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

翻译后摘要：我们的档案数据表明，27%的老年人住院治疗的抑郁症， 出院后3个月自杀意念（SI）仍在继续。有持续的后- 出院SI将个体置于自杀行为和死亡的极高风险中。认知和情感 机制可能决定放电后SI的过程，但中断这些过程仍然存在 挑战性这部分是因为上游可改变的风险因素加剧了 出院后的认知、情感、SI等方面的研究较少。我们建议睡眠-觉醒 干扰是出院后预后的潜在重要因素。睡眠-觉醒障碍 可能影响SI的认知和情感机制。但许多潜在的相关 睡眠-觉醒因素已经被确定，但还没有证据表明是什么标志或驱动了睡眠-觉醒因素。 在放电后使SI永久化的机制。为了开始填补这些空白，我们提出了一个前瞻性 观察性试点研究，检查睡眠-觉醒障碍，以及其他假定的自杀风险因素， 出院后的关键时期。本探索性/发展性研究（R21）提案汇集了 睡眠-觉醒节律和晚年抑郁症专家（Smagula，PhD，PI），睡眠医学（Buysse，MD），晚期抑郁症专家， 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）。 我们将在12周内监测70名成年人（年龄55-75岁，非精神病性主要 抑郁症、当前活动性SI和近期精神病出院）。在6周内，我们将 进行高分辨率数据收集，包括：评估24小时睡眠-觉醒模式（使用活动记录仪和 日记）;测量每日自杀水平（被动意念、主动意念和计划）和影响（抑郁 和焦虑）;以及每周进行一次以前与睡眠有关的认知功能的家庭测试 和自杀（即，注意力、反应抑制和反向学习表现）。我们可检验的假设 基于现有的证据是：（1）每周测量短睡眠时间和睡眠-觉醒节律 中断将暂时先于并独立预测出院后SI的更差过程;以及（2） 这些睡眠-觉醒因素将部分地通过它们对认知和情感的不利影响而与SI的过程相关。 鉴于其重要作用，我们还将评估心理社会因素的影响，并评估其 与睡眠的关系收集这些新的数据将使分析：（1）排名的影响大小， 假定的风险因素，包括睡眠-觉醒，心理，情感和认知措施;（2）检查 风险因素之间的时间关系;（3）初步检验中介模型。结果从这个 研究将为验证性研究的发展提供信息，最终导致新的，循证的， 干预措施。如果睡眠-觉醒因素在决定出院后自杀风险方面发挥作用， 临床转化率很高，因为出院后可以改变和/或监测睡眠-觉醒风险。

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.