Insomnia involves difficulty going to sleep or going back to sleep when awakened in the night or early morning. Approximately 10–15% of adults have insomnia disorder, making it the most prevalent sleep disorder, and periodic symptoms of insomnia are far more common in the general population affecting over 30% annually (Chung et al., Reference Chung, Yeung, Ho, Yung, Yu and Kwok2015; Roth Reference Roth2007). Insomnia can have a profound impact on psychological functioning and has been linked to poorer mental health, cognitive performance deficits and averse work-related outcomes (Kucharczyk et al., Reference Kucharczyk, Morgan and Hall2012; Leger & Bayon Reference Leger and Bayon2010; Léger et al., Reference Léger, Bayon, Ohayon, Philip, Ement, Metlaine, Chennaoui and Faraut2014). The negative impact of insomnia on psychological functioning, at its height, may influence one’s desire to live. Like insomnia, rates of suicide have risen in the United States in recent decades (Garland et al., Reference Garland, Rowe, Repa, Fowler, Zhou and Grandner2018; Reference Hedegaard, Curtin and WarnerHedegaard et al., 2020), and there is mounting evidence for a close association between symptoms of insomnia and suicidality (Pigeon et al., Reference Pigeon, Pinquart and Conner2012). Several psychological factors have been studied as potential mechanisms, and some studies suggest that depression does not fully explain this association (Bernert & Nadorff Reference Bernert and Nadorff2015; Bjørngaard et al., Reference Bjørngaard, Bjerkeset, Romundstad and Gunnell2011; Kay, Dombrovski et al., Reference Kay, Dombrovski, Buysse, Reynolds, Begley and Szanto2016; Simmons et al., Reference Simmons, Burlingame, Korbanka, Eastman, Thomas, Christensen, Jenson, Nadorff and Kay2021; Simmons et al., Reference Simmons, Erickson, Hedges and Kay2020; Tubbs et al., Reference Tubbs, Killgore, Karp, Fernandez and Grandner2022). This study addresses the question, “What role do sleep and circadian rhythms play in psychological functioning including motivation, emotion, cognition and performance?” by testing several psychological factors that may explain the association between insomnia and suicidal ideation frequency including emotion dysregulation, thwarted belongingness and perceived burdensomeness, while accounting for depression.
Emotion regulation, as described by Gratz and Roemer, is a multifaceted construct involving “the (a) awareness and understanding of emotions, (b) acceptance of emotions, (c) ability to control impulsive behaviors and behave in accordance with desired goals when experiencing negative emotions, and (d) ability to use situationally appropriate emotion regulation strategies flexibly to modulate emotional responses as desired in order to meet individual goals and situational demands” (Gratz & Roemer Reference Gratz and Roemer2004). The absence of any of these facets is thought to indicate emotion dysregulation. Emotion dysregulation is associated with insomnia and has been proposed as a mechanism through which insomnia and general psychiatric impairments are related (Vanek et al., Reference Vanek, Prasko, Genzor, Ociskova, Holubova, Sova, Kantor, Slepecky and Nesnidal2020). More specifically, emotion dysregulation may be a mechanism in the association between insomnia and suicidal ideation (Bernert & Joiner Reference Bernert and Joiner2007; Bernert & Nadorff Reference Bernert and Nadorff2015; Chu et al., Reference Chu, Hom, Rogers, Stanley, Ringer-Moberg, Podlogar, Hirsch and Joiner2017).
Joiner’s interpersonal theory of suicide (IPTS) is a prominent explanation of suicide that involves three major risk factors: thwarted belongingness, perceived burdensomeness and acquired capacity (Van Orden et al., Reference Van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner2010). Thwarted belonging refers to an unmet basic human need for social connectedness, leading to social isolation and interpersonal distress. Perceived burdensomeness refers to one’s maladaptive perception that suicide would relieve the burden they impose on the world (Van Orden et al., Reference Van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner2010). These two factors, but not acquired capacity, have been found to correlate with insomnia and suicidality, and there is evidence they may be mechanisms in the association between insomnia and suicidal ideation (Chu et al., Reference Chu, Hom, Rogers, Ringer, Hames, Suh and Joiner2016; Chu et al., Reference Chu, Hom, Rogers, Stanley, Ringer-Moberg, Podlogar, Hirsch and Joiner2017; Golding et al., Reference Golding, Nadorff, Winer and Ward2015; Nadorff et al., Reference Nadorff, Anestis, Nazem, Claire Harris and Samuel Winer2014; Van Orden et al., Reference Van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner2010). Other studies are mixed or failed to show that these factors are involved in the association between insomnia and suicidal ideation (Britton et al., Reference Britton, McKinney, Bishop, Pigeon and Hirsch2019; Chu et al., Reference Chu, Hom, Rogers, Ringer, Hames, Suh and Joiner2016; Hom et al., Reference Hom, Chu, Schneider, Lim, Hirsch, Gutierrez and Joiner2017; Hom et al., Reference Hom, Stanley, Chu, Sanabria, Christensen, Albury, Rogers and Joiner2019). In this study, we aimed to determine whether emotion dysregulation, thwarted belongingness or perceived burdensomeness play a mediating role in the insomnia–suicidal ideation severity association, even when accounting for depression.
Methods
A Qualtrics team recruited participants from the United States to complete an anonymous online survey between April and May of 2022. Participants were recruited from a number of sources including website intercept recruitment, member referrals, targeted email lists, gaming sites, customer loyalty web portals, permission-based networks and social media. We requested that the Qualtrics team strive for a sample that was nationally representative by age (18–34: 30%, 35–54: 32%, 55+: 38%), race (White: 75%, Black: 13%, Asian or Pacific Islander: 6%, American Indian/Alaskan Native or Other: 6%) and gender (male: 48%, female: 52%) based on United States census data to increase the generalizability of our findings. Participants were informed of the risks of the survey and provided informed consent electronically. To protect the participants, the national suicide prevention hotlines and texting services were provided at the beginning and end of the survey. Following informed consent, participants completed several questionnaires to assess demographics, insomnia severity, suicidal ideation frequency, emotional regulation, thwarted belongingness and perceived burdensomeness. Sample size was determined through previous study designs, as well as power analyses. Previous cross-sectional mediational studies investigating the role components of the IPTS play in the association between insomnia symptoms and suicidality have used sample sizes of 552 college students (Chu et al., Reference Chu, Hom, Rogers, Ringer, Hames, Suh and Joiner2016), 937 United States (U.S.) military service members, 3,386 Army recruiters, 417 military veterans (Hom et al., Reference Hom, Chu, Schneider, Lim, Hirsch, Gutierrez and Joiner2017), 469 U.S. undergraduate students, 352 adult mental health outpatients, 858 U.S. firefighters (Chu et al., Reference Chu, Hom, Rogers, Stanley, Ringer-Moberg, Podlogar, Hirsch and Joiner2017), 747 undergraduate students, 604 undergraduate students (Nadorff et al., Reference Nadorff, Anestis, Nazem, Claire Harris and Samuel Winer2014) and 151 adolescent psychiatric inpatients (Zullo et al., Reference Zullo, Horton, Eaddy, King, Hughes, Diederich, Kennard, Emslie and Stewart2017). Further, our power analysis found that a sample of 400 participants would allow us to distinguish small to medium effect sizes (f 2 = 0.04) with .85 power (G*Power 3). Given previous studies’ sample sizes and sample makeup and our power analyses, we suggest that a nationally representative sample of 400 individuals is sufficient for our study and offers a meaningful addition to the literature.
To maximize the variability of insomnia severity, a stratified sample with at least 100 participants for each quartile of insomnia severity according to the Insomnia Severity Index (ISI) was recruited: 106 had minimal insomnia symptoms (ISI = 0–7), 107 had subthreshold insomnia (ISI = 8–14), 108 had moderate severity clinical insomnia symptoms (ISI =15–21) and 103 had severe clinical insomnia (ISI = 22–28).
The Qualtrics team provided a sample of 428 participants who completed the survey without any missing data and who denied having a sleep apnea diagnosis. The Qualtrics team sought to ensure that demographic features were stratified across all four groups to avoid sampling bias. Four participants in the dataset they provided were excluded from analyses for completing the survey too quickly (<490 seconds). The analysis sample approximated national representation, 52% identified as female, 58% were white and 46% endorsed never being married. Participants with education levels from less than a high school diploma to doctorate and professional degrees, ages from 18 to 89 and an annual income from <$10,000 to >$190,000 were represented. Table 1 shows demographic features in the overall sample as well as across insomnia severity groups.
Table 1. Demographic and psychological features across insomnia severity groups
Note: NI = no clinically significant insomnia, SI = subthreshold insomnia, CIM = clinical insomnia (moderate severity), CIS = clinical insomnia (severe), M(SD), n(%).
Measures
Demographics included were gender (woman, man, non-binary, other), age (18–24, 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, 85–89), race (American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian or Other Pacific Islander, White, multiracial, other), education (less than a high school diploma, high school degree or equivalent (e.g., GED), some college, associate degree, bachelor’s degree, master’s degree, professional degree, doctorate), income (<$10,000, >$10,000–$40,000, $40,001–$90,000, $90,001–$190,000, >$190,000) and marital status (never married, married, widowed, divorced, separated). Participants were asked to report the medications they were currently taking in a fill-in-the-blank format and any mental disorders they were currently and formally diagnosed with (depressive, psychotic, anxiety, personality, substance use, bipolar, neurodevelopmental, neurocognitive, trauma-related, obsessive-compulsive and somatic disorders) from a multi-selection item.
Insomnia severity was determined using the ISI, a widely used and well-validated measure of insomnia severity over the past 2 weeks (Bastien et al., Reference Bastien, Vallieres and Morin2001). Emotional dysregulation was determined using the Difficulties in Emotion Regulation Scale (DERS), a 36-item self-report measure that asks participants to indicate the frequency of experiences they have that are related to emotion (Gratz & Roemer Reference Gratz and Roemer2004). The DERS has excellent internal consistency (α = 0.93), correlates well with the Negative Mood Regulation Scale (r = 0.69, p < 0.01) and demonstrates good test-retest reliability (ρ = .88, p < 0.01) (Gratz & Roemer Reference Gratz and Roemer2004). Thwarted belongingness and perceived burdensomeness were determined using the Interpersonal Needs Questionnaire (INQ), a 15-item self-report measure. The sum of the first six items was the subscale for perceived burdensomeness, while the last nine items served as the subscale for thwarted belongingness. The INQ showed a good fit on confirmatory factor analysis in terms of the Comparative Fit Index (0.86–0.92), Tucker-Lewis Index (0.84–0.90), Root Mean Square Error of Approximation (0.06–0.08), and Standardized Root Mean Square Residual (0.05–0.07) (Van Orden et al., Reference Van Orden, Cukrowicz, Witte and Joiner2012). Increased INQ scores predicted higher suicidality (thwarted belongingness 95% Confidence Interval for the Incidence Rate Ratio (CI IRR) = 1.007–1.009 and perceived burdensomeness 95% CI IRR = 1.04–1.90). Suicidal ideation frequency was determined using the Frequency of Suicidal Ideation Inventory (FSII) total score, a 5-item self-report measure that asks participants to assess the frequency of suicidal ideation-related experiences over the past year. The FSII has excellent internal consistency (α = 0.96), strong convergent validity with other measures of depression including the Adult Suicidal Ideation Questionnaire (r = 0.88, p < 0.01), Suicide Behaviors Questionnaire-Revised (r = 0.85, p < 0.01), and Beck Depression Inventory (r = 0.54, p < 0.01), and moderate test-retest reliability (ρ = 0.61) (Chang & Chang, Reference Chang and Chang2016). Depression severity was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Emotional Distress – Depression – Short Form, an 8-item self-report instrument. Anxiety severity was evaluated using the PROMIS Emotional Distress – Anxiety – Short Form, a 7-item self-report measure. The PROMIS measures display high internal consistency (α = .95 and .93, respectively) and good convergent validity with the Center for Epidemiologic Studies Depression Scale (r = .83 and .80, respectively) and are sensitive to change in treatment (Pilkonis et al., Reference Pilkonis, Choi, Reise, Stover, Riley and Cella2011; Schalet et al., Reference Schalet, Pilkonis, Yu, Dodds, Johnston, Yount, Riley and Cella2016).
Statistical analysis
Multiple regression analyses between self-reported insomnia and suicidal ideation frequency were used to gauge the strength of this relationship while controlling for demographic variables, depression and anxiety. We used structural equation modeling to perform an uncontrolled mediational analysis to understand the role emotion regulation, thwarted belongingness and perceived burdensomeness play in the relationship between insomnia severity and suicidal ideation frequency. We then used a controlled mediational model to account for depression in the previously described analysis. The mediational models are saturated. All analyses were completed in STATA 17 (StataCorp, 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC).
Results
Results for the uncontrolled and controlled multiple regression models are presented in Table 2. In both analyses, we controlled for demographic variables (age, gender, race-ethnicity, educational attainment and marital status). In the controlled model, we also included depression and anxiety severity. The uncontrolled model was significant, F (32,391) = 5.39, p < 0.001, R 2 = 0.306. Insomnia severity was associated with increased suicidal ideation frequency, even when accounting for demographic variables. The age categories of 55–64, 65–74 or 75–84 were associated with lower suicidal ideation frequency, and individuals who identified as Black/African American had lower suicidal ideation frequency. The controlled model was also significant, F (32,389) = 11.37, p < 0.001, R 2 = 0.498. Insomnia was not significantly associated with suicidal ideation frequency when controlling for anxiety and depression severity. Individuals who identified as American Indian/Alaska Native or as being multiracial had higher suicidal ideation frequency. Depression severity was also associated with higher suicidal ideation frequency.
Table 2. Insomnia severity as a predictor of suicidal ideation frequency
Note: Model 1 controls for demographic variables. Model 2 controls for demographic variables, anxiety severity and depression severity. *p < 0.05, **p < .01, ***p < .001.
Results for the structural equation models are presented in Figures 1 and 2. In both models, we tested whether the association between insomnia severity and suicidal ideation frequency was mediated by emotion regulation, thwarted belongingness and perceived burdensomeness using maximum likelihood estimation. Both the uncontrolled and controlled models were saturated. Unstandardized beta values are reported.
Figure 1. Uncontrolled mediational model for emotion regulation, thwarted belongingness and perceived burdensomeness in insomnia–suicidal ideation frequency association.
Note: ISI: Insomnia Severity Index, DERS: Difficulties in Emotion Regulation Scale, INQ: Interpersonal Needs Questionnaire, FSII: Frequency of Suicidal Ideation Inventory.
Figure 2. Controlled mediational model for emotion regulation, thwarted belongingness and perceived burdensomeness in insomnia–suicidal ideation frequency association.
Note: ISI: Insomnia Severity Index, DERS: Difficulties in Emotion Regulation Scale, INQ: Interpersonal Needs Questionnaire, PROMIS-Depression: The Patient-Reported Outcomes Measurement Information System Emotional Distress – Depression – Short Form, FSII: Frequency of Suicidal Ideation Inventory.
In the controlled model, we accounted for depression severity in addition to emotion regulation, thwarted belongingness and perceived burdensomeness. In this model, insomnia severity was significantly associated with emotion regulation, thwarted belongingness and perceived burdensomeness. Emotion regulation and perceived burdensomeness were significantly associated with suicidal ideation frequency, while thwarted belongingness was not. The indirect effects for emotion regulation and perceived burdensomeness were significant, while the indirect effect for thwarted belongingness was not. The direct effect, indirect effect and the total effect were significant (Figure 1). Chi-squared fit statistics for the uncontrolled model was χ2 (10, n = 424) = 1195.79, p < 0.001. The ratio of the indirect effect to the total effect between insomnia severity and suicidal ideation frequency was 0.84, suggesting that 84% of the variance in the total effect was explained by the mediator variables. These results suggest that the association between insomnia severity and suicidal ideation frequency is partially mediated by emotion regulation and perceived burdensomeness.
Regarding the direct effects in the controlled model, insomnia severity was significantly associated with emotion regulation, but not with thwarted belongingness or perceived burdensomeness. Emotion regulation and perceived burdensomeness were significantly associated with suicidal ideation frequency, while thwarted belongingness was not. The indirect effects in the insomnia–suicidal ideation frequency path for emotion regulation, thwarted belongingness and perceived burdensomeness were not significant. The direct effect between insomnia severity and depression severity was significant. Further, the direct effects between depression severity and suicidal ideation frequency, emotion regulation, thwarted belongingness and perceived burdensomeness were significant. The indirect effect in the insomnia-suicidality path through depression was significant. The indirect effects in the insomnia-mediator paths through depression were significant for emotion regulation, thwarted belongingness and perceived burdensomeness. The indirect effects for the depression-suicidality paths through the mediator variables were significant for emotion regulation and perceived burdensomeness, but not thwarted belongingness. Regarding the association between insomnia and suicidal ideation frequency, the direct effect was not significant, while the indirect effect and the total effect were significant (Figure 2). Chi-squared fit statistics for the controlled model was, χ2 (15, n = 424) = 1705.86, p < 0.001. The ratio of the indirect effect to the total effect between insomnia severity and suicidal ideation frequency was 0.96, suggesting that 96% of the variance in the total effect was explained by the mediator variables. These results suggest that the association between insomnia severity and suicidal ideation frequency is mediated by emotion regulation and perceived burdensomeness through depression severity.
Discussion
In this study, we found evidence that several psychological factors are involved in the association between insomnia and suicidal ideation. In a sample that approximated a representative U.S. adult sample, we replicated previous studies suggesting that insomnia is an important marker and risk factor for suicidality through several psychological factors. Greater insomnia severity was associated with more frequent suicidal ideation over the past year, even when controlling for demographic features. When accounting for depression, we found that emotion dysregulation and perceived burdensomeness, but not thwarted belongingness, played unique roles in the association between insomnia and suicidal ideation frequency. This is consistent with a previous study where an indirect effect for insomnia symptoms was observed through perceived burdensomeness and depressive symptoms (Zullo et al., Reference Zullo, Horton, Eaddy, King, Hughes, Diederich, Kennard, Emslie and Stewart2017). While insomnia severity was associated with thwarted belongingness, it did not explain the association between insomnia and suicidal ideation frequency. Two previous studies found that thwarted belongingness mediated insomnia and suicidality cross-sectionally but not longitudinally (Chu et al., Reference Chu, Hom, Rogers, Ringer, Hames, Suh and Joiner2016; Chu et al., Reference Chu, Hom, Rogers, Stanley, Ringer-Moberg, Podlogar, Hirsch and Joiner2017), and an additional study indicated a similar mediation effect cross-sectionally but not longitudinally through both thwarted belongingness and perceived burdensomeness (Hom et al., Reference Hom, Stanley, Chu, Sanabria, Christensen, Albury, Rogers and Joiner2019). One study found that thwarted belongingness explained the association between insomnia and suicidal ideation frequency only through depression (Britton et al., Reference Britton, McKinney, Bishop, Pigeon and Hirsch2019), while another found that the relationship between insomnia and suicidal ideation is explained by thwarted belongingness only among Veterans, but not among civilians or service members (Tubbs et al., Reference Tubbs, Killgore, Karp, Fernandez and Grandner2022). Another set of studies indicated that thwarted belongingness and perceived burdensomeness play equally significant roles in mediating the relationship between insomnia symptoms and suicidal ideation. In one sample, thwarted belongingness was found to have a stronger indirect effect on suicidal ideation than perceived burdensomeness (Tucker et al., Reference Tucker, Cramer, Langhinrichsen-Rohling, Rodriguez-Cue, Rasmussen, Oakey-Frost, Franks and Cunningham2021). As collective results are inconclusive, further study, especially with longitudinal methodologies, is necessary to understand the mediating effects of thwarted belongingness in this association. Although thwarted belongingness is an important and overlooked association of insomnia, it is possible that the association between insomnia and suicidal ideation frequency is better accounted for by emotion dysregulation and perceived burdensomeness, via depression.
Our findings suggest that depression is a major factor when considering the specific association between insomnia severity and suicidal ideation frequency. This association was fully mediated by depression symptoms severity. Several prior studies suggest that depression severity may account for the association between insomnia symptoms and suicide risk (Bishop et al., Reference Bishop, Crean, Hoff and Pigeon2019; Britton et al., Reference Britton, McKinney, Bishop, Pigeon and Hirsch2019; Bryan et al., Reference Bryan, Gonzales, Rudd, Bryan, Clemans, Ray-Sannerud, Wertenberger, Leeson, Heron, Morrow and Etienne2015; Guo et al., Reference Guo, Han, Kong, Wu, Kang, Liu and Wang2024; Nadorff et al., Reference Nadorff, Nazem and Fiske2013; Pompili et al., Reference Pompili, Innamorati, Forte, Longo, Mazzetta, Erbuto, Ricci, Palermo, Stefani, Seretti, Lamis, Perna, Serafini, Amore and Girardi2013; Reference Zullo, Horton, Eaddy, King, Hughes, Diederich, Kennard, Emslie and StewartZullo et al., 2017), while many others suggest insomnia is a risk factor for suicidality above and beyond depression (Becker et al., Reference Becker, Dvorsky, Holdaway and Luebbe2018; Bjørngaard et al., Reference Bjørngaard, Bjerkeset, Romundstad and Gunnell2011; Bozzay et al., Reference Bozzay, Karver and Verona2016; Ferentinos et al., Reference Ferentinos, Porichi, Christodoulou, Dikeos, Papageorgiou and Douzenis2016; Kay et al., 2016; Pigeon et al., Reference Pigeon, Pinquart and Conner2012; Simmons et al., Reference Simmons, Burlingame, Korbanka, Eastman, Thomas, Christensen, Jenson, Nadorff and Kay2021; Simmons et al., Reference Simmons, Erickson, Hedges and Kay2020; Wong et al., Reference Wong, Brower and Craun2016). These mixed findings suggest that the role of depression in the association between insomnia and suicidal ideation is complex and may depend to some degree on the sleep and suicidality dimensions measured.
In a review by Littlewood and colleagues, they integrated findings of sleep problems as related to suicidal thoughts and behaviors into a contemporary model. The model included pathways from sleep problems to suicidal thoughts and behaviors through various types of cognitive appraisals such as hopelessness, entrapment, defeat, situational and self-appraisals along with the psychosocial factors of thwarted belongingness and social isolation (Littlewood et al., Reference Littlewood, Kyle, Carter, Peters, Pratt and Gooding2019). Additionally, the integrated motivational-volitional model proposes that ruminative thoughts potentially strengthen relationships between defeat and entrapment (O’Connor, Reference O’Connor2011). Rumination is a symptom commonly experienced with depression. As our model indicates that difficulty sleeping poses a risk for suicidal ideation through depression and then emotion regulation and perceived burdensomeness, rumination could be an upstream target to address in reducing depression, emotion dysregulation and perceived burdensomeness. Other targets for intervention could be focused on adapting negative cognitive appraisals, including those contributing to feelings of hopelessness, entrapment and defeat, or addressing the restoration of healthy sleep. Evidence for cognitive behavioral therapy for insomnia suggests that specifically helping to reduce insomnia symptoms can reduce depression severity and suicidal ideation frequency (Trockel et al., Reference Trockel, Karlin, Taylor, Brown and Manber2015).
We note several limitations of the current study including the use of cross-sectional data and online survey use. We acknowledge the potential statistical biases introduced by implementing mediational analyses with cross-sectional data. Cross-sectional approaches can lead to statistical biases that can significantly overestimate and underestimate the effects, even under ideal circumstances. Thus, we note that our cross-sectional data prevents definitive claims of directionality in these associations. Although a bidirectional association between insomnia and suicidality is supported in the literature (Liu et al., Reference Liu, Yang, Liu and Jia2024), there is compelling evidence that insomnia symptoms are an upstream marker of or risk factor for suicide (Simmons et al., Reference Simmons, Burlingame, Korbanka, Eastman, Thomas, Christensen, Jenson, Nadorff and Kay2021). Thus, investigating the mechanism for this direction is critically important and is addressed by our approach. Limitations of online survey data include the possibility of a non-naïve sample in a non-standardized, non-monitored administration environment with limited checks on the validity of responses. However, this online survey allowed us to gather a large sample quickly and access a nationally representative sample with similar quality to student samples and laboratory data, based on rejection rates, statistical power, distributions and participant involvement (Kees et al., Reference Kees, Berry, Burton and Sheehan2017; Sprouse, Reference Sprouse2011). Additionally, we would like to note that we did not account for medications in the analyses in order to simplify the number of variables in the mediation analyses.
In conclusion, within the context of depression symptoms, perceived burdensomeness and emotion dysregulation are psychological factors that may play key roles in explaining how insomnia and suicidal ideation frequency are associated. We previously showed that insomnia symptoms reported during an intake assessment or during a routine clinical visit on a single-item insomnia question of the Outpatient Questionnaire-45.2 predicted suicide in psychiatric patients (Simmons et al., Reference Simmons, Burlingame, Korbanka, Eastman, Thomas, Christensen, Jenson, Nadorff and Kay2021). Combined with this study, we highlight that insomnia serves as a potent and easily assessed marker for suicide risk and a target for treatment and suicide prevention. Cognitive behavior therapy for insomnia is the frontline treatment for insomnia disorder and may also help in decreasing suicidality (Manber et al., Reference Manber, Bernert, Suh, Nowakowski, Siebern and Ong2011). Our findings add to a growing body of research that suggests insomnia symptoms are an important upstream target for suicide prevention as it may also help improve depression, emotion dysregulation and perceived burdensomeness.
Data Availability Statement
Raw data were generated at Brigham Young University. Derived data supporting the findings of this study are available from the corresponding author DBK on request.
Acknowledgments
This manuscript is a shortened version of Zach Simmons’ dissertation. ChatGPT was used in some parts to help shorten the manuscript.
Author Contribution Statement
Zach Simmons was the lead author of this project. Daniel Kay was the senior author, and Scott Baldwin provided statistical guidance. All other authors were involved in the interpretation and refining of the writing for publication.
Funding Statement
This study was funded using internal funds. We acknowledge the generous donors who helped support the students who worked on this study including the Andrus and Garner Families.
Competing interests
DBK is the Editor-in-Chief of Research Directions: Sleep Psychology. The other authors have no conflicts of interest to declare.
Ethics Statements
Ethical approval was obtained from the ethics committee of Brigham Young University (BYU) (IRB2021-348). Participants provided consent by clicking a consent tab via Qualtrics. A waiver of written informed consent was approved by the BYU IRB to protect participants identity in our anonymous survey.
Open access
Comments
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