摘要：Objectives. We examined the role of sleep disturbance in time to suicide since the last treatment visit among veterans receiving Veterans Health Administration (VHA) services. Methods. Among 423 veteran suicide decedents from 2 geographic areas, systematic chart reviews were conducted on the 381 (90.1%) who had a VHA visit in the last year of life. Veteran suicides with a documented sleep disturbance (45.4%) were compared with those without sleep disturbance (54.6%) on time to death since their last VHA visit using an accelerated failure time model. Results. Veterans with sleep disturbance died sooner after their last visit than did those without sleep disturbance, after we adjusted for the presence of mental health or substance use symptoms, age, and region. Conclusions. Findings indicated that sleep disturbance was associated with time to suicide in this sample of veterans who died by suicide. The findings had implications for using the presence of sleep disturbance to detect near-term risk for suicide and suggested that sleep disturbance might provide an important intervention target for a subgroup of at-risk veterans. Sleep disturbance is prevalent in and strongly associated with a variety of psychiatric and medical conditions. 1,2 Several reviews 3–5 and commentaries 6–8 have highlighted associations of sleep disturbance and suicidal thoughts and behaviors. Insomnia (difficulty initiating or maintaining sleep) and nightmares are the sleep disturbances most commonly associated with suicidal thoughts and behaviors, although some work suggests that sleep disordered breathing and periodic limb movement disorder may also pose risks. 9 Until recent years, empirical data were almost entirely based on studies of suicidal ideation and nonlethal suicide attempts, with unclear generalization to suicide deaths (hereafter referred to as “suicide”). There is, however, small but growing empirical literature linking sleep disturbance and suicide from cohort studies and investigations using postmortem case–control designs. A Finnish national cohort study of 21 to 64 year-old adults was linked with Finland’s National Death Registry to analyze the association of nightmares and suicide over a mean follow-up of approximately 14 years. 10 In adjusted models, the relative risk (RR) for suicide was 1.57 (95% confidence interval [CI] = 1.12, 2.19) for occasional nightmares and 2.05 (95% CI = 1.06, 3.97) for frequent nightmares compared with the no nightmares referent group. Adjusted analyses were not conducted. In Japan, a community cohort of adults aged 30 to 79 years were surveyed, with a mean follow-up of approximately 7 years. 11 Difficulty maintaining sleep was associated with suicide with an age-adjusted RR of 2.4 (95% CI = 1.3, 4.3) and a fully adjusted RR of 2.1 (95% CI = 1.1, 3.9). A 10-year, multisite, observational cohort of older adults (age ≥ 65 years) in the United States was used to compare suicides to control participants drawn from the larger sample. 12 Higher sleep quality scores were found to be protective from suicide with an odds ratio (OR) of 0.72 (95% CI = 0.58, 0.87). A Canadian postmortem case–control investigation compared adults who killed themselves during an episode of major depressive disorder to living patients of comparable age and gender with major depressive disorders. 13 In unadjusted models, insomnia symptoms were associated with suicide (OR 2.37; 95% CI = 1.21, 4.66), and this remained a significant finding after adjusting for the presence of other psychopathologies (OR 1.78; 95% CI = 1.22, 2.58). In a US case–control study of adolescent suicide, 14 hypersomnia and insomnia distinguished suicides from control participants in unadjusted analyses. In adjusted analyses, insomnia in the past week was associated with suicide at a statistically significant level (OR 5.3; 95% CI = 1.4, 20.4). Although samples, methods, and types of sleep disturbance varied across these studies, the findings consistently indicated an association of sleep disturbances to suicide. We are aware of no other published empirical studies of sleep disturbance and suicide in a veteran population. VHA is the largest integrated health care system in the United States. Veterans who receive VHA care are at increased risk for suicide compared with the US general population. 15 More than 1800 VHA users die by suicide each year, representing at least 5% of suicides in the United States annually. Accordingly, suicide prevention among veterans is both a national and VHA priority. 16 Sleep disturbances are prevalent in military returnees from Iraq and Afghanistan with posttraumatic stress disorder 17 or with mild traumatic brain injury. 18 Moreover, VHA users have high rates of sleep disturbance overall, 19 compelling the study of sleep disturbance and suicide in this population. The purpose of our study was to examine sleep disturbance and suicide in a sample of veterans who used Veterans Health Administration (VHA) services and died by suicide. More specifically, we focused on the impact of sleep disturbance on time to death among veteran suicide decedents by comparing a subgroup of suicide decedents with sleep disturbance to a subgroup without sleep problems. Another analysis of this sample showed that mental disorders predicted time to suicide, 20 informing our approach to examine sleep disturbance in time to death in the present study.
