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Nightmares, suicide attempts, and melancholic features in patients with unipolar major depression

https://doi.org/10.1016/j.jad.2006.08.005Get rights and content

Abstract

Objectives

Recently, there has been a growing interest in the relationship between sleep disturbances and suicidality in major depression. Sleep disturbances are one of the ‘modifiable risks’ for suicide in major depression. The present study examines whether there is a relationship among nightmares, suicide attempts, and melancholic features in unipolar major depressed patients.

Methods

One hundred (49 males and 51 females) depressed patients with melancholic features and 49 (23 males and 26 females) patients without melancholic features were included in the study. All patients were classified as those who attempted suicide at least once during current depressive episode and as those who never attempted.

Results

Melancholic attempters had higher rates of nightmares, middle, and terminal insomnia than melancholic non-attempters. There was no significant difference between non-melancholic patients with and without suicidal attempts in terms of the frequency of all types of insomnia and nightmares. Limitations: This study does not have polysomnographic records for sleep variables.

Conclusions

Feeling worse in the morning than later in the day may be related to the intervening dream content and affect and predict suicidal tendency. Melancholia may be associated with increased risk of suicide attempts due to repetitive and frightening dreams.

Introduction

Recently, there has been an increasing interest in the relationship between sleep and suicidality in major depression. Major suggestion is that sleep disturbances have prognostic significance in predicting suicide among patients with mood disorders (Agargun and Besiroglu, 2005). Fawcett et al. (1990) considered insomnia to be one of the ‘modifiable risks’ for suicide. In a recent study, Agargun et al. (1997a) showed that not only insomnia but also hypersomnia associated with suicidal behavior in depressed patients. Agargun et al. (1997b) also demonstrated a significant association between poor sleep quality and suicidal behavior in depression.

Melancholic features are related to short REM latency and increased REM density in depressed patients (Giles et al., 1986, Rush and Weissenburger, 1994). As an essential feature of melancholia, negative affective state in the morning might be related to the intervening dream content and affect in major depression (Besiroglu et al., 2005).

Melancholia is associated with more serious past suicide attempts and with the probability of suicide attempt during follow-up (Grunebaum et al., 2004). On the other hand, nightmares are more common among depressed patients with melancholic features than non-melancholic depressives (Besiroglu et al., 2005). An association between nightmares and suicidal behavior in patients with depression was showed by Agargun et al. in 1998. Thus, we hypothesized that the association of nightmares with suicidal behavior is related to particularly melancholic features in unipolar depression. The present study examines whether there is a relationship among nightmares, suicide attempts, and melancholic features in unipolar major depressed patients.

Section snippets

Methods

The sample consisted of 149 patients (72 males and 77 females) with major depressive disorder. They were selected consequently from the patients seeking psychiatric care for the first time at the Psychiatric Unit between 1999 and 2005. Subjects with organic mental disorders, history of any psychotic disorder, bipolar disorder, post-traumatic stress disorders and alcohol/substance dependence/abuse were excluded. The mean age of the sample was 32.1 ± 10.7 (range 18–65). The subjects were

Results

Twenty-eight (28%) of patients with melancholic features had attempted suicide at least once during current depressive episode. There was a significant difference between melancholic patients with and without suicidal attempts in terms of the frequency of middle and terminal insomnia and nightmares (Table 1). Melancholic attempters had higher rates of nightmares, middle, and terminal insomnia than melancholic non-attempters.

Among 49 patients without melancholic features, 10 (20%) had attempted

Discussion

In this study, nightmares were found to be related to suicide attempts in unipolar depressed patients in terms of melancholic features. Middle and terminal insomnia also were related to suicide attempts in patients with melancholic features. On the contrary, these associations were not found in those without melancholic features. In addition, nightmares were more common among those with suicidal attempt than non-attempters. This is the first study, in our knowledge, examining the relationship

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