SYSTEMATIC REVIEW/META-ANALYSIS

Sleep Disturbances and the Risk of Incident

Suicidality: A Systematic Review and Meta-Analysis of
Cohort Studies
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Min Dong, MD, Li Lu, PhD, Sha Sha, MD, Ling Zhang, MD, Qinge Zhang, MD,
Gabor S. Ungvari, MD, PhD, Lloyd Balbuena, PhD, and Yu-Tao Xiang, MD, PhD

ABSTRACT
Objective: The association between sleep disturbances and suicidality is not well understood partly because of the variability in research
results. This meta-analysis aimed to investigate the predictive value of sleep disturbances for incident suicidality.
Methods: A systematic search was conducted in PubMed, EMBASE, PsycINFO, and Web of Science databases for studies examining
sleep disturbances and incident suicidality. Cohort studies were screened following a registered protocol, and the eligible ones were
meta-analyzed.
Results: Seven studies comprising 1,570,181 individuals at baseline, with 1407 attempting suicide and 1023 completing suicide during
follow-up, were included. Individuals with baseline sleep disturbances had a significantly higher incidence of suicidality than did those
without (relative risk = 2.17, 95% confidence interval [CI] = 1.45–3.24, I2 = 82.50%, p < .001). The risk of an incident suicide attempt
was 3.54-fold higher (95% CI = 3.07–4.09, I2 = 0%, p = .44), whereas the risk of incident completed suicide was 1.80-fold higher
(95% CI = 1.32–2.44, I2 = 59.33%, p = .01) in individuals with baseline sleep disturbances.
Conclusions: Incident suicide attempts and deaths are higher among people with sleep disturbances. Regular screening and preventive
measures should be undertaken for people with sleep disturbances to prevent progression into suicide attempts and deaths.
Clinical Trial Registration: CRD42019136397.
Key words: sleep disturbance, suicidality, incident, meta-analysis.

INTRODUCTION addition, there is increasing evidence that sleep disturbances are

associated with a higher risk of suicide-related behaviors (18–20).
S uicide is a major public health issue and a main cause of pre-
mature death with devastating consequences for families and
society (1). The World Health Organization reported that suicide
A review based on 40 cohort studies found that prolonged
sleep duration was associated with increased all-cause mortality
(21). However, the impact of sleep duration on suicide was not
takes the lives of approximately 800,000 people per year world-
examined separately (21). The predictive value of sleep disturbances
wide, making it the 15th leading cause of death (2). Suicide-related
for suicide varied between studies, ranging from 1.9- to 6.9-fold
behaviors include suicidal ideation, suicide plans, suicide
higher (20,22). The variation could be partly due to different
attempts (SAs), and completed suicide (CS); for the latter, a
sample sizes, study populations, follow-up periods, measures of
prior SA is the most important risk factor (3).
sleep disturbance, and covariates. To the best of our knowledge,
Sleep disturbances comprise difficulty initiating sleep, maintain-
no systematic review or meta-analysis examining the predictive
ing sleep or early morning awakening, sleep-disordered breathing,
role of sleep disturbances for incident suicidality has been
and other sleep disorders (4,5). The prevalence of sleep disturbances
published. Understanding the contribution of sleep disturbances to
varies from 6.6% to 50.5% in general populations (6–8) and is
associated with an increased risk of medical conditions, such as
asthma, diabetes, hypertension, Alzheimer’s disease and psychiatric
CI = confidence interval, CS = completed suicide, HR = hazard ra-
disorders (e.g., depression) (9–14), and cognitive dysfunction, as tio, OR = odds ratio, RR = relative risk, SA = suicide attempt
well as poor quality of life and work performance (15–17). In

From the Guangdong Mental Health Center, Guangdong Provincial People’s Hospital (Dong), Guangdong Academy of Medical Sciences, Guangzhou,
Guangdong, China; Team IETO, Bordeaux Population Health Research Center, UMR U1219, INSERM (Lu), Université de Bordeaux, Bordeaux, France;
The National Clinical Research Center for Mental Disorders, the Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, and the Advanced
Innovation Center for Human Brain Protection (Sha, L. Zhang, Q. Zhang), Capital Medical University, Beijing, China; Division of Psychiatry, School of
Medicine (Ungvari), University of Western Australia/Graylands Hospital, Perth; University of Notre Dame Australia (Ungvari), Fremantle, Australia; De-
partment of Psychiatry, University of Saskatchewan (Balbuena), Saskatoon, Saskatchewan, Canada; Unit of Psychiatry, Department of Public Health and
Medicinal Administration, Faculty of Health Sciences (Xiang), Centre for Cognitive and Brain Sciences (Xiang), and Institute of Advanced Studies in Hu-
manities and Social Sciences (Xiang), University of Macau, Macao SAR, China.
M.D., L.L., S.S., L.Z., and Q.Z. contributed equally to the work.
Address correspondence to Yu-Tao Xiang, MD, PhD, Faculty of Health Sciences, University of Macau, 3/F, Building E12, Avenida da Universidade,
Taipa, Macau SAR, China. E-mail: xyutly@gmail.com
Received for publication June 9, 2020; revision received September 9, 2020.
DOI: 10.1097/PSY.0000000000000964
Copyright © 2021 by the American Psychosomatic Society

Psychosomatic Medicine, V 83 • 739-745 739 September 2021

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 SYSTEMATIC REVIEW/META-ANALYSIS
incident suicidality is essential because sleep is one of the few
modifiable risks for suicide and hence a potential target for
prevention (23). The present work is a meta-analysis of cohort
studies to estimate the risk of incident suicidality (i.e., SA and CS
in this meta-analysis) in people experiencing sleep disturbances. In
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this meta-analysis, we tested the hypothesis that sleep disturbances
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are associated with an increased risk of suicidality.
METHODS
Search Strategy
This meta-analysis was conducted in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses guidelines
and the Meta-analysis of Observational Studies in Epidemiology recommenda-
tions (24). The protocol was registered in PROSPERO (CRD42019136397).
The PubMed, EMBASE, PsycINFO, and Web of Science databases were
systematically and independently searched by two investigators (M.D.
and L.L.) from their inception to March 25, 2019, using the following
search words: “suicid*, sleep, sleep disorder, sleep problems, sleep
disturbances, sleep quality, insomnia, sleepiness, somnolence, sleep
apnea, snoring, sleep disordered breathing, obstructive sleep, apnea,
restless legs syndrome, periodic limb movements disorder, REM sleep
behavior disorder, sleep movement disorder, parasomnias, sleep-wake
disruption, circadian rhythm sleep disorder, sleep phase, sleep pattern,
cohort, follow-up, prospective, and longitudinal.” The same two
investigators (M.D. and L.L.) independently screened titles and abstracts,
and read full texts of potentially relevant articles for eligibility. The reference
lists of relevant articles were also reviewed for additional studies.
FIGURE 1. PRISMA flow chart. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SA = suicide
attempt; CS = completed suicide.
Psychosomatic Medicine, V 83 • 739-745
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Study Selection
Studies satisfying the following criteria were included in the meta-analysis:
a) prospective or retrospective cohort studies that b) measured the associa-
tions between sleep disturbances and incidence of suicidality (SA and CS);
c) assessed sleep disturbances with the use of standardized questions, ques-
tionnaires, or clinical diagnosis; d) reported data that enabled the calcula-
tion of incidence rates of suicidality measured by relative risks (RRs),
odds ratios (ORs), or hazard ratios (HRs) with 95% confidence intervals
(CIs) in persons with sleep disturbances; e) reported RRs, ORs, or HRs ad-
justed for confounding factors; and f ) were published in English. Sleep dis-
turbances included insomnia, sleep-disordered breathing, excessive daytime
sleepiness, sleep-related movement disorder, circadian rhythm sleep disorder,
and nonspecific sleep problems (4). Cross-sectional studies, reviews, and
randomized control trials were excluded. If multiple articles were published
based on the same dataset, the study with the most complete information
was included in the meta-analysis.
Data Extraction and Quality Assessment
Two investigators (M.D. and L.L.) independently extracted the following
demographic and clinical data: first author; publication year; study design;
study site; number of individuals; proportion of men; mean age; number of
individuals with sleep disturbances at baseline and cases with suicidality
during follow-up; assessment of sleep disturbances and suicidality;
follow-up period; RRs, ORs, or HRs with their 95% CIs; and the number
and covariates used for adjustment. If a study provided several adjusted risk
estimates, the fully adjusted figure was used. If risk estimates for more than
one follow-up assessment were reported, the estimate for the longest
follow-up period was used. Discrepancies in study selection and data ex-
traction were resolved by a discussion with a third investigator (Y.-T.X.).
The same two investigators (M.D. and L.L.) independently assessed the
quality of included studies using the Newcastle-Ottawa Scale, which has
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TABLE 1. Characteristics of Studies Included in the Meta-analysis

Age at
Baseline: Individuals
Time of Total range With Sleep Sleep End Suicide Follow-Up Quality
Study Reference Location Survey Subjects (mean), y Male, % Disturbances Variables Point Cases Duration, y Adjusted Confounding Factors Score

Lin et al., (28) Taiwan 2000–2013 479,967 >15 (NA) 49.1 159,989 Insomnia SA 1395 13 Sex, age, low income, 8
2018 catastrophic illness,
urbanization, CCI, drug
dependence, alcohol
dependence, and mental
disorders
Rod et al., (29) Sweden 2000–2010 446,135 16–64 (NA) 73.9 74,543 Sleep apnea CS 439 9 Age, education, country of birth, 9

Psychosomatic Medicine, V 83 • 739-745

2017 family situation, urbanicity of
residence area, comorbidity
Li et al., (22) Hong 2006–2007 1,231 18–65 (42.5) 31.8 267 Insomnia SA 12 1 Sex, age, marital status, 7
2014 Kong employment status, duration of
mental illness, psychiatric
diagnosis
Gunnell (30) Taiwan 1994–2008 542,088 NA 49.4 45,700 Insomnia CS 335 14 Age, sex, education, marital 8
et al., status, smoking, drinking,

741
2013 physical activity, BMI and its
quadratic term
Rod et al., (31) France 1989–2009 12,524 36–52 (NA) 100 318 Sleep CS 44 19 Age, socioeconomic status, 8
2011 disturbances marital status, current smoking,
alcohol consumption, baseline
BMI, night work, and baseline
morbidity, depressive
symptoms
Bjorngaard (20) Norway 1984–2004 74,977 NA (49.6) 49.0 1930 Insomnia CS 157 20 Sex, baseline age, BMI, 9
et al., decreased functional ability in
2011 daily life, use of painkillers and
education, baseline alcohol
use and anxiety/depression
score
Fujino (32) Japan 1986–1999 13,259 30–79 (52.9) 44.6 2565 Insomnia CS 48 14 Living arrangement, marital 5
et al., status, satisfaction with
2005 residence/environment,
self-rated health, stress related
to home life during the

Copyright © 2021 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
previous year, environment

NA = not available; SA = suicide attempt; CCI = Charlson comorbidity index; CS = completed suicide; BMI = body mass index.
Sleep Disturbances and Suicidality

September 2021
 SYSTEMATIC REVIEW/META-ANALYSIS
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FIGURE 2. Forest plot for incident suicidality in sleep disturbances. CI = confidence interval.
three domains: selection of cases and controls (four items), comparability of
study groups (one item), and outcome assessment (three items) (25). The
total score, ranging from 0 to 9, was calculated by adding up all the item
scores. Studies with a Newcastle-Ottawa Scale total score of ≥7 were
considered high quality; 5 to 6, medium quality; and ≤4, low quality (25).
Statistical Analysis
Data analyses were performed using the Comprehensive Meta-Analysis,
version 2.0 (Biostat Inc., Englewood, New Jersey). The effect sizes were
quantified using RRs with 95% CIs. When the incidence rate was low,
ORs and HRs were regarded as approximate RRs (4,26). For studies in
which RRs were provided separately in subgroups (e.g., males and
females, inpatients and outpatients), data from subgroups were combined
to calculate pooled RRs. Statistical heterogeneity between studies was
evaluated with the I2 statistic and Q statistic (27). Random- (I2 ≥ 50%) or
fixed-effects models (I2 < 50%) were applied in the analyses, as appropriate.
Sensitivity analyses were performed by excluding each study one by one
to examine the robustness of the primary results. Subgroup analyses were
conducted to explore possible sources of heterogeneity. The median
splitting method was used for continuous variables. Statistical significance
was set at a two-tailed α of .05.
RESULTS
Literature Search
The study selection is presented in Figure 1. Of the 2490 articles
screened, 1769 were unduplicated and a total of 7 studies met
the selection criteria for the meta-analysis.
Study Characteristics and Quality Assessment
The study characteristics are presented in Table 1. Seven cohort
studies totaling 1,570,181 individuals at baseline were included;
FIGURE 3. Forest plot for incident CS and SA in sleep disturbances. SA = suicide attempt; CS = completed suicide; CI = confidence
interval.
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1407 individuals attempted suicide (2 studies) and 1023 completed
suicide (5 studies) during follow-up. The mean age at baseline
ranged from 42.5 to 52.9 years. Follow-up periods spanned from
1 to 20 years. The seven studies were published between 2005
and 2018. Four studies were conducted in Asia, and three studies
in Europe. One study reported adjusted RRs, another adjusted
ORs, and five studies reported adjusted HRs. One study presented
the risk stratified by sex and inpatients/outpatients (29). Different
types of sleep disturbances were examined: insomnia in five studies
and sleep apnea in one study. The study quality assessments are
shown in Table 1. Six of the seven studies were classified as high
quality and one as medium quality.
Overall Suicide Risk in Individuals With Sleep
Disturbances
The predictive effects of sleep disturbances on incident SA and CS
were meta-analyzed. Individuals with sleep disturbances had a sig-
nificantly higher incidence of suicidality than did those without
(relative risk [RR] = 2.17, 95% CI = 1.45–3.24, I2 = 82.50%); spe-
cifically, the risk of incident SA was 3.54-fold higher (95% CI =
3.07–4.09, I2 = 0%), whereas the risk of incident CS was 1.80-fold
higher (95% CI = 1.32–2.44, I2 = 59.33%). Incident SA risk was
significantly higher than CS risk (p < .001). The pooled RRs are
presented in Figures 2 and 3.
Sensitivity Analysis and Subgroup Analysis
Performing a sensitivity analysis is recommended for meta-analyses
involving more than three studies (4) to examine how each study
impacts on the overall results. Sensitivity analysis was performed by
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 Sleep Disturbances and Suicidality

TABLE 2. Subgroup Analyses

p (Heterogeneity Q (p Across
Subgroup Categories No. Studies Pooled RR 95% CI I2, % Within Subgroup)a Subgroups)b

Sex Male 3 1.45 0.88–2.39 66.33 .051 0.72 (.39)

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Female 2 2.38 0.85–6.64 70.44 .066

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Source of sample Inpatients 2 2.76 1.52–5.01 85.45 .001 1.88 (.38)

Outpatients 2 1.46 0.73–2.90 58.39 .090
General population 4 2.06 1.56–2.72 0 .80
Maximum follow-up, yc <14 2 3.54 3.07–4.09 0 .44 11.69 (.001)
≥14 4 2.06 1.56–2.72 0 .80
Sample sizec <44,118 3 2.62 1.52–4.52 0.59 .36 0.01 (.91)
>44,118 3 2.52 1.56–4.05 81.40 .005
No. adjusted factorsc <8 2 2.86 1.02–8.01 37.29 .20 0.02 (.88)
≥8 4 2.63 1.72–4.02 72.31 .013
Mean age at baseline, yc <49.6 1 6.96 1.21–40.00 0 1 1.79 (.18)
≥49.6 2 2.01 1.24–3.26 0 .84
Suicide behaviors SA 2 3.54 3.07–4.09 0 .44 15.52 (<.001)
CS 5 1.80 1.32–2.44 59.33 .016

RR = relative risk; CI = confidence interval; SA = suicide attempt; CS = completed suicide.

Values in bold denote statistical significance (p < .05).
a
Test of heterogeneity within subgroups.
b
Test across subgroup.
c
Median splitting method was used.

removing studies one at a time; the primary results did not change
significantly after removing all of the seven studies separately.
As shown in Table 2, subgroup analyses revealed that the
pooled RR was significantly higher in the studies having <14 years
of follow-up (RR = 3.54, 95% CI = 3.07–4.09, I2 = 0%, p = .44)
than in those with ≥14 years of follow-up (RR = 2.06, 95% CI =
1.56–2.72, I2 = 0%, p = .80; Q between groups, p = .001). The rest
of the RR comparisons between subgroups were not statistically
significant. The pooled RR in inpatients (RR = 2.76, 95% CI =
1.52–5.01, I2 = 85.45%, p = .001) was not significantly higher than
in outpatients (RR = 1.46, 95% CI = 0.73–2.90, I2 = 58.39%,
p = .090) or in the general population subgroups (RR = 2.06,
95% CI = 1.56–2.72, I2 = 0%, p = .80). The pooled RR in the fe-
male subgroup (RR = 2.38, 95% CI = 0.85–6.64, I2 = 70.44%,
p = .066) was not significantly higher than in the male subgroup
(RR: 1.45, 95% CI = 0.88–2.39, I2 = 66.33%, p = .051). There
were also no significant associations between the increased risk
of suicidality and sample size, mean age, and the number of ad-
justed variables.
DISCUSSION
This study found that the risk of suicidality in individuals with
sleep disturbances was 2.17 times higher than in those without
sleep disorders. The risk of SA (RR = 3.54) was significantly
higher than the risk of CS (RR = 1.80) in individuals with sleep
disturbances compared with those without them. The risk of SA re-
lated to sleep disturbances in this study was higher than the find-
ings (ORs = 1.92) in an earlier meta-analysis (33) that focused
on adolescents and comprised cross-sectional, prospective, and
retrospective studies. In addition, the association is somewhat
stronger in cohort studies than in cross-sectional studies such
as reported previously (33).
The relationship between sleep disturbances and increased risk
of incident suicidality could be accounted for by several reasons.
First, sleep disturbances result in fatigue, pessimism, and reduced
impulse control, all of which are contributing factors to suicidality
(34,35). Sleep disturbances, especially when experienced chronically,
increase aggressive and impulsive behaviors and decrease cognitive
function (36), all of which increase suicide risk (36–38). Second,
sleep deprivation reduces the clearance of metabolic waste in the
brain, promotes neuroinflammation, and disrupts neurogenesis
(39,40). Sleep deprivation is associated with hyperactivity of the
hypothalamic-pituitary-adrenal axis, particularly in major depression
(41,42), which is involved in the biological pathway to suicide (43).
Third, sleep disturbances increase the risk of severe psychiatric
disorders, especially depression (44), whose symptoms include
thoughts of death or self-harm (45). For instance, insomnia increases
the risk of depression by twofold to fivefold (46). Furthermore,
there is a bidirectional relationship between sleep disturbances
and psychiatric disorders (14,47), and their combination could
lead to a higher risk of suicidality. Fourth, sleep disturbances
are risk factors for certain medical conditions, such as diabetes,
obesity, and hypertension (10,11,48), which elevate the level
of psychological distress, thereby contributing to the risk of
suicidality (3).
Subgroup analyses found that the predictive value of sleep dis-
turbances for suicidality was more prominent in studies with
follow-up of <14 years compared with those with ≥14 years. It is
possible that baseline sleep disturbances resolved over the longer
follow-up periods (30) or people experiencing chronic sleep

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 SYSTEMATIC REVIEW/META-ANALYSIS
disturbances may have adapted to them, both of which could
reduce the risk of suicidality.
Differences in the composition of study samples (i.e., inpa-
tients, outpatients, and general population) were accounted for in
this meta-analysis. It is quite surprising that no significantly higher
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risk of suicidality was observed in outpatients compared with inpa-
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tients and the general population. Compared with outpatients and
the general population, inpatients are likely to have more severe
medical and/or psychiatric disorders, which result in a range of
negative outcomes including higher risk of suicidality (29). In
addition, socioeconomic factors related to medical and/or psychiatric
disorders, for example, low income and unemployment (49), also
increase the likelihood of suicidality.
There was an increased risk of suicidality in women compared
with men, but the difference did not reach statistical significance.
Insomnia is 1.4 times more common in women than in men (50).
Traditionally, besides being employed, women spend more time
and energy in family care and household duties, which could
explain their higher rate of sleep disturbances and suicidality (51).
Older people have poor sleep efficiency (52), and those with
sleep apnea have a higher risk of premature death (29). In the
present study, the risk of suicide was higher in individuals younger
than 49.6 years (RR = 6.96) than in their older counterparts
(RR = 2.01), but the difference did not reach statistically significant
level. It should be noted, however, that only three studies were
included in the subgroup analysis; therefore, this finding should
be considered tentative.
The results of this study should be interpreted with caution be-
cause of several methodological limitations. First, similar to previ-
ous meta-analyses of cohort studies (4,26), we included studies
that reported a mix of RRs, ORs, and HRs; thus, the results should
be regarded as preliminary. In addition, the results of increased risk
of SA should be considered provisional, as only two studies were
analyzed. Second, assessment of sleep disturbances with different
measures and the wide range of follow-up intervals (1–20 years) are
sources of heterogeneity between studies. Third, the confounders
adjusted for by the studies differed from study to study, a common
occurrence in any meta-analysis of cohort studies (4,53). Potentially
relevant factors related to the association between sleep disturbances
and suicidality, such as psychiatric comorbidities, substance abuse, and
psychotropic medications, were not explored in some of the studies.
CONCLUSIONS
The results of this meta-analysis provide evidence that sleep dis-
turbances could increase the risk of incident suicidality. It is likely,
therefore, that timely and effective treatment of sleep disturbances
may reduce the risk of suicidality. Because the treatment rate for
sleep disturbances is still low in many areas (e.g., 40.3% in China
and 31% in Latin America (54,55)), widespread and systematic
screening for sleep disturbances and promotion of resilience (56,57)
could be an effective tool for suicide prevention.
Source of Funding and Conflicts of Interest: The study was sup-
ported by the National Science and Technology Major Project for in-
vestigational new drug (2018ZX09201-014), the Beijing Municipal
Science and Technology Commission (No. Z181100001518005), the
University of Macau (MYRG2019-00066-FHS) and Guangdong
Psychosomatic Medicine, V 83 • 739-745
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Provincial Medical Science and Technology Research Foundation
(No. B2020130). There are no conflicts of interests to declare.
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