Sleep Talk: Episode 59 - Sleep and Suicide

Posted September 10, 2021

In Audio, Health Professionals, Podcast, Understanding Sleep

Episode 59: Sleep and Suicide

Suicide is the leading cause of death in young people in Australia and the largest cause of productive life years lost. To understand how we can prevent suicide and links with sleep we spoke to Prof Ian Hickie of the Brain and Mind Centre at University of Sydney. Ian is also a co-host of the Minding your Mind podcast.

Dr Moira Junge (Health Psychologist) and Dr David Cunnington (Sleep Physician) host the monthly podcast, Sleep Talk – Talking all things sleep.

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Audio Timeline / Chapters:

00:00 – 30:52 Theme – Suicide and Sleep
30:52 – 32:03 Clinical Tip
32:03 – 34:26 Pick of the Month
34:26 – 36:06 What’s Coming Up?

Next episode: Burnout

Links mentioned in the podcast:

Presenters:

Guest interview:

Professor Ian Hickie is Co-Director, Health and Policy at The University of Sydney’s Brain and Mind Centre. He is an NHMRC Senior Principal Research Fellow (2013-2017 and 2018-22), having previously been one of the inaugural NHMRC Australian Fellows (2008-12). He was an inaugural Commissioner on Australia’s National Mental Health Commission (2012-18) overseeing enhanced accountability for mental health reform and suicide prevention. He is an internationally renowned researcher in clinical psychiatry, with particular reference to medical aspects of common mood disorders, depression and bipolar disorder. Professor Hickie has been at the forefront of the move to have mental health and suicide prevention integrated with other aspects of health care (notably chronic disease and ambulatory care management). Follow Ian on Twitter at @ian_hickie

Regular hosts:

Dr Moira Junge is a health psychologist working in the sleep field, who has considerable experience working with people with sleeping difficulties in a multidisciplinary practice using a team-based approach. Moira is actively involved with the Australasian Sleep Association (ASA) and a board member of the Sleep Health Foundation. She has presented numerous workshops for psychologists and is involved with Monash University with teaching and supervision commitments. She is one of the founders and clinic directors at Yarraville Health Group which was established in 1998.

Connect with Moira on Twitter – @MoiraJunge

Dr David Cunnington is a sleep physician and director of Melbourne Sleep Disorders Centre, and co-founder and contributor to SleepHub. David trained in sleep medicine both in Australia and in the United States, at Harvard Medical School, and is an International Sleep Medicine Specialist, Diplomate Behavioral Sleep Medicine and Registered Polysomnographic Technologist. David’s clinical practice covers all areas of sleep medicine and he is actively involved in training health professionals in sleep.

Connect with David on Twitter – @DavidCunnington. David also regularly posts information on sleep to his Facebook page.

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At SleepHub we understand the struggle people endure with sleeping problems which is why we have created a comprehensive FAQs page and a range of resources with information for those seeking information about sleep disorders and potential solutions.

Transcript:

Intro: Welcome to Sleep Talk, the podcast about all things sleep brought to you by SleepHub.com.au. Here are your hosts, Dr. David Cunnington and Dr. Moira Junge.

Dr. David Cunnington: So welcome to Episode #59 of Sleep Talk, the podcast talking all things sleep. And welcome again, Moira.

Dr. Dr. Moira Junge: Hello, Dave. It has been a long time.

Dr. David Cunnington: It has been a long time. We were sort of waiting for the pandemic to ease, that all just go away, life to get back to normal, and here we are.

Dr. Moira Junge: I think we thought we had gone through something and then think, “Uh-uh! It’s probably worse this year.”

Dr. David Cunnington: Yeah, and that’s – we’re both health care workers and providing health care and it has been pretty tough for health care workers and both trying to maintain a service to people and people are pretty distressed in the community as well.

Dr. Moira Junge: Yeah. Yeah, extraordinary amount of distress, extraordinary amount of sleep disturbance, and extraordinary amount of people expressing suicidal ideation as well as sometimes not so much suicidal but just a lot of thinking, “I just don’t know – I haven’t got much hope in life. I don’t know what’s worth living for at the moment,” and all those sorts of things, which has prompted us to do the topic that we are doing today which I’ll get you to introduce.

Dr. David Cunnington: So we are going to talk about suicide and its interaction with sleep. There are a number of people who have done a lot of research in this area but we wanted to talk to Professor Ian Hickie because he has published a lot on the relationship between sleep, mood, distress, and the natural consequence of that being suicide. Ian is the Co-Director of the Health and Policy Unit at the University of Sydney’s Brain and Mind Centre.

So thanks a lot for helping us out with the podcast, Ian.

Ian Hickie: Pleasure.

Dr. David Cunnington: And how big a problem is ‘suicide’ in Australia?

Ian Hickie: Suicide is the leading cause of death in young people in Australia between 25 and 44, the leading cause of death of people under 25. Over 3,300 people in Australia lose their lives to suicide every year, 65,000 attempts suicide every year. Now, it is the biggest cause of productive years of life lost. So when you talk about expectancy to meet younger people, it’s 115,000 productive years of life lost every year.

Now, cardiovascular disease which comes second, comes long second at about 78,000, and the various cancers come after down in the 50,000.

So I don’t think most people are aware of the extent to which we are talking about the loss of life, loss of productive life due to a health problem that suicide is streets ahead very sadly of those other common and frequently very well-treated health conditions.

Dr. David Cunnington: So you focused on young people, what about other subgroups where you might see suicide a bit overrepresented?

Ian Hickie: So you see suicide overrepresented in middle-aged men. You see it in certain groups, you certainly see it in our indigenous populations, and there are groups in older people, particularly older men, who are in their own where suicide rates go up.

Now, the so-called comorbidities come into play here. So when people have other medical conditions or chronic pain and other difficulties, certain drug and alcohol and related other problems, and certainly when the situation is complicated by other social factors, so social isolation, loss of jobs, lost relationships, marital breakdown, other factors combined to put people at considerable risk.

Dr. Moira Junge: Ian, it has been great to get you on to speak with us today because you’ve been a real flag-flyer for the link with depression and sleep. And we would like to talk further about this. What are the links between say, suicide and sleep and do we actually know yet?

Ian Hickie: Well, we certainly know about the relationships between various types of depression and the certain types of depression have various different types of sleep and the sleep-wake cycle disturbance. So I often talk about the sleep-wake cycle rather than just sleep. Sometimes I think when people just talk about sleep, they’re thinking only about 8 hours a day but actually, it’s a 24-sleep-wake cycle that most fascinates me and turned to be of a different type. So I say that because of different types of sleep disturbance and their association with different types of neuropsychiatric disorders and then with their consequences like suicide. Very interesting.

Although you can look at epidemiological studies directly at certain kinds of sleep disturbance and suicidal behaviour and try and try and pick the particular relationship. So I think one of the problems we’ve had in psychiatry is to say that sleep is just sort of an epiphenomenon or secondary phenomenon. You have to be depressed first or you have to have some other major problem first and sleep is just of course one of those physiological things that go wrong.

The work I’m associated with goes the other way around. There are certain kinds of sleep-wake cycle disturbances which are fundamental. In fact, we would argue, for example, bipolar disorder, previously known as manic depressive illness, the circadian disturbance is actually the fundamental biological mechanism that the clock goes off, goes off in winter and spring, it goes off and leads to people not being able to sleep at all when they’re manic or being totally oversleeping, becoming hibernating bears in winter when they depressed and it’s really an energy sleep-wake cycle disturbance and the mood is actually the secondary phenomenon hysterically psychiatric colleagues.

But basically treating that and in fact, the world’s most effective treatment is discovered in Melbourne, of all places, lithium in fact moderates the regularity of the clock. A number of antidepressants unfortunately sometimes go the wrong way in making people more light-sensitive and disturbing their clock. So I think in some areas, we argued not only is it important, it probably is the cause or mechanism for the other phenomenon that we see and

bipolar disorder in particular because it has a very high rate of suicide and it’s very hard to treat also with conventional antidepressants. So it doesn’t do well with conventional antidepressants.

Other areas of the sleep-wake cycle or many of our selective serotonin reuptake inhibitors, the Prozac-like drugs, actually make some people more light-sensitive. Again, discoveries made in Melbourne by Sean Cain and his colleagues about light sensitivity and that that make people more likely to become unstable. So, some of the side effects of some of our common antidepressants might be due to their effects on the sleep-wake cycle. Some of the SSRIs again disturb people sleep.

However, on the other side of the coin, there are certain kinds of anxiety, kinds of sleep problems, that can’t fall to sleep, initial insomnia, ruminating thoughts, very anxious with things like cases arise have actually really good treatments and eventually help people to sleep by reducing their anxiety and rumination and fix some initial insomnia. So, initial insomnia tends to run with anxiety. The great majority of depressions are anxious depressions, anxious kids become anxious and depressed teenagers, become depressed and substance abuse in the adults. That’s a lifetime change in the phenotype but the same underlying problem of anxiety type factors and that’s often associated with initial insomnia, broken sleep, daytime fatigue, and other sets of problems.

Of course in the suicide, in classic or very severe depression in middle-aged and older people, really more enlightening with the circadian clock has shifted actually in an opposite direction to teenagers. So in teenagers, we see delayed sleep type factors, kids who would not go to sleep and would not get up and we see in young people with depression and very severe phase shifts in those directions. The kids become basically nocturnal and are awake during the day and expose themselves to light.

In older people, we see the reverse. They are waking up at 3 in the morning and very agitated and very unwell and are highly likely to attempt suicide in those early hours of the morning. And many of the tragedies that we see where someone has killed themselves at 5 in the morning out of a very disturbed sleep-wake cycle.

Other epidemiological work in the United States, I worked with Americans and my colleagues there, where teenagers get dragged out of bed at an ungodly hours, 5 and 6 AM to bus to school to start school early really disrupts their adolescent sleep where you normally should sleep later. And that’s associated with mood disturbance and probably with suicidal behaviour too.

So in recent times, there has been much greater interest amongst my epidemiological colleagues but also my clinical colleagues saying, “Hang on a second, this sleep stuff is not just secondary epiphenomenon, it’s something that a public health level and also the clinical level where we should put much, much more emphasis on.

Dr. David Cunnington: What do you think about distress as another mediator of that relationship between sleep and suicide?

Ian Hickie: So I think one of the great things at the moment and I think for those of us who are being affected by COVID situation at the moment and losing our daytime routine and it’s getting really distressed by loss of social connection and the situation we are living in, as you get distressed, you don’t sleep. If you don’t sleep, you stay distressed.

Now, the great sleepers in the world have a marvelous phenomenon where they’re distressed all day but they go to sleep and then they wake up the next day and go, “Oh, that wasn’t so bad.” The distress has gone. They haven’t remained anxious and aroused during their sleep.

Unfortunately, and you don’t – this is a temperamental or an in-built characteristic, the genetics of this are quite strong, some people will say, “Well, I sleep properly. What about you?” Well, it’s very fortunate that you do but not everybody does.

Those who stay aroused – distressed during the day, aroused during sleep, of course, wake up distressed. They don’t experience that relief that is essential every day to everyday functioning. So that’s a really major of sleep is to break the distress cycle. And you see that in a psychological sense. You see it in arousal mechanisms they recorded during sleep. People can’t even recognized about the number of times they wake up during sleep and then tossing and turning but basically waking up tired. They haven’t been refreshed. And I think increasingly, we are starting to understand the brain mechanisms of repair and regeneration that take place during sleep.

So distress messes with all of that. So I think when things – and of course, people do other stuff then. They drink alcohol more. They do other things. They try and cope in various ways to reduce the distress and result in which is typically to make actually their distress worse but more importantly, to disturb their sleep so they don’t actually get relief from the distress within that 24-hour period. And that’s where distress becomes really risky in terms of suicide. If you never experienced reduction or if you don’t get a break, it just goes from day to day then that builds very quickly. In some people, that reaches a crescendo very quickly. Most of us cannot survive. Very many dies without breaking that cycle of distress.

Dr. Moira Junge: So what do you think about – what further research needs to be done in this area?

Ian Hickie: Well, a lot more work needs to be done I think in both ways. A lot of the work we’ve done with people with lived experience, particularly young people, in the clinical world, often people aren’t really asked about these sleep patterns, the total sleep-wake cycle patterns, to find out what they really do. And then they don’t really look at whether taking interventions, daytime exercises, morning light exposure, various types of other approaches, what effect in their particular situation that has on their mood but also on their sleep pattern.

So the people aren’t often encouraged the kind of experiment to find out the best way to manage that. And if managing their sleep-wake cycle pattern better actually translating to better for example, depression treatment or anxiety treatment, and those particular kind of situations.

So the lack of information and the lack of doctors and clinicians sharing that information, it becomes really important to manage the whole particular kind of phenomenon. I think at a public health level as well, there are a lot of issues around increasing awareness about the importance of monitoring physical activity, making use, of course in Australia, of daylight, light exposure, the timing of activities in addition to the total amount. And that managing your sleep-wake cycle is one of those things that you can do.

And if you don’t have a very robust cycle, I mean if you’re classically like me, more an evening person than a morning person, morning people, can I say I really don’t like morning people and I’ve said this a number of times before and I received a lot of hate mail. Morning people tend to have very regular sleep-wake cycle. So wake up in the morning, bright and chirpy, and they tend to not be perturbed much. They maintain those cycles.

More evening type people are more easily perturbed by what’s going on, by disruptions, by worrying about things and staying up and have more unstable cycles. And those more unstable cycles are associated with high rates of depression and particular issues.

So if you’re one of those people who really need to use more effort daytime activity, physical activity, various kinds of things to maintain a regular cycle, you need to know that about yourself. So I think when we are teaching kind of health literacy, we don’t actually teach much about it. Lots of people run into some periods because of his life like having children, child-birth, other things that happen, where people need to know that managing their sleep-wake cycle and trying to maintain a regular cycle is very important to maintain their overall health, particularly their mental health. They will cope better.

The difficulty is people only seek help when things are going really wrong. And then if people say, “I can’t sleep,” the tendency is to say, “OK. Well, take a sleep medicine,” where there’s a crisis or something. And it’s the first time in their life that they’re really aware that if they don’t sleep, they can’t cope but then they go for a very short term, benzodiazepine type of approach or some sort of hypnotic immediately as the solution without really working out, “Hang on, what is my own intrinsic sleep cycle actually like?” Or if they have other problems, snoring and sleep apnea or other things or pain or other things that are interfering with their sleep that the effect of that will be on their mood, on their cognition, and put them at considerable risk.

So I think there’s quite a lot to be done in education type way. And I think of course, this is where the research really matters. And I think what I like that’s happening at the moment is the personalization within that, the increasing use of activity things, Fitbit type things, other sorts of measures, your phone measures. I hate my phone. It tells me what I haven’t done Monday to Friday in terms of activity compared with weekends.

But that kind of feedback, personal feedback, and then understanding that you can actually take steps within that to manage that more effectively, and if it’s working or not working and you do need further medical assistance or psychological assistance that you’re building the evidence about yourself and what your own cycle is like. And if there are things in your life, work commitments, childcare responsibilities, new child, new baby, whatever else, these are periods in which sleep is going to be disrupted.

Other areas for example, we see quite a lot of middle-aged women passing through menopause whose sleep is disturbed by temperature disregulation during that particular period and other things which have never been really discusses but are having major effects on their lives.

A lot of my work is occurring with teenagers and trying to make sure that teenagers although they have a shift to sleeping later and getting up later don’t become nocturnal, do stay daytime active, do have light exposure, and use exercise and sleep-wake cycle regulation to regulate their mood. Teenagers can be a bit moody and can find themselves. It’s a great age to learn the extent to which management of these sorts of activities, sleep-wake cycle kind of promotion.

Can I say I hate the word sleep hygiene?

Dr. David Cunnington: Oh, yeah.

Ian Hickie: It sounds like staying clean. Yeah, staying clean. If only wash your hands or something.

Dr. David Cunnington: That has got puritanical sort of thing to it that good people are clean around sleep. And it’s like – that’s why the late night types are seen as slovenly, Ian. Didn’t you know that?

Ian Hickie: Yes. Well, I think that’s why they’re unshaven and unwashed and unclean and morning people are clean and tidy. I say this because some of my best friends are surgeons and they always insist to have these meetings at 6:30 in the morning as morning people. Mind you, they never turn up. They’re never there. And those of us who barely have been able to come to consciousness to that point are sort of, well, not very verbal, unwashed.

And I think we need to – therefore, I think we need to change the way we present that away from that kind of simplistic sleep hygiene sort of health information to this much more personally informative type idea. There’s a lot of discussion in medicine between sort of personal is always is messing on what the geneticists prefer to call precision, precision medicine. I prefer the personalize bit. Working out what works for you, it maybe the time you get up, doing morning light exposure, physical activity works for you.

On the other side of the coin, certain kinds of relaxation activities, meditation, mindfulness, yoga, and other various things that you need to do to deactivate in the evening in order to go to sleep rather than going to sleep worked out. If you very much ruminate, learning sort of cognitive techniques to control rumination.

And I think we’ve seen a lot of advances in the psychological care for those sleep type sets of issues. So that although sleep is not something you’re aware of when you’re asleep, it’s something that you can do quite a lot about when you’re awake.

Dr. David Cunnington: Exactly. And I really like your point about sort of people understanding their sleep type. We tend to let teenagers took the career counseling in high school but why not the sort of understand your individual characteristics to set yourself up for a life of sleeping – sleep to win, sleep with your characteristics, undertake your daytime activities to match your underlying type so that you’re not constantly fighting against the tide? That seems a good time to teach people those skills.

Ian Hickie: I don’t think we really struggled in public health, if my public health colleagues don’t mind me saying so with individual differences. So we tend to want to have one message. There’s one set of messages. You must do this, all of you. Don’t drink. Don’t smoke. Sex education. We got to keep that message simple. But the message isn’t that simple at individual level because it doesn’t work. In trying to get people to, for example, fight against their own chronotype, is not always that productive for teenagers, for teenagers as the same as middle-aged adults in terms of what is actually happening to them.

So there’s phase appropriating and of course this is true with kids in trying to settle kids into regular cycle. It’s not necessarily that easy. You’re not a necessarily a bad parent if you can’t your kids to sleep that kind of easily and they’re not easily settled or get easily settled into cycles. A lot of that is built in.

So just coming back to the research area that I think a lot of the research through the genetics, through the individual phenotyping, through interventions, needs to pay more respect to this degree of individual difference that exists. And then what is the best patch between interventions and types?

And I think in the public health sense, learning particularly in high school or learning as a teenager, the relationship fundamental to this discussion we are having, the relationship between sleep-wake cycles and mood and anxiety and capacity to cope. It’s funny how in health, we go on and on and on about risk to cardiovascular disease, we are talking to teenagers about risk to cardiovascular disease, it’s something that might happen to you when you’re 70, not that relevant. Or you’re on and on and on about obesity and its long-term consequences or weight gain, yeah, yeah, yeah, whatever, kind of stuff. You go, “No, no, no. What I’m talking about here is actually your capacity to cope tomorrow and your moodiness and whatever.”

And in fact, with younger people, that means a lot actually. And things like coping with exams or coping with life stressors or particular things. I mean there are other excellent periods. Women who are having babies and I must say the dads as well. Disruptions are going to happen around the perinatal period, around menopause, and you do have other physical illness. We don’t – actually I think we missed the opportunity to take that down to a level where it becomes meaningful.

And if you know certain things about yourself or even more if you know that it runs in your family, those particular – it’s actually hilarious with families that I’m attached to, hilarious discussions about the shared chronotypes, etc. And various of my in-law, out-laws, it’s always the partners think it’s their fault that all these people share these terrible sleep-wake cycles in common, that they’ve caused it. I go, “You haven’t caused it at all. You’re all living with it. They’ve all got that in common.” They are just unfortunately as a group have inherited rather unstable cycles that are easily perturbed and are particularly all the late night tone.

Others who are fortunate to have those more stable morning type patterns and whatever else, so I see much of health, understanding your own risk but taking proactive steps to moderate that risk and finding out what really works for you at certain phases of life. I think this has become more important to maintain daily routines, with a daily routine actually is from a clock point of view or from a sleep-wake cycle point of view and I think from a work or other aspects of one’s life.

Dr. Moira Junge: What about those of us at the audience mostly of people working in sleep like clinicians, researchers, what are your thoughts on how best to assist suicide risk, how to best support people we are working with? Obviously, we focus on improving the sleep but a lot of us don’t have these discussions around suicide risk and what we should be really looking for.

Ian Hickie: Yes. I think there has been if you like, fault on both sides. Many of the clinicians I worked with who asked about suicide and depression barely asked about sleep. I think on the other side of the fence, there are a lot of people who work in sleep and very famous people around the world I had discussions with, “What are these delayed sleep cause people? Aren’t they all depressed?” Oh yeah, but we don’t ask them. “What about all those people who are ruminating and some who are incredibly anxious?” Oh yeah, but we don’t dwell on that.

So I think one of the problems is we have a super specialization within the areas and we are looking for particular phenotypes, particular characteristics, or particular types of disorders that may not have been fully diagnosed before. I mean the world of health is all just insomnia or it’s all just messy sleep. And we are looking for as more specialized clinicians often defined specifics and I think people themselves are often looking for more of the specifics. But we tend to just row down one creek so we ask a lot about sleep and don’t ask about mood or don’t ask about anxiety.

And then of course suicide is by its nature a hard topic. And the danger of course is if you ask, they might say, “Yes.” When people are like this, they often feel that they can’t cope. They often will get to the stage particularly if they are sleeping very poorly, feel life is barely worth living because you can’t enjoy anything. Actually, you can’t sleep.

My favorite topic is actually anhedonia, the absence of hedonism, the absence of pleasure. If you want to make sure that you can’t enjoy anything, just lose our circadian system. Don’t sleep. Most people who have jet lag would be aware of that fact, you could be on the other side of the world and be awake but enjoying almost nothing. You just feel so out of whack and the lack of enjoyment.

So I think the issue is encouraging clinicians particularly sleep clinicians to go down that track and see what the particular other characteristics might actually be and emphasize the link between sleep, mood, and not being able to cope. But not being able to cope at times, the distress associated with that may be in fact suicidal behaviour. Now, it depends how comfortable you are, I mean I see who is depressed, I just assume they are suicidal. If they say they are not, I assume they are lying to me, because of the people who said they weren’t when they are coming, “I was but I just didn’t tell you.”

So I think making the assumption that if people are really struggling with their sleep, they are going to have moods or anxiety problems. And a proportion of those is going to really feel at their wits end with that. And that’s fine. That’s actually the recognition of that. It doesn’t mean you suddenly have to jump and ring the police or ring and ambulance or send people to hospital or whatever, which is often what people fear that if you raise the topic, there will be sort of catastrophic response to it.

And it’s a distinct from people living with it in their head and they are terrified of actually acknowledging it in case somebody does say they lose control of themselves. And we are saying, “No, no, no. That’s really important. That’s quite common for this discussion we are having today is really important.” And actually, it’s quite common in those situations.

Sleep disturbance is a big thing. It’s not a trivial thing. I think it’s one of those things we easily say, “I have trouble sleeping.” As a marker of distress, “A lot happening in my life.” Of course, it disturbs your sleep. If that persists, if it’s severe, it’s then going to be associated with mood disturbance with loss of capacity to cope and inevitably, in that situation, is life worth living?

So I think in a lot of the suicide crises we see, you see that crescendo of that particular thing where the person has not been able to sleep for a particular period, they’ve not been able to relieve their distress in the usual kind of ways, and that becomes part of the straw that breaks the camel’s back.

So whether sleep clinicians like it or not, you’re actually sitting there with the population that underneath actually has quite a high rate of anxiety and depression, and within that or associated with that will be a degree of suicidal thoughts and behaviours. Often, not overtly expressed but better dealt with by being expressed. And I think the point is that with some confidence, interventions around those areas will produce benefits. I think people worry about another area is there’s nothing that can be done or that treatments don’t work or that you’re focusing on a particular thing or maybe even with the sleep people, maybe I should even discuss it with the sleep people. They’re just here to discuss.

I’m always fascinated when people say, “I went to a sleep doctor so I can discuss sleep. I went to a psychiatrist so I can discuss anxiety.” As if the doctor on the other end or the clinician or the psychologist on the other end only has one skill or only has one thing. Actually, they’ll do a better job if they know more of what is happening, “Oh, I didn’t mention my drug and alcohol problem because it was a sleep doctor. I didn’t mention my chronic pain because it was a sleep doctor. I didn’t mention the depression with the sleep doctor.”

We are victims of our specialization I think and somewhat of our own narrow sense of inquiry in certain areas. Even the comorbid I think is a terrible word. You’re seeing a range of phenomena of disturbed function and they are going to affect the sleep-wake cycle. They are going to affect mood. They are going to affect cognition. They are going to affect the person’s metabolic function and concurrently their immune function. So the person is sick. They are sick. Which of the interventions could we focus on that might have the biggest effect? And specifically focusing on sleep and sleep-wake cycle interventions may have big effects on all of those other factors.

Now, I think that’s where the areas of sleep medicine and the areas of circadian medicine have been underrated in terms of their potential to have multiple good outcomes, not just on the target if you like of better sleep.

Dr. David Cunnington: Thanks. That’s really helpful for – and helpful for me so I wouldn’t be so frightened to ask in terms of asking about that. And I like your framework of just assuming, OK, they’re probably thinking about it so you might as well put it on the table and talk about it.

Ian Hickie: Can I just say it, Dave? People experienced a great deal of relief often when they do that. But then you’re thinking – and they might get distressed. I mean the most important thing I have in my office is a box of tissues. And I joke with my PA. The bigger the bloke who comes in, get a big box of tissues, because it might be the first time that they’ve expressed their distress. A lot of distress expressed to a health professional is very protective against the opposite, which is actually suicidal behaviour and people are on their own.

So yeah, people might get distressed and often better to assume they are going to get distressed. But that’s OK. That’s what we are kind of there for. And interestingly, if you look at how many people expressed that distress too, not a lot of people ended up in the hands of psychiatrist. There’s a very small proportion. People do it with their general practitioner, with the hairdresser. They are talking with physiologist. Physiologists always get told enormous amount of stuff while they’re moving people’s joints around.

And so I think we just go to take it from a suicide prevention point of view and make this a serious point, we’ve got to take the opportunity whichever set of health professional people are intersecting with. There’s an opportunity there to pick up that and really put out the positive message that many of these problems can actually be dealt with even if they’re terrifying, even if people are ashamed of them, even if people are afraid of them. We actually got interventions that will really help.

And I think sleep physicians and sleep clinicians generally can make the point. It’s highly likely that if their interventions are effective that people’s mood and cognition will improve, that they will not just sleep better. They will feel better and they will think better and they will think straight better. They will experience relief from their distress in a way which then on the following day or the day after, they will be able to cope.

And in suicide prevention, that’s really important. It’s getting through the next hour to the next day that often matters. So that people can then with their own coping mechanisms but also the social world around them can respond.

So tragically, in many of the deaths by suicide, we have missed the opportunity that would have otherwise been there if it had been expressed and then people through their own mechanisms but also through social support had been able to respond.

Dr. Moira Junge: Ian, thank you so much for speaking with us today. It has been fantastic. It’s really insightful and a lot of useful information for all our listeners. And yeah, thank you very much.

Ian Hickie: Thanks for the opportunity.

Dr. Moira Junge: Well, that was fantastic having Ian speaking with us. What were your take-homes from that conversation?

Dr. David Cunnington: Yeah. It is interesting that we are looking at the link between sleep and suicide that could be mediated via a range of different things. I really like that concept of looking at the whole sleep-wake cycle and the circadian influence. And as we’ve talked about in other episodes, that circadian influence really provides all aspects of life and then how distress maybe adds to that relationship as well because if you think of the patients we see, often, there’s high distress which is what escalates them to come in to see specialists like ourselves in this area and understanding that’s a high risk.

Dr. Moira Junge: Well, it’s fantastic that he rounds it around. Obviously, it is around not just the bottom of the noise, the coping. If you feel like, “I can’t cope anymore,” and you could probably cope until you perhaps if you had a baby or going through a menopause or something, something deep change and then you just say, “Oh well, my circadian system plus my mood plus my relationship plus the distress is just higher and higher,” I think that obviously – even specialists and the big thinker in this area say, “I thought it was just – we could have talked a lot longer. We could probably have a whole day teasing it out a bit more.”

Dr. David Cunnington: If you want to hear more of Ian talking about mental health and a range of other issues, check out his podcast called Minding your Mind available via all the usual podcast apps and streaming services. Ian’s group have also had published a number of key papers in the last 12 months looking at the relationship between mood, depression, circadian rhythms and we will put the links to those in the show notes.

Moira, so what’s your clinical tip?

Dr. Moira Junge: I think the clinical tip and Ian touched on this anyway and I think he expressed it even better but I think it is to remind our listeners and clinicians particularly that we probably do need to assume whether it’s expressed or not that people are experiencing a really quite a deep level of distress and they may not want to even go into how bad they are actually feeling. So I think that we can always – be sure to always have in our assessments actually asking how they are doing. But sometimes it’s less obvious and you’re just not quite sure what they mean by that.

My clinical tip is definitely pick up on that but definitely say, “Can you tell me more about that? Are you saying that you don’t want to live? Are you talking about suicide?” But really just actually help them to bringing out something they find difficult to express and for us to sit with them. I think it’s really important. We don’t have to rush off to 000 very often. Mostly, it’s something we can sit with. It’s something they’re just expressing and you can actually still support them without having to feel like you are a specialist.

So what’s your pick of the month?

Dr. David Cunnington: So I’ve been reading a book this month that I really like called The Body Keeps the Score by Bessel van der Kolk. And it’s about trauma, particularly developmental or early life trauma and how that changes the way both the body responds and how people respond.

And for me, what really resonates is it fits with many people I see in clinical practice who are coming to see me later in life with issues of sleeping, high level of distress, difficulty switching off. But probably began as some early life or developmental trauma that has actually changed the way their brain responds and given that heightened excitability and difficulty switching off.

Dr. Moira Junge: Awesome.

Dr. David Cunnington: Really interesting. And the nice connection for me is Bessel actually worked with Allan Hobson in Massachusetts. And Allan Hobson was a psychiatrist, he has recently died unfortunately, who I really found a wonderful mentor when I was in Boston for a couple of years learning a lot about his work on dreams and his work on consciousness and how that relates to sleep. And so, they had actually worked together so it was really nice for me reading something of what Bessel had written about, his experiences working with Allan Hobson many years ago when he was sort of early in his work with trauma.

Dr. Moira Junge: Fantastic. Well, I’ll put that on my list as well.

Dr. David Cunnington: What about for you, Moira? What’s your pick?

Dr. Moira Junge: Well, I’ve been doing a bit of reading of course preparing for this podcast today and also, you’ve been aware, I’ve been touched by suicide on a personal level recently as well by someone close to me, so just reading, looking at what kind of – what sort of researchers are doing around the world, specifically looking at sleep and suicide behaviors and the protective role perhaps of sleep and something that I think we know that people who perhaps are not sleeping so well, perhaps using drugs and alcohol a bit more to actually disguise or to help with that distress out to get some sleep and help to get some relief and for us to turn our attention to that.

So, just a nice paper that was by Bishop and colleagues. It was published in 2020 in sleep medicine called Sleep, suicide behaviors, and the protective role of medicine. I think we will put that on the show notes too because I think that’s just something that us, who are working in the sleep field, I’m sure someone would be interested in that too.

Tell us what’s coming up in the future episodes, Dave.

Dr. David Cunnington: Well, as you know, we are working up a couple of other episodes at the moment, one on burnout which is something again we see a lot of in clinical practice, and another on dreaming and lucidity during dreaming and this concept of lucid dreaming.

Knowing your interest in some of the social and economic determinants of health, also building an episode looking at sleep and are there social and economic determinants around sleep. So they are a couple of the things we are working on.

People should also look out for the Sleep Down Under Conference, which is going virtual this year and that’s going to be October 11-13. Check it out. Register for the meeting. We’ve both been involved in putting together parts for the program and it’s going to be a really great meeting and a very stimulating meeting. So make sure you look out for that and register for the meeting.

Dr. Moira Junge: Yeah, it’s going to be wonderful. Let’s just hope we can meet face to face soon, in 2022.

Dr. David Cunnington: Yeah. Here’s hoping.

Dr. Moira Junge: So thanks for listening. It’s actually really great to be back. Send us any suggestions at Podcast@SleepHub.com.au, the email we have. We really love to feature early career researchers particularly and really want to hear about your work if you want to drop us a line.

Dr. David Cunnington: And if you like the podcast, review us on iTunes and subscribe via your favorite podcast app. Tell your friends and work colleagues. And we will see you next in your podcast feed.

Outro: This podcast is not intended as a substitute for your own independent health professional’s advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider within your country or place of residency with any questions you may have regarding a medical condition.

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Dr David Cunnington

Dr. David Cunnington is a specialist sleep physician delivering quality healthcare to clients with complex sleep problems and promoting sleep health through education, research and advocacy.