1. Introduction
Suicide is the second leading cause of death among young adults (WHO, 2014), and increased vulnerability to thoughts and behaviors related to suicide (i.e., suicidal ideation) is evidenced in the student population (O’Neill et al., Reference O’Neill, McLafferty, Ennis, Lapsley, Bjourson, Armour, Murphy, Bunting and Murray2018). In the UK, data indicate a twofold increase in suicide deaths among higher education (HE) students over the past decade, with 95 completed attempts in the 2016/17 academic year (Caul, Reference Caul2018). Estimates of lifetime suicidal ideation among UK HE students range from 31 to 72.4% (Akram et al., Reference Akram, Ypsilanti, Gardani, Irvine, Allen, Akram, Drabble, Bickle, Kaye, Lipinski, Matuszyk, Sarlak, Steedman and Lazarus2020; Dhingra et al., Reference Dhingra, Klonsky and Tapola2019; O’Neill et al., Reference O’Neill, McLafferty, Ennis, Lapsley, Bjourson, Armour, Murphy, Bunting and Murray2018), and between 9.8 and 14.6% in the general population (Casey et al., Reference Casey, Dunn, Kelly, Lehtinen, Dalgard, Dowrick and Ayuso-Mateos2008).
The experience of suicidal ideation serves as a risk factor for future suicidal behavior and completion (Ribeiro et al., Reference Ribeiro, Gutierrez, Joiner, Kessler, Petukhova, Sampson and Nock2017), often presenting with extreme psychological distress (Garlow et al., Reference Garlow, Rosenberg, Moore, Haas, Koestner, Hendin and Nemeroff2008). Although suicidal ideation may occur in the absence of other psychiatric disorders (Chiles & Strosahi, Reference Chiles and Strosahl2005), studies have typically shown that suicidal ideation co-occurs alongside underlying, yet treatable, mental health difficulties (Cracknell, Reference Cracknell2015). Insomnia is a recognized public health concern, often related with and leading to long-term physical and mental exhaustion, disturbed mood, concentration and memory deficits, social isolation, body image disturbance, and suicidal ideation (Akram et al., Reference Akram, Ypsilanti, Drabble and Lazuras2019; Reference Akram, Ypsilanti, Gardani, Irvine, Allen, Akram, Drabble, Bickle, Kaye, Lipinski, Matuszyk, Sarlak, Steedman and Lazarus2020; Reference Akram, Allen, Stevenson, Lazarus, Ypsilanti, Ackroyd, Chester, Longden, Peters and Irvine2021a; Reference Akram, Allen, Stevenson, Lazuras, Ackroyd, Chester, Longden, Peters and Irvine2021b; Baglioni et al., Reference Baglioni, Battagliese, Feige, Spiegelhalder, Nissen, Voderholzer, Lombardo and Riemann2011; Byrne, Reference Byrne2019; Choueiry et al., Reference Choueiry, Salamoun, Jabbour, El Osta, Hajj and Khabbaz2016; Ellis et al., Reference Ellis, Perlis, Bastien, Gardani and Espie2014; Kyle et al., Reference Kyle, Morgan and Espie2010; Perlis et al., Reference Perlis, Giles, Buysse, Thase, Tu and Kupfer1997; Ypsilanti et al., Reference Ypsilanti, Lazuras, Robson and Akram2018). Indeed, a recent review of sleep and suicidal ideation data in students (Russell et al., Reference Russell, Allan, Beattie, Bohan, MacMahon and Rasmussen2019) and the general population (Harris et al., Reference Harris, Huang, Linthicum, Bryen and Ribeiro2020; Liu et al., Reference Liu, Steele, Hamilton, Do, Furbish, Burke and Gerlus2020) found insomnia to be consistently associated with an increased risk of future suicidal thoughts and behaviors (Bernert et al., Reference Bernert, Hom, Iwata and Joiner2017; Hom et al., Reference Hom, Stanley, Chu, Sanabria, Christensen, Albury, Rogers and Joiner2019; Littlewood et al., Reference Littlewood, Kyle, Carter, Peters, Pratt and Gooding2019; Shi et al., Reference Shi, Zhu, Wang, Wang, Chen, Li and Jiang2021).
2. Objectives
Although a number of studies have examined the relationship between insomnia and suicidal ideation in specific populations (e.g., military and prison: Carli et al., Reference Carli, Roy, Bevilacqua, Maggi, Cesaro and Sarchiapone2011; Hom et al., Reference Hom, Chu, Schneider, Lim, Hirsch, Gutierrez and Joiner2017), few compare differences between students and nonstudents. Furthermore, studies sampling students from UK institutions remain sparse or limiting samples to particular institutions or course topic (Cardwell et al., Reference Cardwell, Lewis, Smith, Holt, Baillie, Allister and Adams2013). The overall aim of this study was to examine the interaction between insomnia-symptoms (normal-sleepers vs. insomnia-symptoms) and student-status (students vs. non-students) on reports of suicidal thoughts of behaviors. Student psychological well-being is an important global issue of growing interest. Contemporary students face stressors beyond the “traditional” stressors associated with pursuing HE (e.g., exam pressure and deadlines: El Ansari et al., Reference El Ansari, Stock, John, Deeny, Phillips, Snelgrove, Adetunji, Hu, Parke, Stoate and Mabhala2011). Research has shown that the transition into university is associated with documented psychological disturbances (Macaskill, Reference Macaskill2013). In line with independent prevalence estimates (Casey et al., Reference Casey, Dunn, Kelly, Lehtinen, Dalgard, Dowrick and Ayuso-Mateos2008), we expect greater reports of suicidal thoughts and behaviors among students. In addition, when compared with nonstudents, we expect levels of suicidal ideation to be accentuated among students presenting insomnia symptoms.
3. Methods
3.1. Sample and procedure
The protocol was approved by the Sheffield Hallam University Research Ethics Committee. A cross-sectional online questionnaire-based study was implemented comprising of questions designed to examine symptoms of insomnia and suicidal ideation. Students from three UK universities were recruited through institutional course participation schemes, social media, and faculty emails. Members of the general population were recruited using social media platforms and online forums. Overall, 780 participants began or accessed the questionnaire, after incomplete entries were discarded 636 completed entries (mean age = 28.95 ± 13.03, range 18–100, 88% female; final response rate = 81.5%) were kept for analysis. This sample size was sufficient for a 95% confidence level, exceeding our target of 500 responses leaving an acceptable 4.5% margin of error (Niles, Reference Niles2006). SPSS (version 24, IBM Corp., Armonk, NY) was used to perform formal statistical analyses with significance considered at the p < .05 level.
3.2. Measures
Suicidal ideation was examined using the Suicidal Behaviors Questionnaire-Revised (SBQ-R; Osman et al., Reference Osman, Bagge, Gutierrez, Konick, Kopper and Barrios2001). Specifically, four items examine lifetime ideation/attempt, frequency of ideation over the past 12 months, telling someone else about ideation, and likelihood of attempting suicide in the future. Items can be analyzed individually and summated to create a total score ranging between 3 and 18. Higher total scores indicate greater risk of suicidal ideation. A score of ≥7 indicates significant risk for suicidal behavior (sensitivity 93% and specificity 91% in the adult general population; Osman et al., Reference Osman, Bagge, Gutierrez, Konick, Kopper and Barrios2001). Internal consistency was high in the present sample (α = 0.86).
Insomnia symptoms were assessed using Sleep Condition Indicator (SCI), a clinical screening tool developed to appraise insomnia symptoms against the DSM-5 criteria for Insomnia Disorder (Espie et al., Reference Espie, Kyle, Hames, Gardani, Fleming and Cape2014). The scale consists of eight items each scored between 0 and 4 designed to examine insomnia symptomology during the last month. Specifically, questions pertain to sleep onset latency, awakenings during the night, perceived sleep quality, impairment to daytime functioning, and symptom persistence. Items are summed to create a total score between 0 and 32, with lower scores indicating greater insomnia symptom severity. Internal consistency was high in the present sample (α = 0.87).
4. Results
Participants were stratified by student and sleep status. Specifically, normal-sleepers (n = 300; 26.52 ± 11.42 years, 86% female) were determined as those scoring >17 on the SCI, whereas those experiencing insomnia-symptoms (n = 336; 31.11 ± 13.97 years, 90% female) were determined as scoring ≤16. A score of 16 or less on the SCI indicates probable insomnia disorder. Although no sex differences were observed in relation to sleep status (X 2(2) = 4.91, p = .086), the insomnia group was comprised significantly older (31.11 ± 13.97) adults relative to normal-sleepers (26.53 ± 11.42). N = 393 participants confirmed student status (21.30 ± 5.86 years, 87% female) and N = 244 identified as nonstudent (41.23 ± 11.93 years, 90% female). As expected, students were significantly younger than nonstudents (F(1,635) = 788.84, p = .001). No sex differences were observed in relation to student-status (X 2(2) = 1.87, p = .393). Mean scores grouped by student status are presented in Table 1.
Table 1. Mean scores for each measure for the whole sample and separated by suicidal ideation risk
Abbreviations: ±, standard deviation; SBQ-R, Suicide Behaviors Questionnaire Revised; SCI, Sleep Condition Indicator.
* Significance at <.05.
** Significance at <.01.
A series of one-way analysis of variance (ANOVA) examined differences in insomnia symptoms and suicidal ideation between students and nonstudents. Here, students presented increased reports of insomnia symptoms (F(1,636) = 13.55, p = .001) and total suicidal ideation scores (F(1,636) = 5.45, p = .02) compared to nonstudents. Individual examination of SBQ-R items revealed greater reports of lifetime ideation/attempt (F(1,636) = 4.59, p = .03), frequency of ideation over the past 12 months (F(1,636) = 5.32, p = .02). However, no group differences were observed in telling someone else about ideation (F(1,636) = 1.98, p = .16) and the likelihood of attempting suicide in the future (F(21,636) = 3.69, p = .06) among students.
A 2 (sleep: normal-sleeper vs. insomnia-symptoms) × 2 (student-status: student vs. nonstudent) mixed measures ANOVA with total SBQ-R scores as the dependant variable examined the interaction between sleep status and student status. The results demonstrated significant main effects of sleep (F(1,633) = 65.72, p = .001) and student-status (F(1,633) = 11.74, p = .001). Although no sleep × student-status interaction was observed (F(1,633) = 2.10, p = .15), individual analysis of total suicidal ideation scores in the insomnia group revealed a significant difference between students (7.70 ± 4.03) and nonstudents (6.36 ± 3.54: F(1,335) = 10.09, p = .002, see Figure 1). However, total suicidal ideation scores in normal-sleepers failed to differ between students (5.08 ± 2.74) and nonstudents (4.54 ± 2.15: F(1,298) = 2.85, p = .09). Therefore, the experience of insomnia symptoms may contribute to suicidal thoughts and behaviors in the student population.
Figure 1. Bar chart decomposing the interaction between sleep (normal-sleeper vs. insomnia symptoms) and student status (student vs. nonstudent) on total SBQ-R scores. No difference in total SBQ-R scores observed between normal sleeping students and nonstudents (left). Significantly higher total SBQ-R scores displayed among students with insomnia symptoms (right). Abbreviations: SBQ-R, Suicidal Behaviors Questionnaire-Revised. *Significance at <.01.
5. Discussion
This study examined the interaction between sleep-status (insomnia-symptoms: normal vs. insomnia) and student-status (students vs. nonstudents) on reports of suicidal thoughts of behaviors. Partially supporting our first hypothesis, when compared to nonstudents, students indicated greater reports of both total and lifetime ideation while also considering suicidal behavior within the past year. However, no differences were observed in reports of possible future attempt(s) and the disclosure of suicidal thoughts and behaviors to another person. These outcomes are in line with previous estimates of suicidal ideation which from population-specific studies appear greater in the UK student population (31–72.4%) relative to the UK general public 9.8–14.6% (Akram et al., Reference Akram, Allen, Stevenson, Lazuras, Ackroyd, Chester, Longden, Peters and Irvine2021b; Casey et al., Reference Casey, Dunn, Kelly, Lehtinen, Dalgard, Dowrick and Ayuso-Mateos2008; Dhingra et al., Reference Dhingra, Klonsky and Tapola2019; O’Neill et al., Reference O’Neill, McLafferty, Ennis, Lapsley, Bjourson, Armour, Murphy, Bunting and Murray2018). Moreover, we highlight the specific nature of elevated suicidal thoughts and behaviors in the student population.
Overall, students exhibited greater levels of insomnia-symptoms. Interestingly, we observed significantly elevated suicidal ideation among students in the insomnia group when compared with nonstudents. These outcomes highlight the possible role of insomnia symptoms in accentuating suicidal thoughts and behaviors in the student population (Bernert et al., Reference Bernert, Hom, Iwata and Joiner2017; Hom et al., Reference Hom, Stanley, Chu, Sanabria, Christensen, Albury, Rogers and Joiner2019; Littlewood et al., Reference Littlewood, Kyle, Carter, Peters, Pratt and Gooding2019; Russell et al., Reference Russell, Allan, Beattie, Bohan, MacMahon and Rasmussen2019; Shi et al., Reference Shi, Zhu, Wang, Wang, Chen, Li and Jiang2021). The current student population was comprised younger adults in a transitional life period. In this context, the stress of academic life may perpetuate symptoms of insomnia due to increased worry and ruminative thinking when attempting to initiate sleep. This thought pattern is known to facilitate negatively toned cognitive activity, arousal and distress that contributes to delayed sleep-onset latency (Harvey, Reference Harvey2002). In turn, daytime consequences of insomnia diminish the capacity to sufficiently cope with social and interpersonal difficulties and academic stressors faced by students, which may precipitate the onset of psychiatric difficulty (Staner, Reference Staner2010) and suicidal thoughts and behaviors (Becker et al., Reference Becker, Dvorsky, Holdaway and Luebbe2018; Holdaway et al., Reference Holdaway, Luebbe and Becker2018).
Student-based mental health services in the UK should refine screening processes to identify at-risk populations and engage in early intervention (Beiter et al., Reference Beiter, Nash, McCrady, Rhoades, Linscomb, Clarahan and Sammut2015). Psychiatric problems can be readily identified and targeted for intervention, and screening for sleep-disorders, such as insomnia would prove useful when considering its relationship with suicidal ideation among students (Becker et al., Reference Becker, Dvorsky, Holdaway and Luebbe2018; Holdaway et al., Reference Holdaway, Luebbe and Becker2018; Sheaves et al., Reference Sheaves, Porcheret, Tsanas, Espie, Foster, Freeman, Harrison, Wulff and Goodwin2016).
The present sample comprised mostly of female participants, and as such the present findings may not be fully generalizable to males. However, it should be noted that women are more likely than men to experience insomnia (Zhang & Wing, Reference Zhang and Wing2006). Moreover, the cross-sectional nature of the present study limits our ability to draw conclusions about causal relationships. Indeed, it is possible that the experience of suicidal ideation leads to or accentuates pre-existing sleep disturbances. Despite these caveats, we highlight the possible role of insomnia symptoms in accentuating suicidal thoughts and behaviors in the student population. Further longitudinal research should explore the role of disturbed sleep in predicting suicidal thoughts and behaviors in the UK student population.
Funding statement
No funding was received for this research.
Author contribution
The experiment was designed and conceived by UA. Data was collected by U.A., K.I., S.A., J.S. Data was analysed by U.A. & J.S. An initial version of the manuscript was written by U.A. and J.S. Following, input was sought from K.I., S.A. All authors approved the final version of the manuscript.
Conflict of interest
No conflicts of interest declared in relation to this paper.
Data Availability Statement
Data will be made available on reasonable request.
Open access
Comments
Comments to the Author: This is a nice and concise m/s looking at the association between insomnia status and suicidal ideation in students compared to non-students. I like the m/s and have some questions/comments the answers to which I think might add clarity to the m/s.
1. I would be cautious in using phases such as ‘completed suicides’ suicide deaths would work.
2. Although rates of suicide has increased in student populations, it remains lower than general population.
3. Some of the references used are quite outdated (e.g. Casey et al, 2008) – several more recent sources exist.
4. I’m not convinced that social media platforms/ online forums = general population sample.
5. Should sleep status/ demographics be in measures?
6. Were the data assessed for age/gender differences? How do the data compare to sleep in these groups?
I hope the authors find these suggestions useful in revising their m/s.