Despite substantial evidence linking insomnia with increased suicidality in non-autistic populations, its role in autism remains under-explored. Poor sleep, most commonly insomnia symptoms (hereafter insomnia), is a significant issue in autism, affecting up to 80% of autistic children and adults, compared with 30%-50% of children and about 45% of adults in the general population. Sleep, along with quality of life, anxiety, depression, and social well-being, is a top mental health research priority for autistic adults. These factors are all significantly associated with insomnia in both autistic and non-autistic individuals. Current findings highlight the association between depression, psychosocial factors, and suicidality in autistic individuals. Key factors in suicidality for autistic people include increased autistic traits, loneliness, lack of social support, and experiences such as camouflaging and burnout. What is under-explored is the role of sleep in suicidality and mental health in autism. Effective psychological interventions for insomnia in autistic individuals are lacking, and there is limited understanding of whether treating insomnia can reduce suicidality. Only two pilot studies have investigated insomnia treatments for autistic adults. In this commentary, we argue that, given the high rate of suicidality in autism and the potential role of insomnia, it is crucial to investigate whether insomnia contributes to suicidality in autistic people and if addressing sleep through prevention strategies, supports, and interventions improves outcomes. Collaboration with the autistic community is essential for addressing this knowledge gap and developing effective interventions.

Objective: To evaluate sleep continuity, timing, quality, and disorder in relation to suicidal ideation and attempts among college students. Participants: Eight hundred eighty-five undergraduates aged 18-25 in the southwestern United States. Methods: Participants completed questionnaires on sleep, suicide risk, mental health, and substance use. Differences in sleep variables were compared by lifetime and recent suicidal ideation and suicide attempts using covariate-adjusted and stepwise regression models. Results: A total of 363 (41.0%) individuals reported lifetime suicidal ideation, of whom 172 (47.4%) reported suicidal ideation in the last 3 months and 97 (26.7%) had attempted suicide in their lifetime. Sleep disturbances were prevalent among those with lifetime suicidal ideation or a lifetime suicide attempt. Insomnia was identified as the best predictor of recent suicidal ideation, but this relationship did not survive adjustment for covariates. Conclusions: Sleep continuity, quality, and sleep disorders are broadly associated with suicidal thoughts and behaviors among college students.

Although nightmares are known to predict the clinical course of posttraumatic stress disorder (PTSD), research on the relationship between specific nightmare characteristics and PTSD severity is sparse. This study conducted a secondary analysis to explore how five nightmare characteristics are cross-sectionally related to PTSD severity in 76 combat veterans with PTSD and at-risk alcohol use. Consistent with emotional processing theory, we hypothesized that more replicative, threatening, realistic, and easily recalled nightmares would be associated with more severe PTSD, whereas those with greater symbolism would predict lower PTSD severity. Nightmares narratives were audio-recorded and rated by multiple coders. Multiple analyses of variance explored the relationship between nightmare characteristics and PTSD clinical indicators. Most nightmares were realistic, easily recalled, and involved significant threat. Greater realism and replication were associated with greater PTSD severity. Realistic and replicative nightmares may be markers of more severe PTSD and may indicate that less emotional processing of the trauma has occurred.

Self-harm in adolescents is prevalent and is the most significant predictor of future self-harm and suicide. Longitudinal data on the incidence and predictors of repeat self-harm in the general population of adolescents are limited. This study investigated 1-year incidence and psychosocial predictors of repeat self-harm in Chinese adolescents.

Shandong Adolescent Behavior and Health Cohort is a longitudinal study of behavior and health in adolescents in Shandong Province, China. Of 7072 participants who were assessed in 2015 and again 1 year later in 2016, 1879 reported a history of self-harm at the baseline survey and were included for this analysis. A self-administered structured questionnaire was used to assess behavioral and emotional problems, sleep, life stress, previous history of self-harm and suicidal thought, and family factors at baseline and self-harm at 1-year follow-up.

Mean age of the sample was 14.86 (SD 1.36) years and 54.6% were female. At 1-year follow-up, 22.1% participants engaged in repeat self-harm. Multiple logistic regression analyses showed that female gender (OR 1.45, 95% CI 1.11-1.89), alcohol use (OR 1.95, 95% CI 1.48-2.57), frequent nightmares (OR 1.61, 95% CI 1.14-2.28), elevated depression score (OR 1.59, 95% CI 1.05-2.42), and prior suicidal thought (OR 1.79, 95% CI 1.37-2.34) were independently and significantly associated with an increased risk of repeat self-harm.

More than one in five Chinese adolescents who had a history of self-harm engaged in self-harm at 1-year follow-up. Multiple psychosocial factors including female gender, alcohol use, frequent nightmares, depression, and prior suicidal thought appeared to be significant predictors of repeat self-harm. Our findings highlight the importance of comprehensive psychosocial assessment and intervention of repeat self-harm in adolescents.

Prior research suggests that sleep disturbances are associated with increased risk of suicide. However, sleep disturbances are associated with a wide range of psychiatric disorders, and it is unknown whether this association is independent of psychopathology. In a large nationally representative prospective survey, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), we used structural equation modeling to examine the shared and specific effects of three sleep complaints (i.e., trouble falling asleep, early morning awakening, and hypersomnia) on the 3-year occurrence of attempting suicide. Because psychiatric disorders increase the risk of suicide attempt almost exclusively through a general psychopathology factor representing their shared effect, covariates included that factor, prior history of suicide attempt, and a wide range of sociodemographic and clinical characteristics. The 3-year prevalence rate of suicide attempt was 0.6% (n = 241). Compared with participants who did not attempt suicide between the two waves, those who did reported significantly more frequently having trouble falling asleep (44.6% vs. 16.6%), early morning awakening (38.9% vs. 12.7%), and hypersomnia (35.0% vs. 10.7%). Following adjustments, effects of sleep complaints on this risk were significant and exerted almost exclusively through a general sleep complaints factor representing the shared effect across all sleep complaints. There were no residual associations of any individual sleep complaint with attempting suicide above that association. Sleep complaints are associated with an increased risk of attempting suicide independently of psychopathology, and should be included in suicide risk assessments as these symptoms may provide targets for reducing the risks of suicidal behaviors.

Repurposing ketamine in the therapy of depression could well represent a breakthrough in understanding the etiology of depression. Ketamine was originally used as an anesthetic drug and later its use was extended to other therapeutic applications such as analgesia and the treatment of addiction. At the same time, the abuse of ketamine as a recreational drug has generated a concern for its psychotropic and potential long-term effects; nevertheless, its use as a fast acting antidepressant in treatment-resistant patients has boosted the interest in the mechanism of action both in psychiatry and in the wider area of neuroscience. This article provides a comprehensive overview of the actions of ketamine and intends to cover: (i) the evaluation of its clinical use in the treatment of depression and suicidal behavior; (ii) the potential use of ketamine in pediatrics; (iii) a description of its mechanism of action; (iv) the involvement of specific brain areas in producing antidepressant effects; (v) the potential interaction of ketamine with the hypothalamic-pituitary-adrenal axis; (vi) the effect of ketamine on neuronal transmission in the bed nucleus of stria terminalis and on its output; (vii) the evaluation of any gender-dependent effects of ketamine; (viii) the interaction of ketamine with the inflammatory processes involved in depression; (ix) the evaluation of the effects observed with single or repeated administration; (x) a description of any adverse or cognitive effects and its abuse potential. Finally, this review attempts to assess whether ketamine's use in depression can improve our knowledge of the etiopathology of depression and whether its therapeutic effect can be considered an actual cure for depression rather than a therapy merely aimed to control the symptoms of depression.

Nightmares are a significant risk factor of suicidal behavior. This study examined the longitudinal associations of nightmare frequency and distress with suicidal thought (ST), suicide plan (SP), and suicide attempt (SA) and mediating role of depressive symptoms in adolescents.

A total of 6,923 adolescents who participated in the 1-year follow-up of Shandong Adolescent Behavior & Health Cohort were included for the analysis. Participants completed a self-administered questionnaire to assess nightmares, sleep duration, insomnia, depressive symptoms, substance use, prior suicidal behavior, and family demographics in November-December in 2015. One year later, a follow-up survey was conducted to ask participants to report their depressive symptoms and suicidal behaviors.

Of the sample, 26.2% reported having frequent nightmares (at least twice/month) at baseline, and 10.0%, 3.6%, and 2.7% reported having ST, SP, and SA over 1-year follow-up. The rates of subsequent ST, SP, and SA all significantly increased with baseline nightmare frequency and distress. Path analyses showed that depressive symptoms played a significant mediating role in the associations of frequent nightmares and elevated nightmare distress with ST, SP, and SA before and after adjusting for adolescent and family covariates and prior suicidal behavior.

Suicidal risk increased with nightmare frequency and distress among adolescents. The association between nightmares and suicidal behavior was at least partially mediated by depressive symptoms. Assessing and intervening nightmares and depressive symptoms associated with nightmares may have important implications for preventing adolescent suicidal behavior.

Previous laboratory research has shown that exposure to odours of contrasting pleasantness during sleep differentially affects the emotional tone of dreams. In the present study, we sought to investigate how a generally pleasant (vanillin) and unpleasant (thioglycolic acid [TGA]) smell influenced various dream characteristics, dream emotions, and post-sleep core affect during all-night exposure, controlling for appraisal of the olfactory environment during the assessments and sleep stage from which the participants woke up. We expected that exposure to vanillin would result in more pleasant dreams, more positive and less negative dream emotions, and a more positive post-sleep core affect compared to the control condition, whereas exposure to TGA would have the opposite effect. Sixty healthy volunteers (36 males, mean age 24 ± 4 years) were invited to visit the sleep laboratory three times in weekly intervals. The first visit served to adapt the participants to the laboratory environment. On the second visit, half the participants were exposed to an odour (vanillin or TGA, 1:1) and the other half to the odourless control condition. On the third visit, they received control or exposure in a balanced order. On each visit, the participants woke up twice, first from the rapid eye movement (REM) sleep stage and then in the morning, usually from a non-REM sleep stage. Repeated measures were taken upon each awakening. Dream pleasantness, emotional charge of the dream, positive and negative emotions experienced in the dream, and four dimensions of post-sleep core affect (valence, activation, pleasant activation - unpleasant deactivation, and unpleasant activation - pleasant deactivation) were assessed. We found a small effect of condition (exposure vs. control) in interaction with appraisal of the ambient olfactory environment on dream pleasantness. Specifically, false alarms (i.e., perceiving odour in the absence of the target stimulus) were associated with lower dream pleasantness than correct rejections. Although exposure had a statistically significant positive influence on post-sleep core affect (namely, valence, activation, and pleasant activation - unpleasant deactivation), the size of the effect was small and lacked practical significance. The hypothesised differential effects of vanillin and TGA were only modelled for dream ratings because they decreased the fit of the other models. Neither dream pleasantness nor emotionality differed according to the odour used for stimulation. The results of the present study suggest that all-night exposure to odours is unlikely to produce practically significant positive effects on dreams and post-sleep core affect.

A causal relationship between sleep disturbances and suicidal behavior has been previously reported. Insomnia and nightmares are considered as hallmarks of posttraumatic stress disorder (PTSD). In addition, patients with PTSD have an increased risk for suicidality. The present article gives an overview about the existing literature on the relationship between sleep disturbances and suicidality in the context of PTSD. It aims to demonstrate that diagnosing and treating sleep problems as still underestimated target symptoms may provide preventive strategies with respect to suicidality. However, heterogeneous study designs, different samples and diverse outcome parameters hinder a direct comparison of studies and a causal relationship cannot be shown. More research is necessary to clarify this complex relationship and to tackle the value of treatment of sleep disturbances for suicide prevention in PTSD.

Sleep has been shown to impact on both physical and mental health, and sleep problems present a considerable burden for individuals and society. There appears to be a complex bidirectional relationship between sleep disturbance and psychiatric symptoms, each potentially influencing the other. In particular, sleep disorders have been associated with more severe symptoms and are predictive of relapse in those with psychotic disorders. This article discusses the relationship between psychosis and insomnia, sleep apnoea, nightmares, circadian rhythm abnormalities and the impact of medications on these relationships. We also discuss the clinical implications of the relationship between sleep disturbance and psychotic disorders along with potential targets for intervention.

Post-traumatic nightmares (PTN) are a common and enduring problem for individuals with post-traumatic stress disorder (PTSD) and other clinical presentations. PTN cause significant distress, are associated with large costs, and are an independent risk factor for suicide. Pharmacological and non-pharmacological treatment options for PTN exist. A previous review in this journal demonstrated that Prazosin, an alpha blocker, was a preferred pharmacological treatment for PTN and imagery rescripting therapy (IRT) was a preferred non-pharmacological treatment. Since that time, new and important research findings create the need for an updated review.

Based on the results of a recent study in the New England Journal of Medicine, Prazosin has been downgraded by both the American Academy of Sleep Medicine (AASM) and the Veterans Health Administration/Department of Defense (VA/DoD) for PTN. In Canada, Nabilone, a synthetic cannabinoid, appears to be promising. Few recent studies have been published on non-pharmacological interventions for PTN; however, recent data is available with regard to using IRT on an inpatient setting, with German combat veterans, and through the use of virtual technology. Recent evidence supports the use of exposure, relaxation, and rescripting therapy (ERRT) with children and individuals with comorbid bipolar disorder and PTN. Prazosin is no longer considered a first-line pharmacological intervention for PTN by AASM and VA/DoD. However, in the absence of a suitable alternative, it will likely remain the preferred option of prescribers. IRT and ERRT remain preferred non-pharmacological treatments of PTN. Combining cognitive behavior therapy for insomnia (CBT-I) with IRT or ERRT may lead to improved outcomes.

Although nightmares have been shown to increase the risk for suicide, less is known about the mechanisms underlying this relationship. In order to address this gap and guided by the hopelessness theory of suicide risk, we examined hopelessness and male depressive symptoms as risk factors for suicide while considering the frequency of and impairment due to nightmares. Data were collected from 172 psychiatrically hospitalized, adult patients (91 women, 81 men) with an average age of 39.15 (SD = 13.48) years. Patients were administered self-report measures of nightmare frequency/impairment, hopelessness, and male depressive symptoms, as well as undergoing a fully structured diagnostic clinical interview to determine diagnoses and suicide risk. Compared to patients with yearly or no nightmares, those with monthly or weekly nightmares reported nightmares reported higher levels of hopelessness, male depressive symptoms, and suicide risk. Male depressive symptoms significantly mediated the relation between hopelessness and suicide risk in patients who reported monthly to weekly nightmares, but not in those who reported yearly or no nightmares. Moreover, impairment due to nightmares was significantly and positively associated with male depression, but not hopelessness or suicide risk. The results also provide evidence and further understanding about possible mechanisms of emerging suicide.

A growing body of evidence supports a bidirectional relationship between posttraumatic stress disorder (PTSD) and sleep disturbances. Fragmented sleep induced by sleep-related breathing disorders, insomnia, and nightmares impacts recovery and treatment outcomes and worsens PTSD symptoms. Despite recent attention, management of these disorders has been unrewarding in the setting of PTSD. This review summarizes the evidence for empirically supported treatments of these sleep ailments, including psychotherapeutic and pharmacologic interventions, as it relates to PTSD. Recent advances in positive airway pressure technology have made treatment of OSA more acceptable; however, adherence to CPAP therapy presents a substantial challenge. Concomitant insomnia, which engenders psychiatric and medical conditions, including depression, suicide, and alcohol and substance abuse, can be managed with cognitive behavioral therapy. Hypnotic agents are considered an alternative therapy, but concerns about adverse events and lack of high-level evidence supporting their efficacy in PTSD treatment have limited their use to resistant cases or as adjuncts to behavioral therapy when the response is less than desirable. Intrusion of nightmares can complicate PTSD treatment and exert serious strain on social, occupational, and marital relations. Imagery rehearsal therapy has shown significant reduction in nightmare intensity and frequency. The success of noradrenergic blocking agents has not been consistent among studies, with one-half reporting treatment failure. An integrated stepped care approach that includes components of both behavioral and pharmacologic interventions customized to patients' sleep-maladaptive behaviors may offer a solution to delivering accessible, effective, and efficient services for individuals with PTSD.