Suicide risk in young people appears to follow a diurnal pattern, increasing at night, new research shows.
Investigators found that suicidal ideation and attempts were lowest in the mornings and highest in the evenings, particularly among youth with higher levels of self-critical rumination.
"These are preliminary findings and there is a need for more data, but they signal potentially that there's a need for support, particularly at nighttime, and that there might be a potential of targeting self-critical rumination in daily lives of youth," said lead researcher Anastacia Kudinova, PhD, with the Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.
The findings were presented at the late-breaker session at SLEEP 2023, the 37th annual meeting of the Associated Professional Sleep Societies.
Urgent Need
Suicidal ideation (SI) is a "robust" predictor of suicidal behavior and, "alarmingly," both suicidal ideation and suicidal behavior have been increasing, Kudinova said.
"There is an urgent need to describe proximal time-period risk factors for suicide so that we can identify who is at a greater suicide risk on the time scale of weeks, days, or even hours," she told attendees.
The researchers asked 165 psychiatrically hospitalized youth aged 11 to 18 (72% female) about the time of day of their most recent suicide attempt.
More than half (58%) said it occurred in the evenings and nights, followed by daytime (35%) and mornings (7%).
They also assessed the timing of suicidal ideation at home in 61 youth aged 12 to 15 (61% female) who were discharged after a partial hospitalization program.
They did this using ecological momentary assessments (EMAs) three times a day over 2 weeks. EMAs study people's thoughts and behavior in their daily lives by repeatedly collecting data in an individual's normal environment at or close to the time they carry out that behavior.
As in the other sample, youth in this sample also experienced significantly more frequent suicidal ideation later in the day (P < .01).
There was also a significant moderating effect of self-criticism (P < .01), such that more self-critical youth evidenced the highest levels of suicidal ideation later in the day.
True Variation or Mechanics?
Reached for comment, Paul Nestadt, MD, with Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland, noted that EMA is becoming "an interesting way to track high-resolution temporal variation in suicidal ideation and other psych symptoms."
Nestadt, who was not involved in the study, told Medscape Medical News that "it's not surprising" that the majority of youth attempted suicide in evenings and nights, "as adolescents are generally being supervised in a school setting during daytime hours. It may not be the fluctuation in suicidality that impacts attempt timing so much as the mechanics ― it is very hard to attempt suicide in math class."
The same may be true for the youth in the second sample who were in the partial hospital program. "During the day, they were in therapy groups where feelings of suicidal ideation would have been solicited and addressed in real time," Nestadt noted.
"Again, suicidal ideation later in the day may be a practical effect of how they are occupied in the partial hospital program, as opposed to some inherent suicidal ideation increase linked to something endogenous, such as circadian rhythm or cortisol level rises. That said, we do often see more attempts in the evenings in adults as well," he added.
A Vulnerable Time
Also weighing in, Casey O'Brien, PsyD, a psychologist in the Department of Psychiatry at Columbia University Irving Medical Center in New York, said the findings in this study "track" with what she sees in the clinic.
Teens often report in session that the "unstructured time of night ― especially the time when they usually should be getting to bed but are kind of staying up ― tends to be a very vulnerable time for them," O'Brien told Medscape Medical News.
"It's really nice to have research confirm a lot of what we see reported anecdotally from the teens we work with," said O'Brien.
O'Brien heads the intensive adolescent dialectical behavior therapy (DBT) program at Columbia for young people struggling with mental health issues.
"Within the DBT framework, we try to really focus on accepting that this is a vulnerable time and then planning ahead for what the strategies are that they can use to help them transition to bed quickly and smoothly," O'Brien said.
These strategies may include spending time with their parents before bed, reading, or building into their bedtime routines things that they find soothing and comforting, like taking a longer shower or having comfortable pajamas to change into, she explained.
"We also work a lot on sleep hygiene strategies to help develop a regular bedtime and have a consistent sleep-wake cycle. We also will plan ahead for using distress tolerance skills during times of emotional vulnerability," O'Brien said.
The Columbia DBT program also offers phone coaching "so teens can reach out to a therapist for help using skills outside of a therapeutic hour and we do find that we get more coaching calls closer to around bedtime," O'Brien told Medscape Medical News.
Support for the study was provided by the National Institute of Mental Health and Bradley Hospital COBRE Center. Kudinova, Nestadt, and O'Brien have disclosed no relevant financial relationships.
SLEEP 2023: the 37th Annual Meeting of the Associated Professional Sleep Societies. Abstract LBA-002. Presented June 5, 2023.
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Cite this: Suicidality Risk in Youth at Highest at Night - Medscape - Jun 06, 2023.
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