Treatment Strategies
The benefit of treating insomnia and nightmares, in regards to reducing suicidality, continues to be an area of active research. Many of the previous studies have theorized that treating symptoms of insomnia and nightmares may indirectly reduce suicide. Pharmaceutical and nonpharmaceutical treatments are currently being used to help treat patients with insomnia and nightmares, but the benefit for reducing suicidality is still unknown.
Dr. William V. McCall
One of the main treatment modalities for insomnia is hypnotic medication; however, these medications carry their own potential risk for suicide. Reports of suicide death in conjunction with hypnotic medication has led the FDA to add warnings about the increased risk of suicide with these medications. Some of these medications include zolpidem, zaleplon, eszopiclone, doxepin, ramelteon, and suvorexant. A review of research studies and case reports was completed in 2017 and showed that there was an odds ratio of 2 to 3 for hypnotic use in suicide deaths. However, most of the studies that were reviewed reported a potential confounding bias of the individual’s current mental health state. Furthermore, many of the suicide case reports that involved hypnotics also had additional substances detected, such as alcohol. Hypnotic medication has been shown to be an effective treatment for insomnia, but caution needs to be used when prescribing these medications. Strategies that may be beneficial when using hypnotic medication to reduce the risk of an adverse outcome include using the lowest effective dose and educating the patient of not combining the medication with alcohol or other sedative/hypnotics (McCall W, et al. Am J Psychiatry. 2017;174[1]:18).
For patients who have recurrent nightmares in the context of PTSD, the alpha-1 adrenergic receptor antagonist, prazosin, may provide some benefit; however, the literature is divided. There have been several randomized, placebo-controlled clinical trials with prazosin, which has shown a moderate to large effect for alleviating trauma-related nightmares and improving sleep quality. Some of the limitations of these studies were that the trials were small to moderate in size, and the length of the trials was 15 weeks or less. In 2018, Raskin and colleagues completed a follow-up randomized, placebo-controlled study for 26 weeks with 304 participants and did not find a significant difference between prazosin and placebo in regards to nightmares and sleep quality (Raskind MA, et al. N Engl J Med. 2018;378[6]:507).
Cognitive behavioral therapy for insomnia (CBT-I) and image rehearsal therapy (IRT) are two sleep-targeted therapy modalities that are evidence based. CBT-I targets dysfunctional beliefs and attitudes regarding sleep (McCall W, et al. J Clin Sleep Med. 2013;9[2]:135). IRT, on the other hand, specifically targets nightmares by having the patient write out a narrative of the nightmare, followed by re-scripting an alternative ending to something that is less distressing. The patient will rehearse the new dream narrative before going to sleep. There is still insufficient evidence to determine if these therapies have benefit in reducing suicide (Littlewood DL, et al. J Clin Sleep Med. 2016;12[3]:393).
While the jury is still out on how best to target and treat the risk factors of insomnia and nightmares in regards to suicide, there are still steps that health-care providers can take to help keep their patients safe. During the patient interview, new or worsening insomnia and nightmares should prompt further investigation of suicidal thoughts and behaviors. After a thorough interview, treatment options, with a discussion of risks and benefits, can be tailored to the individual’s needs. Managing insomnia and nightmares may be one avenue of suicide prevention.
Drs. Locrotondo and McCall are with the Department of Psychiatry and Health Behavior at the Medical College of Georgia, Augusta University, Augusta, Georgia.