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Insomnia is a unique and robust indicator of suicidal thoughts, regardless of the co-existence of a mood disorder, such as depression. And the intervention that is most effective for insomnia may also reduce suicidality. Research and clinical practice have repeatedly shown that Cognitive Behavioral Therapy for insomnia (CBT-I) is the best intervention for insomnia—superior to medication. More recent studies have shown that improving sleep itself may also reduce suicidal thoughts, which tend to remit by about half after treatment for insomnia compared to control groups, even without directly attempting to reduce suicidal thoughts. In addition, a digital (electronic) option to treat insomnia and suicidal thoughts may be as effective as CBT-I, making it less costly and more accessible for more people than in-person care.
CBT-I includes behavioral components such as sleep restriction, sleep hygiene, and stimulus control, as well as cognitive components like cognitive restructuring, paradoxical intention, and psychoeducation. It also frequently includes relaxation practices such as progressive muscle relaxation, breathing, and mindfulness. All of these components are tailored over multiple sessions for each person.
In-Person Treatment Leads to Reduction in Suicidal Thoughts
Three studies support CBT-I in-person treatment for reducing suicidal thoughts:
- Over 300 people with depression attended seven 90-minute group sessions regarding sleep and after treatment had reduced suicidal ideation by more than half (from 23% to 10%), along with improved sleep, energy, productivity, self-esteem, other aspects of well-being (Manber, et al, 2011).
- A study with over 600 veterans with insomnia found five individual sessions reduced suicidal thoughts from 32% to 21% (Trockel M, et al., 2015).
- A smaller randomized controlled trial (RCT) showed that four 30-minute sessions in a primary care setting reduced suicidal thoughts for veterans with major depression and post-traumatic stress disorder (PTSD) (Pigeon, et al, 2019).
Digital Treatment for Sleep Leads to Reduction in Suicidal Thoughts
A similar trend was found with pregnant women using a digital CBT-I intervention, with suicidal thoughts going from 5.5% to 0% (Kalmbach, et al, 2020). The same researchers at the Thomas Roth Sleep Disorders and Research Center in Detroit used a digital intervention of CBT-I in a larger study over six treatment sessions. This intervention was an automated and interactive online program. They used an eHealth animated “virtual therapist” that was fully-automated and standardized to track participant progress and make suggestions based on the sleep data they submitted.
The results of this study showed a 70% reduction in suicidal thoughts in the CBT-I condition at posttreatment. “[This] remained consistent a year later at a 72% reduction,” they report. The control condition, which had the same number of contact sessions but with educational information only, had a 45% reduction in suicidal thoughts. While the control group effects may be dismissed as placebo effect, 45% still strikes me as a powerful shift. And, I would argue it is important to realize that even without the tailored intervention, care-based attention, hope, and taking actions of self-care play a powerful role in wellness in ways we may not expect.
This study was the first study to demonstrate CBT-I efficacy for alleviating and preventing suicidal thoughts using an eHealth digital delivery format. Overall, these findings suggest that digital CBT-I can serve a role in alleviating and even preventing suicidal thoughts in insomnia patients and that insomnia remission is a critical part of mitigating suicide risk. These findings are consistent with prior studies supporting the effectiveness of CBT-I on suicidal risk. This may be especially important, as some studies have found that the night-time risk of suicide is approximately three times that of daytime risk (Tubbs, et al., 2020).
If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.
References
Del Pozo, J. (2023). Sleep Anxiety, Insomnia, and Rhythm Disruptions: A Complete Behavioral Treatment Plan for Improving Sleep and Co-Morbid Conditions, 2-day course with PESI.
Kalmbach DA, Cheng P, Ahmedani BK, Peterson EL, Reffi AN, Sagong C, Seymour GM, Ruprich MK, Drake CL. (2022). Cognitive-behavioral therapy for insomnia prevents and alleviates suicidal ideation: insomnia remission is a suicidolytic mechanism. Sleep; 45(12):zsac251. doi: 10.1093/sleep/zsac251. PMID: 36242607; PMCID: PMC9742891.
Pigeon WR, et al. (2012). Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. J Clin Psychiatry; 73(9):e116011734–e1160e1167.
Manber R, et al. (2011). CBT for insomnia in patients with high and low depressive symptom severity: adherence and clinical outcomes. J Clin Sleep Medicine; 7(6):645–652.
Trockel M, et al. (2015). Effects of cognitive behavioral therapy for insomnia on suicidal ideation in veterans. Sleep; 38(2):259–265. doi: 10.5665/sleep.4410.
Pigeon WR, et al. (2019) Brief CBT for insomnia delivered in primary care to patients endorsing suicidal ideation: a proof-of-concept randomized clinical trial. Transl Behav Medicine;9(6):1169–1177. doi: 10.1093/tbm/ibz108.
Kalmbach DA, et al. (2020). A randomized controlled trial of digital cognitive behavioral therapy for insomnia in pregnant women. Sleep Medicine; 72:82–92. doi: 10.1016/j.sleep.2020.03.016.
Tubbs AS, et al. (2020). Relationship of nocturnal wakefulness to suicide risk across months and methods of suicide. J Clin Psychiatry; 81(2):12825.
