Polysomnographic markers of suicidal ideation in untreated unipolar major depressed individuals
Introduction
Since around 900,000 individuals commit suicide worldwide each year, suicide is a major public health problem (World Health Organization, 2014). In addition, suicide is the second cause of mortality in young people (<30 years) (World Health Organization, 2014). In general population, one of the main risk factors for suicide is the presence of a major depressive episode (Dong et al., 2018). However, in some cases, major depression may manifest mainly by somatic symptoms (such as sleep disturbances), which may delay the establishment of effective treatment and lead to an increased risk of suicide (Fang et al., 2019; Simon et al., 1999). Nevertheless, before suicidal acting, major depressed individuals generally present suicidal ideation (SI) indicating the presence of a more severe major depressive episode (Oquendo et al., 2004; Sokero et al., 2003). Among major depressed individuals, these SI have a prevalence of 11 to 63% and lead to suicidal acting in 15% of cases (Vuorilehto et al., 2014). In major depression, SI may therefore be considered as an important symptom since they constitute the first step of major depressed individuals in their suicide plan (American Psychiatric Association, 2013). Thus, in order to better prevent this excess mortality by suicide in major depressed individuals, it is essential to identify reliable biological markers for these SI so that they may be managed early and adequately.
There is a particular relationship between sleep disorders and suicidality (SI, suicide attempts and suicides) in major depressed individuals (Owusu et al., 2020). Indeed, sleep disorders (especially insomnia and nightmares) are associated with increased suicidality in this particular subpopulation (Pigeon et al., 2012; Wang et al., 2019) which could be explained by the fact that the sleep deprivation induced by these sleep disorders may be associated with a lesser activity of the frontal lobe altering the ability to solve problems and favouring impulsive behaviours (such as suicidality) (Perlis et al., 2016). Furthermore, at the polysomnographic level, it has been demonstrated that major depressed individuals had an increased risk of SI in case of early morning awakenings, deep NREMS (slow-wave sleep [SWS]) deficit, reduced sleep efficiency and increased wake after sleep onset (Ballard et al., 2016; Bernert et al., 2017). Regarding power spectral analyses, it has been highlighted that the nocturnal EEG activity of major depressed individuals with SI was characterized by increased high frequency activity and decreased delta activity (Dolsen et al., 2017). These various elements therefore seem to indicate that the deep NREMS (SWS) alterations could play a central role in the occurrence of SI in major depression. However, most of these studies have been performed on particular subpopulations of major depressed individuals characterized by the presence of resistance to antidepressant treatment and/or by mixed samples of unipolar and bipolar depression (Ballard et al., 2016; Bernert et al., 2017; Dolsen et al., 2017), which may limit the interpretation of their results and seems to justify the realization of additional studies.
In order to avoid these potential limitations, the aim of our study was to empirically identify polysomnographic markers specific to SI in a large sample of untreated unipolar major depressed individuals. Our hypothesis was that the deep NREMS (SWS) deficit is a specific polysomnographic marker of SI in unipolar major depression. The highlighting of this potential polysomnographic marker of SI in unipolar major depression could allow better identification of major depressed individuals at high-risk of suicide and therefore better prevention of excess mortality by suicide in this particular subpopulation.
Section snippets
Material and method
The methodology used in this study is similar to that used in previous studies of our research group on major depression (Hein et al., 2017a, Hein et al., 2017b, Hein et al., 2017c; Hein et al., 2020).
Demographic results (Table 1)
Compared to healthy controls, major depressed individuals with and without SI have higher BDI and ISI scores. Major depressed individuals with SI present higher BDI scores than those without SI. The three groups studied do not differ significantly in terms of age, gender and body mass index.
Comparison between the control group and the different groups of major depressed individuals (Table 1)
Compared to healthy controls, major depressed individuals with and without SI show: 1) an increase in wake after sleep onset and 2) a reduction in sleep efficiency and total sleep time. Moreover, unlike
Discussion
In our study, we highlighted that in untreated unipolar major depressed individuals, the presence of SI was associated with a decrease in deep NREMS (SWS) and an increase in light NREMS (stage 1 + stage 2), which seems to confirm the existence of potential polysomnographic markers specific to SI in this particular subpopulation.
In our study, the prevalence of SI (26.9%) seems to be lower than those of other studies available in the literature investigating the potential polysomnographic markers
Conclusions
In our study, we highlighted the existence of potential polysomnographic markers of SI in untreated unipolar major depressed individuals, which seems to open up new perspectives for the identification and the targeted management of individuals at high-risk of suicide in this particular subpopulation.
Ethics approval and consent to participate
This research protocol was approved by the Hospital and Medical School Ethics Committee of the Erasme Hospital (Brussels University Clinics) (Erasme Reference: P2020/029). At Erasme Hospital, all patients are informed that their data could be used retrospectively for scientific research. If patients do not wish for their data to be used, they must inform the hospital, at which time, this directive is indicated in their medical records, and any future use of their data is prohibited.
Consent for publication
Not applicable.
Availability of data and material
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
IZ: Principal investigator of the study with active participation in the encoding of data, statistical analysis, interpretation of results and writing of the article. JL: Active participation in the extraction and calculation of data from polysomnography for the realization of the database. BW: Active participation in the extraction of data from polysomnography and calculation of REMS density. AM: Support in drafting the manuscript and supervision of research work. GL: Support in drafting the
Declaration of competing interest
The authors have no conflicts of interest with the work carried out in this study.
Acknowledgements
I want to thank Christelle Bouchart (MD) for this support as well as the sleep laboratory team from the Erasme Hospital for technical support.
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2022, Journal of Psychiatric ResearchCitation Excerpt :However, in this study, there were no differences in polysomnographic parameters between individuals with and without current SI, which could be explained by several elements. Indeed, unlike most studies investigating the polysomnographic markers associated with current SI (Bernert et al., 2017; Cai et al., 2020; Zeoli et al., 2021), the use of psychotropic drugs and the presence of comorbid sleep disorders (sleep breathing disorders and sleep movement disorders) were not exclusion criteria in our study since the main objective was not to study the polysomnographic pattern associated with current SI in individuals with insomnia. However, both psychotropic drugs and comorbid sleep disorders may induce changes in sleep architecture (Hardy De Buisseret et al., 2017; Riemann and Nissen, 2012; Shahveisi et al., 2018), which could have masked the presence of differences in polysomnographic parameters between the individuals with and without current SI in this study.
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