Faculty Bibliography

Sleep disturbances have been linked to suicidal ideation and behaviors in adolescents. Specifically, insomnia and nightmares are associated with current suicide risk and predict future ideation. Associations between hypersomnia, sleep apnea, and suicide remain inconclusive. Potential biological mechanisms underlying these relationships include executive functioning deficits and hyperarousal. Related psychological factors may include thwarted belongingness, perceived burdensomeness, and negative appraisals. Assessing suicide risk in patients with sleep disturbances, and vice versa, is needed. Therapeutic interventions such as cognitive behavior therapy for insomnia and imagery rehearsal treatment, as well as pharmacologic treatments, show promise in treating sleep disorders and suicidal behavior.

Children with psychiatric comorbidities frequently are referred for evaluation of sleep complaints. Common sleep symptoms can include difficulty falling asleep, frequent nocturnal awakening, restless sleep, and symptoms of restless legs syndrome (RLS). The understanding of the sleep condition in relation to the psychiatric comorbidity often is a challenge to the physician and often sleep disorders remain undiagnosed, untreated, or undertreated. Restless legs syndrome has been associated with psychiatric comorbidities and with certain medications, such as antidepressants, antihistamines, and antipsychotics. This article reviews the presentation of RLS and restless sleep, the association with psychiatric comorbidities, and treatment options.

Maggie is a 16-year-old girl who came to see me because she wanted help with her longstanding difficulties falling asleep at night and waking up in the morning. She goes to bed between midnight and 3 am and usually lies awake worrying until falling asleep at 3 to 4 am. She often video-calls or texts her boyfriend before sleep. Her wakeup time is 8 am; she typically wakes exhausted, having slept 4 to 5 hours. Although a good student, she is often late for classes. On weekends, she wakes around noon. She is tired, anxious, and demoralized. She cannot concentrate as well as she did prior to the onset of her sleep symptoms at age 10 to 11 years. Her psychiatric history includes a diagnosis of anxiety and depression, both in remission, treated with fluoxetine 30 mg daily for several years. Difficulties falling asleep and waking in the morning are common complaints among adolescents and young adults. Before my additional year of training in sleep medicine, I would have misdiagnosed Maggie as having insomnia rather than delayed sleep phase disorder (DSPD), a circadian rhythm disorder.