Sleep-wake, cognitive, and affective risks for a worse course of post-discharge suicidal ideation in older adults with major depression

摘要：我们的档案数据显示，27%的老年人患有严重的抑郁症和 自杀率在出院三个月后继续报告自杀意念(SI)。有持之以恒的职位- 出院后的SI使个人有很高的自杀行为和死亡风险。认知和情感 机制可能决定了放电后SI的进程，但中断这些过程仍然存在 很有挑战性。这在一定程度上是因为上游可修改的风险因素加剧了与 对放电后阶段的认知、情感和SI知之甚少。我们建议睡眠唤醒 干扰是潜在的出院后预后的重要因素。睡眠-觉醒障碍 可信地影响构成SI基础的认知和情感机制。但许多潜在的相关 睡眠-觉醒因素已经被识别出来，目前还没有证据表明是哪个标志或驱动因素 在放电后使SI永久化的机制。为了开始填补这些空白，我们提出了一种 观察性先导研究检查睡眠-唤醒障碍，以及其他可能的自杀风险因素，在 关键的出院后时期。此探索性/发展性研究(R21)建议书汇集了 睡眠-觉醒节律和晚年抑郁症(Smagula，PhD，PI)，睡眠医学(马里兰州Buysse)，晚年- 生命自杀(Szanto，MD，Co-I)、认知老化(Butters，PhD)和时间序列分析(Krafty，PhD，Co-I)。 我们将监测70名成年人(年龄55-75岁，非精神病专业)在12周内的自杀过程 抑郁障碍、目前活跃的SI和最近的精神病院出院)。在6周内，我们将 执行高分辨率数据收集，包括：评估24小时睡眠-唤醒模式(使用活动记录仪和 日记)；测量日常自杀水平(消极想法、积极想法和计划)和影响(抑郁 和焦虑)；以及对以前与睡眠有关的认知功能进行每周一次的家庭测试 和自杀(即注意、反应抑制和反转学习表现)。我们的可测试假设 根据现有的证据：(1)每周测量短睡眠时间和睡眠-觉醒节律 干扰将在时间上先于并独立地预测出院后SI更糟糕的过程；以及(2) 这些睡眠-觉醒因素将与SI的进程有关，部分是通过它们对认知和情感的不利影响。 鉴于他们的重要作用，我们也将评估心理社会因素的影响，并评估他们的 与睡眠的关系。收集这些新颖的数据将使分析成为可能：(1)对影响大小进行排名 假定的风险因素包括睡眠-觉醒、心理社会、情感和认知测量；(2)检查 风险因素之间的时间关系；(3)初步检验中介模型。由此产生的结果 研究将为验证性研究的发展提供信息，最终导致新的、基于证据的、 干预措施。如果睡眠-觉醒因素在确定出院后自杀风险中起作用，那么 考虑到出院后睡眠觉醒风险可以被修改和/或监测，临床转换率很高。

Abstract: Our archival data indicates that 27% of older adults hospitalized with major depression and suicidality continue to report suicidal ideation (SI) three months after discharge. Having persistent post- discharge SI places individuals at very high risk for suicidal behaviors and death. Cognitive and affective mechanisms likely determine the course of post-discharge SI, but interrupting these processes remains challenging. This is, in part, because the upstream modifiable risk factors that exacerbate problems with cognition, affect, and SI in the post-discharge period are poorly understood. We propose that sleep-wake disturbances are potentially important contributors to the post-discharge prognosis. Sleep-wake disturbances plausibly influence the cognitive and affective mechanisms that underlie SI. But many potentially relevant sleep-wake factors have been identified, and there is not yet evidence regarding which mark or drive the mechanisms that perpetuate SI after discharge. To begin filling these gaps, we propose a prospective observational pilot study examining sleep-wake disturbances, alongside other putative suicide risk factors, in the critical post-discharge period. This Exploratory/Developmental Research (R21) proposal brings together experts in sleep-wake rhythms and late-life depression (Smagula, PhD, PI), sleep medicine (Buysse, MD), late- life suicide (Szanto, MD, Co-I), cognitive aging (Butters, PhD), and time series analytics (Krafty, PhD, Co-I). We will monitor the course of suicidality over 12-weeks in 70 adults (age 55-75, with non-psychotic major depressive disorder, current active SI, and a recent psychiatric hospital discharge). Over 6 weeks, we will perform high-resolution data collection including: assessing 24-hour sleep-wake patterns (using actigraphy and diary); measuring daily suicidality levels (passive ideation, active ideation, and planning) and affect (depression and anxiety); and administering weekly home-based tests of cognitive functions previously linked with sleep and suicide (i.e., attention, response inhibition, and reversal learning performance). Our testable hypotheses based on existing evidence are that: (1) weekly measures of short sleep duration and sleep-wake rhythm disruption will temporally precede and independently predict a worse course of post-discharge SI; and (2) these sleep-wake factors will relate to the course of SI, in part, via their adverse effects on cognition and affect. Given their important roles, we will also evaluate the effects of psychosocial factors and assess their relationships with sleep. Collecting these novel data will enable analyses: (1) ranking the effect sizes of putative risk factors including sleep-wake, psychosocial, affective, and cognitive measures; (2) examining the temporal relationships between risk factors; and (3) preliminarily testing mediational models. Results from this study will inform the development of confirmatory studies ultimately leading to novel, evidence-based, interventions. If sleep-wake factors have a role in determining post-discharge suicide risk, the potential for clinical translation is high, given that sleep-wake risks could be modified and/or monitored after discharge.