in examining
this relationship in our sample of suicide attempters. The aims of
the current study were to examine the prevalence of specific sleep
disturbances in suicide attempters and to test the associations
between specific sleep disturbances and suicidality.
Study participants were recruited among patients aged 18 to 69
years who took part in a routine clinical interview in connection
with hospital care after a suicide attempt.
Suicide attempt was defined as “a situation in which a person
has performed an actually or seemingly life-threatening behavior
with the intent of jeopardizing his life, or to give the appearance
of such an intent, but which has not resulted in death.”6 Only reg-
istered residents of the Sahlgrenska University Hospital catch-
ment area (210,000 inhabitants) with at least basic knowledge
of Swedish and cognitive capacity to understand were included.
Seventy-nine attempters who otherwise fulfilled inclusion criteria
were released before they could be approached to take part in the
clinical interview and 38 refused. In all, 206 patients completed
the clinical interview during the study period (October 1, 2001,
- June 30, 2004). One hundred and sixty-five of these (80%) ac-
cepted participation in the research project.
Three experienced psychiatric nurses and 1 senior psychiatrist
carried out the interviews at the Sahlgrenska University Hospital.
The face-to-face clinical interview, which took place within a
week after admission, included self-rating instruments assessing
symptoms present during the past 3 days.
The Structured Clinical Interview for Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV) SCID-I
was used to assess DSM-IV Axis-I disorders. Axis-I diagnoses
were grouped according to the Swedish SCID-I interview manu-
Nightmares and Sleep Disturbances in Relation to Suicidality in Suicide Attempters
Nisse Sjöström, RN1; Margda Wærn, MD1; Jerker Hetta, MD2
1Institute of Neurosience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy at Göteborg University, Blå Stråket 15,
SE 413 45 Göteborg, Sweden 2Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden
Nightmares and Suicidal Behavior—Sjöström et al
This was not an industry supported study. Dr. Wærn has participated in
speaking engagements supported by Pfizer. Drs. Sjöström and Hetta have
indicated no financial conflicts of interest.
Submitted for publication February 17, 2006
Accepted for publication September 7, 2006
Address correspondence to: Nisse Sjöström, Department of Psychiatry and
Neurochemistry, Sahlgrenska University Hospital, SE-413 45 Göteborg,
Sweden; Tel: 46 31 342 21 63, 46 70 743 71 10; Fax: 46 31 82 81 63; E-mail:
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 Uni-
versity Hospital after a suicide attempt.
Measurements: The face-to-face interview included Structured Clinical
Interview for DSM-IV-IV and the Suicide Assessment Scale. Two self-re-
port instruments were employed, the Uppsala Sleep Inventory and Com-
prehensive Psychopathological Self-rating Scale for Affective Syndromes.
The latter assessed symptom burden. Using multiple logistic regression
analyses, we examined associations between sleep complaints and sui-
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 relation-
ship remained after adjustment for psychiatric diagnosis and psychiatric
Conclusions: Sleep disturbances are common among suicide attempt-
ers. Nightmares are associated with suicidality. Our findings suggest that
questions concerning sleep disturbance and nightmares should be ad-
dressed in the clinical assessment of suicidal patients.
Keywords: Nightmare, suicide, sleep
Citation: Sjöström N; Wærn M; Hetta J. Nightmares and sleep disturbanc-
es in relation to suicidality in suicide attempters. SLEEP 2007:30(1);91-