Insomnia as a Predictor of High-Lethality Suicide Attempts
Insomnia as a Predictor of High-Lethality Suicide Attempts
The sample consisted of consecutive patients admitted from January 2010 to December 2011 to the ED of Sant'Andrea Hospital and assessed by the psychiatrist in charge satisfying the inclusion criteria (e.g. admission to the ED, ability to take part in the assessment procedure and provision of informed consent). Exclusion criteria included the presence of mental retardation (IQ < 70), delirium, and all other factors affecting the ability of the psychiatrist in charge to complete the assessment of mental status and sleep patterns. Patients participated voluntarily in the study and provided written informed consent. The study protocol was approved by the local research ethics review board.
A total of 885 patients seeking psychiatric consultation were admitted to the ED in the time frame considered for the study, and 843 gave their informed consent (response rate = 95.3%). Patients who denied informed consent and those included in the final sample did not differ for sex and age. For these patients, a detailed clinical record was provided by the ED physician, which included a comprehensive psychiatric evaluation conducted by the psychiatrist on duty. Depending on the seriousness of the symptoms, patients were referred either to outpatient clinics or hospitalised. Of the 843 patients included in the final sample, 300 patients were hospitalised in the Department of Psychiatry (see Table 1 for sociodemographic variables). The initial evaluation was performed in the ED for each patient and was discussed in a diagnostic conference to determine the appropriate diagnosis (according to ICD-10 criteria, which is the official mode for providing diagnoses in the Italian Health Service) within 3 days of the admission.
All patients admitted to the ED suffering from psychiatric disorders and/or who had attempted suicide were referred to a psychiatrist while in the ED, where an interview was conducted. During the interviews, a complete mental examination was performed and patients were asked about 'ongoing' suicidal ideation or plans for suicide. According to the revised nomenclature, these acts should be labelled suicide attempts type II, that is, a self-destructive act with some degree of intent to end one's life and some identifiable injuries. Patients were interviewed as soon as the psychiatrist on call had medical clearance.
Ongoing suicidal ideation was defined as thoughts of serving as the agent of one's own death. Patients who were deemed suicidal ideators were those who were still thinking that suicide was a good option for their problems, wished that they were dead, or were unhappy to be rescued.
Clinicians performing the mental examination relied on the Mini International Neuropsychiatric Interview (MINI). In this study, MINI diagnoses were confirmed by clinical DSM-IV-TR diagnoses. Clinical diagnoses were assigned by a staff psychologists and the attending psychiatrist. Clinicians on duty at the ED were seven psychiatrists who were trained to administer the MINI interview; inter-rater reliability between those performing such task was κ = 0.89.
Clinicians evaluated insomnia according to the estimate of sleep difficulties occurring during the last month before the assessment. The assessment of insomnia was based on a checklist of items on the Athens Insomnia Scale which evaluated the frequency and severity of difficulties with sleep (e.g. time to fall asleep after turning-off the lights, awakenings during the night, final awakening earlier than desired), and the general quality of sleep (i.e. total sleep duration, overall quality of sleep). The patients were considered to have insomnia if difficulties occurred at least three times per week in the last month and were causing a markedly insufficient total sleep duration or a markedly unsatisfactory quality of sleep. Most patients had a combination of initiating and maintaining sleep (56%), some had difficulty initiating sleep (27%); only 17% of these patients had early morning awakening.
Chi-squared tests with Yates's correction, one-way Fisher's exact tests and t-tests were conducted for the bivariate analyses. Benjamini and Hochberg's procedure was used to correct for multi-testing. Log-linear models were employed to assess the multivariate association among variables. Variables statistically significant (p < 0.05) after correction for multi-testing were selected for inclusion in the multivariate model. Odds Ratios (ORs) and their significance values were calculated. All statistical analyses were performed using the Spss 19.0 statistical software package (IBM Corp., Armonk, NY, USA).
Methods
Design
The sample consisted of consecutive patients admitted from January 2010 to December 2011 to the ED of Sant'Andrea Hospital and assessed by the psychiatrist in charge satisfying the inclusion criteria (e.g. admission to the ED, ability to take part in the assessment procedure and provision of informed consent). Exclusion criteria included the presence of mental retardation (IQ < 70), delirium, and all other factors affecting the ability of the psychiatrist in charge to complete the assessment of mental status and sleep patterns. Patients participated voluntarily in the study and provided written informed consent. The study protocol was approved by the local research ethics review board.
Participants
A total of 885 patients seeking psychiatric consultation were admitted to the ED in the time frame considered for the study, and 843 gave their informed consent (response rate = 95.3%). Patients who denied informed consent and those included in the final sample did not differ for sex and age. For these patients, a detailed clinical record was provided by the ED physician, which included a comprehensive psychiatric evaluation conducted by the psychiatrist on duty. Depending on the seriousness of the symptoms, patients were referred either to outpatient clinics or hospitalised. Of the 843 patients included in the final sample, 300 patients were hospitalised in the Department of Psychiatry (see Table 1 for sociodemographic variables). The initial evaluation was performed in the ED for each patient and was discussed in a diagnostic conference to determine the appropriate diagnosis (according to ICD-10 criteria, which is the official mode for providing diagnoses in the Italian Health Service) within 3 days of the admission.
Measures
All patients admitted to the ED suffering from psychiatric disorders and/or who had attempted suicide were referred to a psychiatrist while in the ED, where an interview was conducted. During the interviews, a complete mental examination was performed and patients were asked about 'ongoing' suicidal ideation or plans for suicide. According to the revised nomenclature, these acts should be labelled suicide attempts type II, that is, a self-destructive act with some degree of intent to end one's life and some identifiable injuries. Patients were interviewed as soon as the psychiatrist on call had medical clearance.
Ongoing suicidal ideation was defined as thoughts of serving as the agent of one's own death. Patients who were deemed suicidal ideators were those who were still thinking that suicide was a good option for their problems, wished that they were dead, or were unhappy to be rescued.
Clinicians performing the mental examination relied on the Mini International Neuropsychiatric Interview (MINI). In this study, MINI diagnoses were confirmed by clinical DSM-IV-TR diagnoses. Clinical diagnoses were assigned by a staff psychologists and the attending psychiatrist. Clinicians on duty at the ED were seven psychiatrists who were trained to administer the MINI interview; inter-rater reliability between those performing such task was κ = 0.89.
Clinicians evaluated insomnia according to the estimate of sleep difficulties occurring during the last month before the assessment. The assessment of insomnia was based on a checklist of items on the Athens Insomnia Scale which evaluated the frequency and severity of difficulties with sleep (e.g. time to fall asleep after turning-off the lights, awakenings during the night, final awakening earlier than desired), and the general quality of sleep (i.e. total sleep duration, overall quality of sleep). The patients were considered to have insomnia if difficulties occurred at least three times per week in the last month and were causing a markedly insufficient total sleep duration or a markedly unsatisfactory quality of sleep. Most patients had a combination of initiating and maintaining sleep (56%), some had difficulty initiating sleep (27%); only 17% of these patients had early morning awakening.
Statistical Analysis
Chi-squared tests with Yates's correction, one-way Fisher's exact tests and t-tests were conducted for the bivariate analyses. Benjamini and Hochberg's procedure was used to correct for multi-testing. Log-linear models were employed to assess the multivariate association among variables. Variables statistically significant (p < 0.05) after correction for multi-testing were selected for inclusion in the multivariate model. Odds Ratios (ORs) and their significance values were calculated. All statistical analyses were performed using the Spss 19.0 statistical software package (IBM Corp., Armonk, NY, USA).
Source...