Staff Perspective: Article Review - Screening for Suicide Risk in Adult Sleep Patients

Staff Perspective: Article Review - Screening for Suicide Risk in Adult Sleep Patients

Summary and implications of the following article:

Drapeau, C. W., Nadorff, M. R., McCall, W. V., Titus, C. E., Barclay, N., & Payne, A.
(2019). Screening for suicide risk in adult sleep patients. Sleep Medicine Reviews,
46, 17-26.

This article provides rationale for utilizing a suicide screening procedure in a sleep medicine setting and offers suggested elements for such screening. The authors note that the connection between sleep problems and suicide risk has become well established, although the mechanisms of this relationship are not yet clear. Even though research on the relationship between sleep problems and suicide is not new (these authors note that the relationship was known nearly sixty years ago!), an increase in the amount and specificity of research examining sleep and suicide has been fairly recent and has led to the inclusion of sleep disturbance as both a risk factor and a warning sign for suicide risk.

As a result of empirical findings linking sleep problems and suicide, national suicide prevention efforts have called for more primary care (PC) involvement in suicide-specific assessment, screening, and referral for patients. This is based on the knowledge that most individuals with sleep problems are seen by their PC provider rather than a mental health professional. Also, suicide research suggests that the majority of those who die by suicide have seen a PC provider in the past year for some kind of health problem. Importantly, one study cited in this article showed that a substantial number of suicide decedents reported sleep problems to their healthcare provider within one month of their death.

Although there is no known research reflecting numbers of sleep clinic visits among suicide decedents before death, the connection between sleep problems and increased suicide risk is well established as noted above. In addition, bringing PC providers and possibly other medical providers such as sleep medicine providers into the network of medical professionals assessing for suicide risk is a natural and logical opportunity, according to the authors of this study. Therefore, they propose several screening activities in sleep medicine clinics.

First, the proposal for screening for suicide in sleep medicine environments is discussed within the context of current and existing screening for suicide in other areas such as PC. Although there are findings like those discussed above that implicate the need to assess for suicide in areas of healthcare other than behavioral health, the recommendations that exist (such as the current Joint Commission requirement that a systematic assessment for suicide occur for every hospital patient with a mental health complaint), are based on relatively little empirical support. In fact, in 2004 and 2014, the US Preventative Services Task Force determined that there is actually not enough evidence to assess the risks and benefits of screening for suicide risk in PC settings. Other larger reviews drew similar conclusions, but a fairly recent randomized control trial found no adverse impact of doing such screening. Since we have data that supports an important link between suicide and sleep, AND the field has produced evidence indicating that the iatrogenic impact of screening is low, these authors propose the need to include sleep medicine clinics in the group of healthcare workers screening for suicide risk. Another important factor that these authors provide in support of doing screenings in sleep clinics is the evidence in the literature that suggests that physician inquiries about suicide risk are low when they are interacting with depressed patients. Further, since several sleep disorders are also listed in the DSM-5, sleep medicine providers need to decide how to proceed with assessing all relevant needs among their patient population.

In their recommendations about addressing suicide risk in sleep medicine clinics, the authors comment on the following areas:

  1. Screening issues. In addition to the lack of literature pointing to clear advantages to screening in non-behavioral health settings, the authors note instrument limitations for accurately predicting suicide. The PHQ-9, item 9, is used as an example. While this is a widely used measure in PC and behavioral health settings and has some support for predicting suicide in the next 12 months, its ability to predict imminent suicide risk has not been supported, making it less useful in a clinical setting. The recommended screening procedure is to provide each new patient a depression screening measure that has at least one item assessing for suicidal ideation (e.g., the Beck Depression Inventory) and a more in-depth assessment of suicide risk if a suicide-specific item is endorsed. The authors suggest using the the Columbia Suicide Severity Rating Scale (CSSRS) for a more thorough and suicide-specific assessment for the following reasons: a) the CSSRS is less likely to result in false-positive assessments than item 9 from the PHQ-9 and b) the CSSRS has been shown to have sufficient predictive validity and also screens for other correlates of greater suicide risk (e.g., preparatory behavior). A final and important recommendation from the authors about screening is to conduct recurring assessments for patients who endorsed suicide risk previously. This seems to have particular relevance for sleep medicine clinics given that the severity and chronicity of insomnia has been found to be important in its relationship to suicide risk.
  2. Referral recommendations. The authors emphasize the importance of referring patients who endorse any of the six items on the CSSRS to a licensed mental health professional. And, if needed, an avenue for an immediate acute safety evaluation is recommended if screening measures suggest an imminent risk. The authors note that not all endorsement of suicide risk suggests imminent risk and that those working in sleep clinics learn appropriate referral actions and resources to utilize.
  3. Iatrogenic effects. The authors speak to the myth that asking patients about suicide may increase their risk. While there is no evidence to support this, and there is evidence to suggest benefits of asking directly about suicide, the fear of liability among healthcare workers exists. An important aspect of training, then, is to educate non-behavioral healthcare workers about the role that adequate assessment and referral of patients can play in patient safety AND risk management/liability.
  4. Clinician-patient alliance. Of paramount importance when working with potentially suicidal patients is the role of the provider-patient relationship. Perhaps those working in sleep medicine clinics would benefit from expanded training about this in the context of assessing for suicide risk, as it is likely that their usual patient encounters do not rely as heavily on relationship aspects such as trust and accurate empathy to elicit accurate patient report of symptoms.

In summary, this article extends important empirical findings regarding suicide and sleep disturbance to make the proposal that screening for suicide be conducted in sleep medicine clinics. The authors present balanced information about the state of the literature, recognizing that there are still significant gaps in our knowledge about how effective it is to screen for suicide in settings outside of behavioral health. However, they also review important literature linking sleep problems of various types to increased suicide risk. This, in combination with the fact that screening patients in sleep clinics may identify patients who would not otherwise be assessed defines the sleep medicine setting as a needed part of a broader suicide prevention effort in healthcare settings.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Regina Shillinglaw, Ph.D., is a Senior Military Internship Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.