Bio


I am an Assistant Professor of Psychiatry and Behavioral Sciences and a licensed clinical psychologist in the Stanford University School of Medicine. I am a suicidologist, with subspecialty expertise in clinical trials, epidemiology, and suicide prevention best practices. I have joint specialty in behavioral sleep medicine, treatment development, and thanatology. I am Founding Director of The Stanford Suicide Prevention Research Laboratory, and Co-Chair a number of initiatives to support multidisciplinary efforts in suicide prevention. Our program utilizes cognitive, biological (e.g., fMRI), and behavioral testing paradigms, with an emphasis on translational therapeutics across the lifespan. Our mission is to identify novel therapeutics, including seminal work to establish the subfield of sleep and suicide prevention. A special focus is the development of rapid-action, low-risk interventions for the prevention of suicide. Our mission is to evaluate transdiagnostic risk factors and biomarkers underlying treatment response that may inform etiology, reduce stigma, and advance innovation. Advocating for its utility as a visible, yet non-stigmatizing warning sign of suicide—our earliest work delineated sleep as a risk factor for suicidal behaviors. Funded by NIH and DOD, we subsequently conducted the first suicide prevention clinical trials, testing efficacy of a rapid-action (6 h) insomnia treatment for suicidal behaviors. These use a mechanisms focus to identify central disease processes (eg, underlying neural circuitry, behavioral factors) for anti-suicidal response. An overarching aim is to harness new technologies to aid risk prediction, precision medicine, and intervention opportunity. We are committed to improving national training practices (e.g., national needs-assessment of medical training parameters; AI for suicide prevention), and lead hospital best practices for safety in screening, triage, and postvention.

Regarding translation to policy, I have served as a content expert for nationally-directed health initiatives with NIH, VA, DOD, DARPA, SAMHSA, CDC, and The White House. I recently led development of the CA 2020-25 Statewide Strategy for Suicide Prevention, following invited testimony (CA State Assembly) and a commissioned Policy Brief on suicide prevention best practices. Advisory and advocacy work centers on how research guides public health policy and implementation. I am especially committed to initiatives promising impact to suicide prevention on a broad scale, including universal strategies for lethal means restriction and real-time surveillance of suicidal behaviors. To this end, I have been honored to serve as a content expert to The White House Office of Science and Technology for initiatives focused on technology innovation and led advisory work promoting suicide deterrent systems for private organizations and public sites, such as the Golden Gate Bridge. I have consulted for technology companies, as well as private industry and healthcare partners.

Inspired by maternity leaves coinciding with the above work, I have a separate research line examining organizational development, inclusive practices, sleep and employee wellness. This addresses disparate impact of institutional and federal medical leave practices on recruitment and retention of women. Our program focuses on cost-effective policy for diversity training and reduced attrition of women in medicine, law, STEM and technology fields. As such, I am dedicated to spearheading development of a Stanford Center for Policy, Inclusive Practices, and Equity Education.

To donate or partner with us, please contact Deborah Stinchfield (Stanford Medical Center Development) medicalgiving@stanford.edu or please contact us directly.

Clinical Focus


  • Clinical Psychology
  • Best Practices in Suicide Prevention and Postvention
  • Evidence-Based Treatments for Suicidal Behaviors
  • Behavioral Sleep Medicine, Insomnia and Nightmare Treatments
  • Circadian Rhythm Sleep Disorders, Chronotherapy, Shift Work
  • CBT for Insomnia (CBTi), Imagery Rehearsal Treatment (IRT) for Nightmares
  • Mood Disorders, Depression and Bipolar Treatments
  • Grief and Bereavement; Thanatology
  • Behavioral Medicine; Behavioral Pain Management
  • Suicidology; Military Suicide Prevention; Traumatology

Academic Appointments


Administrative Appointments


  • Instructor, Psychiatry and Behavioral Sciences, Stanford University School of Medicine (2011 - 2015)
  • Director, Stanford Suicide Prevention Research Laboratory, Psychiatry and Behavioral Sciences (2012 - Present)
  • Investigator, Mental Illness Research, Education and Clinical Centers (MIRECC), VA Palo Alto Health Care System (2013 - Present)
  • Co-Chair, The Center for Premature Mortality and Suicide Prevention, Stanford University School of Medicine (2015 - Present)

Boards, Advisory Committees, Professional Organizations


  • Board Member, Bridge Rail Foundation (BRF) (2013 - Present)
  • Co-Chair, Lethal Means Restriction Advisory Workgroup, The City of Palo Alto and Project Safety Net (2016 - Present)
  • Lead Technical Consultant, CA 2020 State Strategy, California Mental Health Services Oversight and Accountability Commission (CA MHSOAC) (2018 - 2020)

Professional Education


  • PhD Training: Florida State University (2009) FL
  • Undergraduate Education, University of Oregon, English and Psychology
  • Graduate Education, Florida State University, Clinical Psychology
  • Predoctoral Fellowship, NIH/NHGRI, Intramural Research Training Award in Biomedical Sciences
  • Predoctoral Fellowship, NIH/NIMH, Florida State University, National Research Service Award (F31)
  • Residency, VA Palo Alto Health Care System (VAPAHCS), Clinical Psychology
  • Postdoctoral Fellowship, NIH/NIMH, Stanford University, National Research Service Award (T32)
  • Faculty Fellowship, Stanford Clayman Institute for Gender Research, Diversity and Inclusive Practices Policy (2019)
  • Fellow in Thanatology (FT), Association for Death Education and Counseling (ADEC), Thanatology: Death, Dying, and Bereavement (2023)

Clinical Trials


  • A Brief Behavioral Sleep Intervention for Depression Among Military Veterans Not Recruiting

    This study investigates the impact of brief behavioral insomnia treatment on depressive symptoms among military veterans.

    Stanford is currently not accepting patients for this trial. For more information, please contact Nyree White, BA, 650-724-5368.

    View full details

  • A Sleep-Oriented Intervention for Suicidal Behaviors Not Recruiting

    An open-label trial to investigate the use of a behavioral insomnia treatment for suicidal ideation.

    Stanford is currently not accepting patients for this trial. For more information, please contact Austyn Lee, 650-723-5030.

    View full details

Projects


  • A Sleep-Oriented Intervention for Suicidal Behaviors, NIH/NIMH

    Location

    Stanford

  • Developing a Data Monitoring Infrastructure for the Study and Prevention of Local Suicide Clusters, SPECTRUM PHS Pilot Grant

    Location

    Stanford

  • A Fatality Statistics Database and Monitoring System for Rail Suicide Prevention, SCC Department of Health, Division of Integrated Behavioral Health, Suicide Prevention Oversight Committee

    Location

    Stanford

  • Suicide Risk Assessment Training Practices in Pediatric Residency Programs: A Nationwide Assessment Survey, John A. Majda, M.D. Memorial Fund (Faculty Sponsor)

    Location

    Stanford

  • Pediatric Sleep Disturbances as a Proposed Biomarker and Emergency Department Target, Suicide Prevention through Outreach (SPOt) Fund, Stanford University School of Medicine Department of Psychiatry and Behavioral Sciences in partnership with Lucile Packard Children's Hospital and the Child Health Research Institute

    Location

    Stanford

  • Advancing Women in Science: Establishing a Departmental Mentoring Program in Academic Medicine, Stanford University VPFDD, VPTL, VPUE, in partnership with OpenXChange

    Location

    Stanford

  • Evaluating the Visibility and Use of Family-Friendly Policies to Enhance Faculty Diversity and Inclusion, Jointly funded by the Stanford University Diversity Cabinet, VPFDD, and the Stanford Dean's Office of the School of Medicine

    Location

    Stanford

2023-24 Courses


Graduate and Fellowship Programs


All Publications


  • Social zeitgeber and sleep loss as risk factors for suicide in American Indian adolescents. Transcultural psychiatry Ehlers, C. L., Gilder, D. A., Benedict, J., Wills, D. N., Phillips, E., Gonzales, C., Karriker-Jaffe, K. J., Bernert, R. A. 2024: 13634615241227679

    Abstract

    American Indians / Alaska Natives (AI/AN) bear a high burden of suicide, the reasons for which are not completely understood, and rates can vary by tribal group and location. This article aims to identify circumstances reported by a community group of American Indian adolescent participants to be associated with their depression and/or suicide. American Indian adolescents (n  =  360) were recruited from contiguous reservations and were assessed with a semi-structured diagnostic interview. Twenty percent of the adolescents reported suicidal thoughts (ideation, plans), an additional 8% reported a history of suicide attempts, and three deaths due to suicide were reported. Suicidal behaviors and major depressive disorder (MDD) co-occurred and were more common among female adolescents. The distressing events that adolescents most often reported were: death in the family, family disruption, peer relationship problems, and school problems. All of these events were significantly associated with suicidal behaviors, however those with suicidal acts were more likely to report death in the family. Those with MDD but no suicidal behaviors were more likely to report disruptions in the family. Disruptions in falling asleep were also associated with suicidal behaviors and having experienced a death in the family. Disruptions in important relationships, particularly through death or divorce, may be interpreted as a loss or disruption in "social zeitgebers" that may in turn disturb biological rhythms, such as sleep, thus potentially increase the risk for MDD and/or suicide. Prevention programs aimed at ameliorating the impact of disruptions in important relationships may potentially reduce suicidal behaviors in AI/AN adolescents.

    View details for DOI 10.1177/13634615241227679

    View details for PubMedID 38311923

  • Genetic factors associated with suicidal behaviors and alcohol use disorders in an American Indian population. Molecular psychiatry Peng, Q., Gilder, D. A., Bernert, R. A., Karriker-Jaffe, K. J., Ehlers, C. L. 2024

    Abstract

    American Indians (AI) demonstrate the highest rates of both suicidal behaviors (SB) and alcohol use disorders (AUD) among all ethnic groups in the US. Rates of suicide and AUD vary substantially between tribal groups and across different geographical regions, underscoring a need to delineate more specific risk and resilience factors. Using data from over 740 AI living within eight contiguous reservations, we assessed genetic risk factors for SB by investigating: (1) possible genetic overlap with AUD, and (2) impacts of rare and low-frequency genomic variants. Suicidal behaviors included lifetime history of suicidal thoughts and acts, including verified suicide deaths, scored using a ranking variable for the SB phenotype (range 0-4). We identified five loci significantly associated with SB and AUD, two of which are intergenic and three intronic on genes AACSP1, ANK1, and FBXO11. Nonsynonymous rare and low-frequency mutations in four genes including SERPINF1 (PEDF), ZNF30, CD34, and SLC5A9, and non-intronic rare and low-frequency mutations in genes OPRD1, HSD17B3 and one lincRNA were significantly associated with SB. One identified pathway related to hypoxia-inducible factor (HIF) regulation, whose 83 nonsynonymous rare and low-frequency variants on 10 genes were significantly linked to SB as well. Four additional genes, and two pathways related to vasopressin-regulated water metabolism and cellular hexose transport, also were strongly associated with SB. This study represents the first investigation of genetic factors for SB in an American Indian population that has high risk for suicide. Our study suggests that bivariate association analysis between comorbid disorders can increase statistical power; and rare and low-frequency variant analysis in a high-risk population enabled by whole-genome sequencing has the potential to identify novel genetic factors. Although such findings may be population specific, rare functional mutations relating to PEDF and HIF regulation align with past reports and suggest a biological mechanism for suicide risk and a potential therapeutic target for intervention.

    View details for DOI 10.1038/s41380-023-02379-3

    View details for PubMedID 38177348

    View details for PubMedCentralID 5861703

  • Comorbidity of anxiety/affective, conduct/antisocial, attention deficit, and alcohol use disorders with suicidal behaviors in an American Indian community sample of adults and adolescents. Journal of psychiatric research Ehlers, C. L., Gilder, D. A., Karriker-Jaffe, K. J., Bernert, R. 2023; 167: 63-70

    Abstract

    To study the associations of anxiety/affective disorders, conduct/antisocial disorders (ASPD/CD), attention deficit disorders (ADHD), and alcohol use disorders (AUD) with suicidal behaviors in an American Indian (AI) community sample of adolescents and adults.Participants were AI (360 adolescents, 925 adults) recruited from reservations who were assessed with the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA).Among AI adults (mean age = 33 years), 17% percent reported lifetime experiences of suicidal thoughts (ideation and/or plans) and 14% reported suicidal acts (including either a suicide attempt history or verified death by suicide; n = 19 deaths). Among AI adolescents (mean age = 15 years), 20% experienced suicidal thoughts and 9% experienced suicidal acts (including 3 deaths). In logistic regression analyses, suicidal thoughts were significantly associated with lifetime diagnoses of affective disorder, CD and ADHD in adolescents, and with anxiety disorder, affective disorder, and ASPD/CD in adults. Suicidal acts were associated with affective disorder, ADHD, and alcohol drinking in adolescents and with anxiety disorder, ASPD/CD and AUD in adults. The number of comorbid disorders greatly increased the risk of both suicidal thoughts and acts among both adolescents and adults.In addition to affective disorders, both ADHD and CD in adolescents, and ASPD in adults, demonstrated an association with suicidal thoughts. Alcohol use by adolescents and AUD among adults also were associated with suicidal attempts in this AI sample. These findings suggest need for additional research and potential integration of alcohol in screening and intervention programs focused on the prevention of suicide among AI.

    View details for DOI 10.1016/j.jpsychires.2023.10.005

    View details for PubMedID 37837862

  • Genetic Factors Associated with Suicidal Behaviors and Alcohol Use Disorders in an American Indian Population. Research square Gilder, D., Bernert, R., Karriker-Jaffe, K., Ehlers, C., Peng, Q. 2023

    Abstract

    American Indians (AI) demonstrate the highest rates of both suicidal behaviors (SB) and alcohol use disorders (AUD) among all ethnic groups in the US. Rates of suicide and AUD vary substantially between tribal groups and across different geographical regions, underscoring a need to delineate more specific risk and resilience factors. Using data from over 740 AI living within eight contiguous reservations, we assessed genetic risk factors for SB by investigating: (1) possible genetic overlap with AUD, and (2) impacts of rare and low frequency genomic variants. Suicidal behaviors included lifetime history of suicidal thoughts and acts, including verified suicide deaths, scored using a ranking variable for the SB phenotype (range 0-4). We identified five loci significantly associated with SB and AUD, two of which are intergenic and three intronic on genes AACSP1, ANK1, and FBXO11. Nonsynonymous rare mutations in four genes including SERPINF1 (PEDF), ZNF30, CD34, and SLC5A9, and non-intronic rare mutations in genes OPRD1, HSD17B3 and one lincRNA were significantly associated with SB. One identified pathway related to hypoxia-inducible factor (HIF) regulation, whose 83 nonsynonymous rare variants on 10 genes were significantly linked to SB as well. Four additional genes, and two pathways related to vasopressin-regulated water metabolism and cellular hexose transport, also were strongly associated with SB. This study represents the first investigation of genetic factors for SB in an American Indian population that has high risk for suicide. Our study suggests that bivariate association analysis between comorbid disorders can increase statistical power; and rare variant analysis in a high-risk population enabled by whole-genome sequencing has the potential to identify novel genetic factors. Although such findings may be population specific, rare functional mutations relating to PEDF and HIF regulation align with past reports and suggest a biological mechanism for suicide risk and a potential therapeutic target for intervention.

    View details for DOI 10.21203/rs.3.rs-2950284/v1

    View details for PubMedID 37398076

    View details for PubMedCentralID PMC10312956

  • Poor self-reported sleep quality associated with suicide risk in a community sample of American Indian adults. Sleep advances : a journal of the Sleep Research Society Ehlers, C. L., Karriker-Jaffe, K. J., Bernert, R. 2023; 4 (1): zpad024

    Abstract

    Although American Indian/Alaska Native (AI/AN) have high suicide rates few studies have systematically investigated sleep quality and its association with suicidal behaviors in AI/AN. This study is a cross-sectional investigation of self-reported sleep quality and suicidal behaviors in an adult AI population.A semi-structured interview was used to collect data on suicidal ideation, suicidal plans, and suicidal attempts and the Pittsburgh Sleep Quality Index (PSQI) was collected to assess sleep quality in American Indian adults.In this sample (n = 477), 91 (19%) of the participants endorsed suicidal ideation (thoughts and plans), and 66 (14%) reported suicidal attempts, including four who subsequently died by suicide. More women reported suicidal thoughts or acts than men. Those endorsing suicidal thoughts slept fewer hours during the night, reported more nocturnal awakenings, and showed poorer subjective sleep quality according to PSQI total scores compared to those with no suicidal thoughts or acts. Participants with suicidal acts (n = 66) reported more bad dreams and higher PSQI total scores compared to those with no suicidal thoughts or acts. When those with any suicidal thoughts or acts (n = 157, 33%) were compared to those without, they were more likely to endorse nocturnal awakenings and bad dreams and demonstrated significantly higher PSQI total scores.Although additional research is needed to evaluate sleep disturbances as a proximal, causal risk factor for suicidal behaviors in AI, findings highlight need for further study of sleep as a warning sign and intervention tool for suicide prevention among American Indian adults.

    View details for DOI 10.1093/sleepadvances/zpad024

    View details for PubMedID 37293513

    View details for PubMedCentralID PMC10246582

  • Using a Safety Planning Mobile App to Address Suicidality in Young People Attending Community Mental Health Services in Ireland: Protocol for a Pilot Randomized Controlled Trial. JMIR research protocols Melia, R., Francis, K., Duggan, J., Bogue, J., O'Sullivan, M., Young, K., Chambers, D., McInerney, S. J., O'Dea, E., Bernert, R. 2023; 12: e44205

    Abstract

    BACKGROUND: Over 700,000 people die by suicide annually, making it the fourth leading cause of death among those aged 15-29 years globally. Safety planning is recommended best practice when individuals at risk of suicide present to health services. A safety plan, developed in collaboration with a health care practitioner, details the steps to be taken in an emotional crisis. SafePlan, a safety planning mobile app, was designed to support young people experiencing suicidal thoughts and behaviors and to record their plan in a way that is accessible immediately and in situ.OBJECTIVE: The aim of this study is to assess the feasibility and acceptability of the SafePlan mobile app for patients experiencing suicidal thoughts and behaviors and their clinicians within Irish community mental health services, examine the feasibility of study procedures for both patients and clinicians, and determine if the SafePlan condition yields superior outcomes when compared with the control condition.METHODS: A total of 80 participants aged 16-35 years accessing Irish mental health services will be randomized (1:1) to receive the SafePlan app plus treatment as usual or treatment as usual plus a paper-based safety plan. The feasibility and acceptability of the SafePlan app and study procedures will be evaluated using both qualitative and quantitative methodologies. The primary outcomes are feasibility outcomes and include the acceptability of the app to participants and clinicians, the feasibility of delivery in this setting, recruitment, retention, and app use. The feasibility and acceptability of the following measures in a full randomized controlled trial will also be assessed: the Beck Scale for Suicide Ideation, Columbia Suicide Severity Rating Scale, Coping Self-Efficacy Scale, Interpersonal Needs Questionnaire, and Client Service Receipt Inventory. A repeated measures design with outcome data collected at baseline, post intervention (8 weeks), and at 6-month follow-up will be used to compare changes in suicidal ideation for the intervention condition relative to the waitlist control condition. A cost-outcome description will also be undertaken. Thematic analyses will be used to analyze the qualitative data gathered through semistructured interviews with patients and clinicians.RESULTS: As of January 2023, funding and ethics approval have been acquired, and clinician champions across mental health service sites have been established. Data collection is expected to commence by April 2023. The submission of completed manuscript is expected by April 2025.CONCLUSIONS: The framework for Decision-making after Pilot and feasibility Trials will inform the decision to progress to a full trial. The results will inform patients, researchers, clinicians, and health services of the feasibility and acceptability of the SafePlan app in community mental health services. The findings will have implications for further research and policy regarding the broader integration of safety planning apps.TRIAL REGISTRATION: OSF Registries osf.io/3y54m; https://osf.io/3y54m.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/44205.

    View details for DOI 10.2196/44205

    View details for PubMedID 36809171

  • Trauma, historical trauma, PTSD and suicide in an American Indian community sample. Journal of psychiatric research Ehlers, C. L., Yehuda, R., Gilder, D. A., Bernert, R., Karriker-Jaffe, K. J. 2022; 156: 214-220

    Abstract

    To study the associations between perceived historical trauma, current traumatic events, diagnoses of post-traumatic stress disorder (PTSD), and suicidal behaviors in an American Indian community sample.Participants were American Indians recruited from reservations who were assessed with the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA), as well as the Historical Loss Scale, Historical Loss Associated Symptoms Scale, and Stressful Life Events Scale.In data from 447 American Indian adults (mean age = 33 years), twenty percent reported lifetime experiences of suicidal thoughts (ideation and/or plans) and 14% reported suicidal acts, (including either a suicide attempt history or verified death by suicide (n = 4)). Diagnosis of PTSD and experience of assaultive trauma were each significantly associated with suicidal thoughts and acts, although assaultive trauma did not remain significant in models adjusting for gender and PTSD. High endorsement of symptoms associated with historical trauma was significantly associated with suicidal acts, and this remained significant when adjusting for gender and PTSD.PTSD and historical trauma have an association with suicide and suicidal attempts in this American Indian community. Although further research is needed to evaluate the causal nature of these relations, these findings suggest treatment and prevention programs for American Indian suicide may benefit from addressing issues related to feelings of historical losses, PTSD, and their associated symptomatology.

    View details for DOI 10.1016/j.jpsychires.2022.10.012

    View details for PubMedID 36265258

  • Examining subjective sleep quality in adults with hoarding disorder. Journal of psychiatric research Mahnke, A. R., Linkovski, O., Timpano, K., van Roessel, P., Sanchez, C., Varias, A. D., Mukunda, P., Filippou-Frye, M., Lombardi, A., Raila, H., Anderson, K., Sandhu, T., Wright, B., McCarthy, E. A., Garcia, G. E., Asgari, S., Qiu, T., Bernert, R., Rodriguez, C. I. 2020

    Abstract

    Hoarding disorder (HD), characterized by difficulty parting with possessions and functionally impairing clutter, affects 2-6% of the population. Originally considered part of Obsessive-Compulsive Disorder (OCD), HD became a distinct diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. While sleep impacts OCD, little is known about sleep in HD. As HD patients often report poor sleep in clinical settings, understanding global subjective sleep quality and disturbances may lead to novel therapeutic targets. To address this gap, the authors used a sample of convenience: an existing data set designed to screen research study eligibility and explore the psychopathology and phenomenology of OCD and HD. The data set included information collected from individuals with HD (n=38), OCD (n=26), and healthy participants (n=22) about insomnia, sleep quality, and mood using interviews and structured instruments including the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and Depression Anxiety Stress Scales (DASS). In this data set, HD and OCD groups reported significantly greater insomnia symptoms and poorer sleep quality compared with healthy controls while controlling for depression, age, and gender. A sizable minority of HD and OCD individuals met criteria for comorbid sleep disorders. OCD and HD groups differed in delayed sleep phase prevalence. To our knowledge, this is the first study examining subjective sleep quality and insomnia in HD as compared to healthy individuals and those with OCD, while controlling for relevant clinical characteristics. Given that there are evidence-based treatments for insomnia and other sleep disorders, our study raises the possibility that treatment interventions targeting sleep may improve HD outcomes.

    View details for DOI 10.1016/j.jpsychires.2020.10.044

    View details for PubMedID 33309063

  • Delta Event-Related Oscillations Are Related to a History of Extreme Binge Drinking in Adolescence and Lifetime Suicide Risk. Behavioral sciences (Basel, Switzerland) Ehlers, C. L., Wills, D. N., Karriker-Jaffe, K. J., Gilder, D. A., Phillips, E., Bernert, R. A. 2020; 10 (10)

    Abstract

    Alcohol exposure typically begins in adolescence, and heavy binge drinking is associated with health risk behaviors. Event-related oscillations (EROs) may represent sensitive biomarkers or endophenotypes for early alcohol exposure as well as other risk behaviors such as suicidal thoughts and actions. In this study, young adults (age 18-30 years) of American Indian (AI) (n = 479) and Mexican American (MA) (n = 705) ancestry were clinically assessed, and EROs were generated to happy, sad and neutral faces. Extreme adolescent binge drinking (10+ drinks) was common (20%) in this population of AI/MA and associated with a significantly increased risk of a lifetime history of suicidal acts (SA, suicide attempts, deaths) but not suicidal thoughts (ST, ideation, plans). ST were reported among MA participants, whereas SA were more common among AI young adults. Extreme adolescent binge drinking was also associated with errors in detection of sad and neutral faces, increases in delta ERO energy, and decreases in phase locking (PL), particularly in parietal areas. A lifetime history of ST was associated with increases in delta ERO energy and PL, whereas SA were associated with decreases in both. These studies suggest that ERO measures may represent important potential biomarkers of adolescent extreme binge drinking and risk for suicidal behaviors.

    View details for DOI 10.3390/bs10100154

    View details for PubMedID 33036364

  • Artificial Intelligence and Suicide Prevention: A Systematic Review of Machine Learning Investigations. International journal of environmental research and public health Bernert, R. A., Hilberg, A. M., Melia, R., Kim, J. P., Shah, N. H., Abnousi, F. 2020; 17 (16)

    Abstract

    Suicide is a leading cause of death that defies prediction and challenges prevention efforts worldwide. Artificial intelligence (AI) and machine learning (ML) have emerged as a means of investigating large datasets to enhance risk detection. A systematic review of ML investigations evaluating suicidal behaviors was conducted using PubMed/MEDLINE, PsychInfo, Web-of-Science, and EMBASE, employing search strings and MeSH terms relevant to suicide and AI. Databases were supplemented by hand-search techniques and Google Scholar. Inclusion criteria: (1) journal article, available in English, (2) original investigation, (3) employment of AI/ML, (4) evaluation of a suicide risk outcome. N = 594 records were identified based on abstract search, and 25 hand-searched reports. N = 461 reports remained after duplicates were removed, n = 316 were excluded after abstract screening. Of n = 149 full-text articles assessed for eligibility, n = 87 were included for quantitative synthesis, grouped according to suicide behavior outcome. Reports varied widely in methodology and outcomes. Results suggest high levels of risk classification accuracy (>90%) and Area Under the Curve (AUC) in the prediction of suicidal behaviors. We report key findings and central limitations in the use of AI/ML frameworks to guide additional research, which hold the potential to impact suicide on broad scale.

    View details for DOI 10.3390/ijerph17165929

    View details for PubMedID 32824149

  • Suicide Risk Assessment and Management Training Practices in Pediatric Residency Programs: A Nationwide Needs Assessment Survey. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Schoen, L. E., Bogetz, A. L., Hom, M. A., Bernert, R. A. 2019

    Abstract

    PURPOSE: Youth suicide is a public health emergency, and its prevention is a national imperative. Pediatric providers are critical to risk assessment, triage, and intervention, yet little is known about the content, quality, and perceived adequacy of suicide prevention pediatric residency training. We thus sought to (1) characterize suicide risk assessment and management training practices in pediatric residency programs nationwide and (2) assess areas of training need to guide curricular development.METHODS: An online nationwide needs assessment was distributed to all 204 pediatric residency program directors (PDs) and 494 pediatric chief residents (CRs) through the Association of Pediatric Program Directors listservs (May to June 2017). Descriptive statistics and comparisons between PDs and CRs are reported.RESULTS: Ninety-five PDs and 210 CRs (47% and 43% response rate, respectively) completed the survey. Although 82% of respondents rated suicide prevention training in residency as "very" or "extremely" important, a minority (18% PDs and 10% CRs) reported adequate preparation relative to need. Formal training was not universal (66% PDs and 45% CRs) and practices varied across programs (PD median= 3hours [interquartile range: 1-4.5hours], CR median= 1.5hours [interquartile range: 0-3hours]). Top-ranked educational priorities included interviewing adolescents about risk, risk factor identification, and locating community resources. Training barriers included limited time, lack of training resources, and need for additional expert faculty to guide training.CONCLUSIONS: PDs and CRs reported constraints to suicide prevention training for pediatric residents despite high perceived importance and need. Programs may benefit from explicit guidelines and standardized curricula that emphasize educational priorities, building on these findings.

    View details for DOI 10.1016/j.jadohealth.2019.02.012

    View details for PubMedID 31129034

  • NIGHTMARES PREDICT CROSS-SECTIONAL RISK FOR SUICIDAL IDEATION, BUT NOT PERCEIVED STIGMA IN A HIGH-RISK SAMPLE OF US MILITARY VETERANS Hilberg, A. M., Murphy, L., Pham, S., Bernert, R. A. OXFORD UNIV PRESS INC. 2019
  • The Validity of Google Trends Search Volumes for Behavioral Forecasting of National Suicide Rates in Ireland. International journal of environmental research and public health Barros, J. M., Melia, R. n., Francis, K. n., Bogue, J. n., O'Sullivan, M. n., Young, K. n., Bernert, R. A., Rebholz-Schuhmann, D. n., Duggan, J. n. 2019; 16 (17)

    Abstract

    Annual suicide figures are critical in identifying trends and guiding research, yet challenges arising from significant lags in reporting can delay and complicate real-time interventions. In this paper, we utilized Google Trends search volumes for behavioral forecasting of national suicide rates in Ireland between 2004 and 2015. Official suicide rates are recorded by the Central Statistics Office in Ireland. While similar investigations using Google trends data have been carried out in other jurisdictions (e.g., United Kingdom, United Stated of America), such research had not yet been completed in Ireland. We compiled a collection of suicide- and depression-related search terms suggested by Google Trends and manually sourced from the literature. Monthly search rate terms at different lags were compared with suicide occurrences to determine the degree of correlation. Following two approaches based on vector autoregression and neural network autoregression, we achieved mean absolute error values between 4.14 and 9.61 when incorporating search query data, with the highest performance for the neural network approach. The application of this process to United Kingdom suicide and search query data showed similar results, supporting the benefit of Google Trends, neural network approach, and the applied search terms to forecast suicide risk increase. Overall, the combination of societal data and online behavior provide a good indication of societal risks; building on past research, our improvements led to robust models integrating search query and unemployment data for suicide risk forecasting in Ireland.

    View details for DOI 10.3390/ijerph16173201

    View details for PubMedID 31480718

  • Cross-cultural relevance of the Interpersonal Theory of suicide across Korean and U.S. undergraduate students. Psychiatry research Suh, S., Ebesutani, C. K., Hagan, C. R., Rogers, M. L., Hom, M. A., Ringer, F. B., Bernert, R. A., Kim, S., Joiner, T. E. 2017; 251: 244-252

    Abstract

    This study investigated the cross-cultural relevance and validity of the Interpersonal Theory of Suicide (ITS) utilizing young adult samples from South Korea (n =554) and the United States (U.S.; n =390). To examine the ITS, all participants completed self-report questionnaires measuring Thwarted Belongingness, Perceived Burdensomeness, and Capability for Suicide. We examined whether each construct significantly predicted the severity of suicidal risk in both samples. We also determined whether the strength of the effects of Thwarted Belongingness and Perceived Burdensomeness on suicidal ideation differed between the two samples due to the greater degree of importance placed on interpersonal relationships in collectivistic cultures such as South Korea. Structural equation modeling was used to examine these hypotheses. Thwarted Belongingness, Perceived Burdensomeness, and Capability for Suicide significantly predicted elevated suicidal risk. However, there were no significant differences in the paths from Thwarted Belongingness or Perceived Burdensomeness to suicide risk between the South Korean and U.S.These findings support the cross-cultural relevance and applicability of the ITS, whereby Thwarted Belongingness and Perceived Burdensomeness serve as indicators of suicide risk in both Western (U.S.) and East Asian (Korean) samples.

    View details for DOI 10.1016/j.psychres.2017.02.005

    View details for PubMedID 28214784

  • Sleep architecture parameters as a putative biomarker of suicidal ideation in treatment-resistant depression JOURNAL OF AFFECTIVE DISORDERS Bernert, R. A., Luckenbaugh, D. A., Duncan, W. C., Iwata, N. G., Ballard, E. D., Zarate, C. A. 2017; 208: 309-315

    Abstract

    Disturbed sleep may confer risk for suicidal behaviors. Polysomnographic (PSG) sleep parameters have not been systematically evaluated in association with suicidal ideation (SI) among individuals with treatment-resistant depression (TRD).This secondary data analysis included 54 TRD individuals (N=30 with major depressive disorder (MDD) and N=24 with bipolar depression (BD)). PSG sleep parameters included Sleep Efficiency (SE), Total Sleep Time (TST), Wakefulness After Sleep Onset (WASO), REM percent/latency, and non-REM (NREM) Sleep Stages 1-4. The Hamilton Depression Rating Scale (HAM-D) was used to group participants according to presence or absence of SI. Sleep abnormalities were hypothesized among those with current SI. ANOVA analyses were conducted before (Model 1) and after adjusting for depression (Model 2) and diagnostic variables (Model 3).Significant differences in PSG parameters were observed in Model 1; those with SI had less NREM Stage 4 sleep (p<.05). After adjusting for central covariates, Models 2 and 3 revealed significantly less NREM Stage 4 sleep, lower SE (P<.05), and higher WASO (P<.05) among those with SI. BD participants with SI also had less NREM Stage 4 and more NREM Stage 1 sleep.1) a predominantly white sample; 2) exclusion of imminent suicide risk; 3) concomitant mood stabilizer use among BD patients; and 4) single-item SI assessment.Independent of depression severity, SI was associated with less NREM Stage 4 sleep, and higher nocturnal wakefulness across diagnostic groups. Sleep may warrant further investigation in the pathogenesis of suicide risk, particularly in TRD, where risk may be heightened.

    View details for DOI 10.1016/j.jad.2016.08.050

    View details for Web of Science ID 000390732600045

  • Objectively Assessed Sleep Variability as an Acute Warning Sign of Suicidal Ideation in a Longitudinal Evaluation of Young Adults at High Suicide Risk. The Journal of clinical psychiatry Bernert, R. A., Hom, M. A., Iwata, N. G., Joiner, T. E. 2017; 78 (6): e678–e687

    Abstract

    Young adults attempt suicide at disproportionately high rates relative to other groups and demonstrate high rates of sleep disturbance. No study has yet prospectively evaluated disturbed sleep as an acute indicator of risk using an objective index of sleep. We investigated objective and subjective parameters of disturbed sleep as a warning sign of suicidal ideation among young adults over an acute period.A longitudinal study across a 21-day observation period and 3 time points. Fifty of 4,847 participants (aged 18-23 years) were prescreened from a university undergraduate research pool (February 2007-June 2008) on the basis of suicide attempt history and recent suicidal ideation. Actigraphic and subjective sleep parameters were evaluated as acute predictors of suicidal ideation (Beck Scale for Suicide Ideation), with adjustment for baseline symptoms. Hierarchical regression analyses were employed to predict residual change scores.Ninety-six percent of participants (n = 48) endorsed a suicide attempt history. Mean actigraphy values revealed objectively disturbed sleep parameters; 78% (n = 39) and 36% (n = 18) endorsed clinically significant insomnia and nightmares, respectively. When results were controlled for baseline suicidal and depressive symptoms, actigraphic and subjective sleep parameters predicted suicidal ideation residual change scores at 7- and 21-day follow-ups (P < .001). Specifically, actigraphy-defined variability in sleep timing, insomnia, and nightmares predicted increases in suicidal ideation (P < .05). In a test of competing risk factors, sleep variability outperformed depressive symptoms in the longitudinal prediction of suicidal ideation across time points (P < .05).Objectively and subjectively measured sleep disturbances predicted acute suicidal ideation increases in this population, independent of depressed mood. Self-reported insomnia and nightmares and actigraphically assessed sleep variability emerged as acute warning signs of suicidal ideation. These findings highlight the potential utility of sleep as a proposed biomarker of suicide risk and a therapeutic target.

    View details for PubMedID 28682534

  • Antisuicidal Response Following Ketamine Infusion Is Associated With Decreased Nighttime Wakefulness in Major Depressive Disorder and Bipolar Disorder. journal of clinical psychiatry Vande Voort, J. L., Ballard, E. D., Luckenbaugh, D. A., Bernert, R. A., Richards, E. M., Niciu, M. J., Park, L. T., Machado-Vieira, R., Duncan, W. C., Zarate, C. A. 2016

    Abstract

    Insomnia and disrupted sleep are associated with increased risk of suicide. The N-methyl-D-aspartate antagonist ketamine has been associated with reduced suicidal thoughts, but the mechanism of action is unknown. This study sought to evaluate differences in nocturnal wakefulness in depressed individuals who did and did not have an antisuicidal response to ketamine.Thirty-four participants with baseline suicidal ideation diagnosed with either DSM-IV major depressive disorder (n = 23) or bipolar depression (n = 11) between 2006 and 2013 completed nighttime electroencephalography (EEG) the night before and the night after a single ketamine infusion (0.5 mg/kg over 40 minutes). Suicidal ideation was assessed at baseline and the morning after ketamine infusion via several measures, including the Hamilton Depression Rating Scale suicide item, the suicide item of the Montgomery-Asberg Depression Rating Scale, and the first 5 items of the Scale for Suicide Ideation. A generalized linear mixed model evaluated differences in nocturnal wakefulness, as verified by EEG, between those who had an antisuicidal response to ketamine and those who did not, controlling for baseline nocturnal wakefulness. Results were also compared to the sleep of healthy controls (n = 22).After analyses adjusted for baseline sleep, participants with an antisuicidal response to ketamine showed significantly reduced nocturnal wakefulness the night after ketamine infusion compared to those without an antisuicidal response (F₁,₂₂ = 5.04, P = .04). Level of nocturnal wakefulness after antisuicidal response to ketamine did not differ significantly from nocturnal wakefulness in the control sample but did differ at a trend level (F₁,₄₀ = 3.15, P = .08).Reductions in wakefulness following ketamine may point to a biological mechanism underlying the effect of ketamine on suicidal ideation.ClinicalTrials.gov identifier: NCT00088699.

    View details for DOI 10.4088/JCP.15m10440

    View details for PubMedID 27929610

  • Sleep architecture parameters as a putative biomarker of suicidal ideation in treatment-resistant depression. Journal of affective disorders Bernert, R. A., Luckenbaugh, D. A., Duncan, W. C., Iwata, N. G., Ballard, E. D., Zarate, C. A. 2016; 208: 309-315

    Abstract

    Disturbed sleep may confer risk for suicidal behaviors. Polysomnographic (PSG) sleep parameters have not been systematically evaluated in association with suicidal ideation (SI) among individuals with treatment-resistant depression (TRD).This secondary data analysis included 54 TRD individuals (N=30 with major depressive disorder (MDD) and N=24 with bipolar depression (BD)). PSG sleep parameters included Sleep Efficiency (SE), Total Sleep Time (TST), Wakefulness After Sleep Onset (WASO), REM percent/latency, and non-REM (NREM) Sleep Stages 1-4. The Hamilton Depression Rating Scale (HAM-D) was used to group participants according to presence or absence of SI. Sleep abnormalities were hypothesized among those with current SI. ANOVA analyses were conducted before (Model 1) and after adjusting for depression (Model 2) and diagnostic variables (Model 3).Significant differences in PSG parameters were observed in Model 1; those with SI had less NREM Stage 4 sleep (p<.05). After adjusting for central covariates, Models 2 and 3 revealed significantly less NREM Stage 4 sleep, lower SE (P<.05), and higher WASO (P<.05) among those with SI. BD participants with SI also had less NREM Stage 4 and more NREM Stage 1 sleep.1) a predominantly white sample; 2) exclusion of imminent suicide risk; 3) concomitant mood stabilizer use among BD patients; and 4) single-item SI assessment.Independent of depression severity, SI was associated with less NREM Stage 4 sleep, and higher nocturnal wakefulness across diagnostic groups. Sleep may warrant further investigation in the pathogenesis of suicide risk, particularly in TRD, where risk may be heightened.

    View details for DOI 10.1016/j.jad.2016.08.050

    View details for PubMedID 27810712

  • Suicide and sleep: Is it a bad thing to be awake when reason sleeps? Sleep medicine reviews Perlis, M. L., Grandner, M. A., Chakravorty, S., Bernert, R. A., Brown, G. K., Thase, M. E. 2016; 29: 101-107

    Abstract

    Suicide is the second leading cause of death, worldwide, for those between the ages of 24 and 44 y old. In 2013, more than 41,000 suicides occurred in the United States. These statistics underscore the need to 1) understand why people die by suicide and 2) identify risk factors that are potentially modifiable. While it has been posited that sleep disturbance may represent one such factor, systematic research in this arena did not begin until the 2000s. Since that time, sleep disturbance has been reliably identified as a risk factor for suicidal ideation, suicide attempts, and suicide. While insomnia, nightmares, and other sleep disorders have each been found to contribute to the risk for suicidal ideation and behavior, it is also possible that these factors share some common variance. One possibility is that sleep disturbance results in being awake at night, and being awake at night also confers risk. The hypothesis proffered here is that being awake when one is not biologically prepared to be so results in "hypofrontality" and diminished executive function, and that this represents a common pathway to suicidal ideation and behavior. Such a proposition is highly testable under a variety of possible protocols. The current review summarizes the extant literature on suicide rates by time-of-day, and discusses circadian, psychosocial, and neurocognitive explanations of risk. Such a focus promises to enhance our understanding of how sleep disturbance may confer risk, allows for the identification of future lines of research, and further justifies the need for interventions that promote good sleep continuity among at-risk individuals.

    View details for DOI 10.1016/j.smrv.2015.10.003

    View details for PubMedID 26706755

    View details for PubMedCentralID PMC5070474

  • Limitations of a single-item assessment of suicide attempt history: Implications for standardized suicide risk assessment. Psychological assessment Hom, M. A., Joiner, T. E., Bernert, R. A. 2016; 28 (8): 1026-1030

    Abstract

    Although a suicide attempt history is among the single best predictors of risk for eventual death by suicide, little is known about the extent to which reporting of suicide attempts may vary by assessment type. The current study aimed to investigate the correspondence between suicide attempt history information obtained via a single-item self-report survey, multi-item self-report survey, and face-to-face clinical interview. Data were collected among a high-risk sample of undergraduates (N = 100) who endorsed a past attempt on a single-item prescreening survey. Participants subsequently completed a multi-item self-report survey, which was followed by a face-to-face clinical interview, both of which included additional questions regarding the timing and nature of previous attempts. Even though 100% of participants (n = 100) endorsed a suicide attempt history on the single-item prescreening survey, only 67% (n = 67) reported having made a suicide attempt on the multi-item follow-up survey. After incorporating ancillary information from the in-person interview, 60% of participants qualified for a Centers for Disease Control and Prevention (CDC)-defined suicide attempt. Of the 40% who did not qualify for a CDC-defined suicide attempt, 30% instead qualified for no attempt, 7% an aborted attempt, and 3% an interrupted attempt. These findings suggest that single-item assessments of suicide attempt history may result in the misclassification of prior suicidal behaviors. Given that such assessments are commonly used in research and clinical practice, these results emphasize the importance of utilizing follow-up questions and assessments to improve precision in the characterization and assessment of suicide risk. (PsycINFO Database Record

    View details for DOI 10.1037/pas0000241

    View details for PubMedID 26502202

    View details for PubMedCentralID PMC4846594

  • Nocturnal Wakefulness Is Associated With Next-Day Suicidal Ideation in Major Depressive Disorder and Bipolar Disorder JOURNAL OF CLINICAL PSYCHIATRY Ballard, E. D., Voort, J. L., Bernert, R. A., Luckenbaugh, D. A., Richards, E. M., Niciu, M. J., Furey, M. L., Duncan, W. C., Zarate, C. A. 2016; 77 (6): 825-831

    Abstract

    Self-reported sleep disturbances may confer elevated risk for suicidal ideation, suicide attempts, and death. However, limited research has evaluated polysomnographically determined sleep disturbance as an acute physiologic risk factor for suicidal thoughts. This study sought to investigate the relationship between nocturnal wakefulness in association with next-day suicidal ideation using overnight polysomnography assessment from data collected between 2006 and 2013.Sixty-five participants with DSM-IV-diagnosed major depressive disorder or bipolar depression underwent overnight polysomnography monitoring in a sleep laboratory. The Hamilton Depression Rating Scale (HDRS) was administered the morning after polysomnography recording to assess next-day suicidal ideation, severity of depressive symptoms, and subjective sleep disturbances.Using a generalized linear mixed model, a significant time-by-ideation interaction was found indicating greater nocturnal wakefulness at 4:00 am among participants with suicidal ideation (F4,136 = 3.65, P = .007). Increased time awake during the 4:00 am hour (4:00 to 4:59) was significantly associated with elevated suicidal thoughts the next day (standardized β = 0.31, P = .008). This relationship persisted after controlling for age, gender, diagnosis, and severity of depressive symptoms.Greater nocturnal wakefulness, particularly in the early morning hours, was significantly associated with next-day suicidal thoughts. Polysomnographically documented sleep disruption at specific times of night may represent an acute risk factor of suicidal ideation that warrants additional research.ClinicalTrials.gov identifier: NCT00024635.

    View details for DOI 10.4088/JCP.15m09943

    View details for Web of Science ID 000379302500021

    View details for PubMedID 27337418

  • The Association between Sleep Disturbances and Depression among Firefighters: Emotion Dysregulation as an Explanatory Factor JOURNAL OF CLINICAL SLEEP MEDICINE Hom, M. A., Stanley, I. H., Rogers, M. L., Tzoneva, M., Bernert, R. A., Joiner, T. E. 2016; 12 (2): 235-245

    Abstract

    To investigate emotion regulation difficulties in association with self-reported insomnia symptoms, nightmares, and depression symptoms in a sample of current and retired firefighters.A total of 880 current and retired United States firefighters completed a web-based survey of firefighter behavioral health. Self-report measures included the Center for Epidemiologic Studies Depression Scale, Insomnia Severity Index, PTSD Checklist, and Difficulties in Emotion Regulation Scale.A notable portion of participants reported clinically significant depression symptoms (39.6%) and insomnia symptoms (52.7%), as well as nightmare problems (19.2%), each of which demonstrated a strong association with emotion regulation difficulties (rs = 0.56-0.80). Bootstrapped mediation analyses revealed that the indirect effects of overall emotion regulation difficulties were significant both for the relationship between insomnia and depression (95% CI: 0.385-0.566) and nightmares and depression (95% CI: 1.445-2.365). Limited access to emotion regulation strategies emerged as the strongest, significant indirect effect for both relationships (insomnia 95% CI: 0.136-0.335; nightmares 95% CI: 0.887-1.931).Findings extend previous affective neuroscience research by providing evidence that insomnia and nightmares may influence depression symptoms specifically through the pathway of explicit emotion regulation difficulties. Sleep disturbances may impair the ability to access and leverage emotion regulation strategies effectively, thus conferring risk for negative affect and depression.

    View details for DOI 10.5664/jcsm.5492

    View details for Web of Science ID 000374138900012

    View details for PubMedCentralID PMC4751428

  • Sleep disturbances as an evidence-based suicide risk factor. Current psychiatry reports Bernert, R. A., Kim, J. S., Iwata, N. G., Perlis, M. L. 2015; 17 (3): 554-?

    Abstract

    Increasing research indicates that sleep disturbances may confer increased risk for suicidal behaviors, including suicidal ideation, suicide attempts, and death by suicide. Despite increased investigation, a number of methodological problems present important limitations to the validity and generalizability of findings in this area, which warrant additional focus. To evaluate and delineate sleep disturbances as an evidence-based suicide risk factor, a systematic review of the extant literature was conducted with methodological considerations as a central focus. The following methodologic criteria were required for inclusion: the report (1) evaluated an index of sleep disturbance; (2) examined an outcome measure for suicidal behavior; (3) adjusted for presence of a depression diagnosis or depression severity, as a covariate; and (4) represented an original investigation as opposed to a chart review. Reports meeting inclusion criteria were further classified and reviewed according to: study design and timeframe; sample type and size; sleep disturbance, suicide risk, and depression covariate assessment measure(s); and presence of positive versus negative findings. Based on keyword search, the following search engines were used: PubMed and PsycINFO. Search criteria generated N = 82 articles representing original investigations focused on sleep disturbances and suicide outcomes. Of these, N = 18 met inclusion criteria for review based on systematic analysis. Of the reports identified, N = 18 evaluated insomnia or poor sleep quality symptoms, whereas N = 8 assessed nightmares in association with suicide risk. Despite considerable differences in study designs, samples, and assessment techniques, the comparison of such reports indicates preliminary, converging evidence for sleep disturbances as an empirical risk factor for suicidal behaviors, while highlighting important, future directions for increased investigation.

    View details for DOI 10.1007/s11920-015-0554-4

    View details for PubMedID 25698339

  • Sleep Disturbances and Suicide Risk. Sleep medicine clinics Bernert, R. A., Nadorff, M. R. 2015; 10 (1): 35-39

    Abstract

    Suicide occurs in the presence of psychiatric illness, and is associated with biological, psychological, and social risk factors. Insomnia symptoms and nightmares appear to present elevated risk for suicidal ideation, attempts, and death by suicide. Failure to account for the presence of psychopathology and frequent use of single item assessments of sleep and suicidal ideation are common methodological problems in this literature. Preliminary research, addressing these issues, suggests that subjective sleep complaints may confer independent risk for suicidal behaviors.

    View details for DOI 10.1016/j.jsmc.2014.11.004

    View details for PubMedID 26055671

  • The Association between Sleep Disturbances and Depression among Firefighters: Emotion Dysregulation as an Explanatory Factor. Journal of clinical sleep medicine Hom, M. A., Stanley, I. H., Rogers, M. L., Tzoneva, M., Bernert, R. A., Joiner, T. E. 2015; 12 (2): 235-245

    Abstract

    To investigate emotion regulation difficulties in association with self-reported insomnia symptoms, nightmares, and depression symptoms in a sample of current and retired firefighters.A total of 880 current and retired United States firefighters completed a web-based survey of firefighter behavioral health. Self-report measures included the Center for Epidemiologic Studies Depression Scale, Insomnia Severity Index, PTSD Checklist, and Difficulties in Emotion Regulation Scale.A notable portion of participants reported clinically significant depression symptoms (39.6%) and insomnia symptoms (52.7%), as well as nightmare problems (19.2%), each of which demonstrated a strong association with emotion regulation difficulties (rs = 0.56-0.80). Bootstrapped mediation analyses revealed that the indirect effects of overall emotion regulation difficulties were significant both for the relationship between insomnia and depression (95% CI: 0.385-0.566) and nightmares and depression (95% CI: 1.445-2.365). Limited access to emotion regulation strategies emerged as the strongest, significant indirect effect for both relationships (insomnia 95% CI: 0.136-0.335; nightmares 95% CI: 0.887-1.931).Findings extend previous affective neuroscience research by providing evidence that insomnia and nightmares may influence depression symptoms specifically through the pathway of explicit emotion regulation difficulties. Sleep disturbances may impair the ability to access and leverage emotion regulation strategies effectively, thus conferring risk for negative affect and depression.

    View details for DOI 10.5664/jcsm.5492

    View details for PubMedID 26350604

    View details for PubMedCentralID PMC4751428

  • The prediction of study-emergent suicidal ideation in bipolar disorder: a pilot study using ecological momentary assessment data BIPOLAR DISORDERS Thompson, W. K., Gershon, A., O'Hara, R., Bernert, R. A., Depp, C. A. 2014; 16 (7): 669-677

    Abstract

    Bipolar disorder is associated with idiosyncratic precursors of clinically important states such as suicidal ideation. Ecological momentary assessment (EMA) - high frequency data collection in a subject's usual environment - provides the potential for development of temporal, individualized prediction of risk states. The present study tested the ability of EMA data to predict individual symptom change in clinician-rated suicidal ideation.Thirty-five adults diagnosed with inter-episode bipolar disorder completed daily measures of affect in their home environments using diaries administered over an eight-week assessment timeline. Suicidal ideation was assessed monthly at in-person visits using the Inventory of Depressive Symptomatology-Clinician Rated. We used a novel application of functional linear models (FLMs) to generate prospective predictions of suicidal ideation at in-person clinician assessments based on intensively sampled trajectories of daily affect.Eight instances of suicidal ideation scores > 0 were recorded during the study period on six participants. Utilizing trajectories of negative and positive affect, cross-validated predictions attained 88% sensitivity with 95% specificity for elevated suicidal ideation one week prior to in-person clinician assessment. This model strongly outperformed prediction models using cross-sectional data obtained at study visits alone.Utilizing EMA data with FLM prediction models substantially increases the accuracy of prediction of study-emergent suicidal ideation. Prediction algorithms employing intensively sampled longitudinal EMA data could sensitively detect the warning signs of suicidal ideation to facilitate improved suicide risk assessment and the timely delivery of preventative interventions.

    View details for DOI 10.1111/bdi.12218

    View details for Web of Science ID 000344373100001

  • Obsessive compulsive symptoms and sleep difficulties: Exploring the unique relationship between insomnia and obsessions. Journal of psychiatric research Timpano, K. R., Carbonella, J. Y., Bernert, R. A., Schmidt, N. B. 2014; 57: 101-107

    Abstract

    Sleep complaints have been linked with Obsessive Compulsive Disorder (OCD), though there is a dearth of research exploring the association between a range of disturbed sleep indicators and obsessive compulsive symptoms (OCS). Two separate studies were conducted to rigorously investigate this relationship in further detail, considering a number of different sleep indices and also the heterogeneous nature of OCS.Study 1 (n = 167) examined the relationship between OCS and the gold standard self-report assessments for delayed bedtime, sleep quality, nightmares, and insomnia symptoms. Study 2 (n = 352) replicated the primary findings from Study 1 in an independent sample and with an alternative measure of OCD, which takes into account the different OCS dimensions.Results revealed a significant, independent link between obsessions and insomnia symptoms, but not between insomnia and compulsions. When examining the different OCS dimensions, insomnia was again found to bear a specific relationship to obsessions, above and beyond that with the other dimensions. Although depression is often highly comorbid with both OCD and sleep disturbances, depressive symptoms did not explain the OCS-sleep relationship in either study, suggesting a unique association between obsessions and insomnia.Findings indicate that high levels of intrusive thoughts exhibit a specific association with insomnia symptoms-one that is not observed with other OCS. Future research may help elucidate the mechanisms and causal nature of this relationship.

    View details for DOI 10.1016/j.jpsychires.2014.06.021

    View details for PubMedID 25038630

  • A review of multidisciplinary clinical practice guidelines in suicide prevention: toward an emerging standard in suicide risk assessment and management, training and practice. Academic psychiatry Bernert, R. A., Hom, M. A., Roberts, L. W. 2014; 38 (5): 585-592

    Abstract

    The current paper aims to: (1) examine clinical practice guidelines in suicide prevention across fields, organizations, and clinical specialties and (2) inform emerging standards in clinical practice, research, and training.The authors conducted a systematic literature review to identify clinical practice guidelines and resource documents in suicide prevention and risk management. The authors used PubMed, Google Scholar, and Google Search, and keywords included: clinical practice guideline, practice guideline, practice parameters, suicide, suicidality, suicidal behaviors, assessment, and management. To assess for commonalities, the authors reviewed guidelines and resource documents across 13 key content categories and assessed whether each document suggested validated assessment measures.The search generated 101 source documents, which included N = 10 clinical practice guidelines and N = 12 additional resource documents (e.g., non-formalized guidelines, tool-kits). All guidelines (100 %) provided detailed recommendations for the use of evidence-based risk factors and protective factors, 80 % provided brief (but not detailed) recommendations for the assessment of suicidal intent, and 70 % recommended risk management strategies. By comparison, only 30 % discussed standardization of risk-level categorizations and other content areas considered central to best practices in suicide prevention (e.g., restricting access to means, ethical considerations, confidentiality/legal issues, training, and postvention practices). Resource documents were largely consistent with these findings.Current guidelines address similar aspects of suicide risk assessment and management, but significant discrepancies exist. A lack of consensus was evident in recommendations across core competencies, which may be improved by increased standardization in practice and training. Additional resources appear useful for supplemental use.

    View details for DOI 10.1007/s40596-014-0180-1

    View details for PubMedID 25142247

  • Association of poor subjective sleep quality with risk for death by suicide during a 10-year period: a longitudinal, population-based study of late life. JAMA psychiatry Bernert, R. A., Turvey, C. L., Conwell, Y., Joiner, T. E. 2014; 71 (10): 1129-1137

    Abstract

    Older adults have high rates of sleep disturbance, die by suicide at disproportionately higher rates compared with other age groups, and tend to visit their physician in the weeks preceding suicide death. To our knowledge, to date, no study has examined disturbed sleep as an independent risk factor for late-life suicide.To examine the relative independent risk for suicide associated with poor subjective sleep quality in a population-based study of older adults during a 10-year observation period.A longitudinal case-control cohort study of late-life suicide among a multisite, population-based community sample of older adults participating in the Established Populations for Epidemiologic Studies of the Elderly. Of 14 456 community older adults sampled, 400 control subjects were matched (on age, sex, and study site) to 20 suicide decedents.Primary measures included the Sleep Quality Index, the Center for Epidemiologic Studies-Depression Scale, and vital statistics.Hierarchical logistic regressions revealed that poor sleep quality at baseline was significantly associated with increased risk for suicide (odds ratio [OR], 1.39; 95% CI, 1.14-1.69; P < .001) by 10 follow-up years. In addition, 2 sleep items were individually associated with elevated risk for suicide at 10-year follow-up: difficulty falling asleep (OR, 2.24; 95% CI, 1.27-3.93; P < .01) and nonrestorative sleep (OR, 2.17; 95% CI, 1.28-3.67; P < .01). Controlling for depressive symptoms, baseline self-reported sleep quality was associated with increased risk for death by suicide (OR, 1.30; 95% CI, 1.04-1.63; P < .05).Our results indicate that poor subjective sleep quality is associated with increased risk for death by suicide 10 years later, even after adjustment for depressive symptoms. Disturbed sleep appears to confer considerable risk, independent of depressed mood, for the most severe suicidal behaviors and may warrant inclusion in suicide risk assessment frameworks to enhance detection of risk and intervention opportunity in late life.

    View details for DOI 10.1001/jamapsychiatry.2014.1126

    View details for PubMedID 25133759

  • A Review of Multidisciplinary Clinical Practice Guidelines in Suicide Prevention: Toward an Emerging Standard in Suicide Risk Assessment and Management, Training and Practice ACADEMIC PSYCHIATRY Bernert, R. A., Hom, M. A., Roberts, L. W. 2014; 38 (5): 585-592

    Abstract

    The current paper aims to: (1) examine clinical practice guidelines in suicide prevention across fields, organizations, and clinical specialties and (2) inform emerging standards in clinical practice, research, and training.The authors conducted a systematic literature review to identify clinical practice guidelines and resource documents in suicide prevention and risk management. The authors used PubMed, Google Scholar, and Google Search, and keywords included: clinical practice guideline, practice guideline, practice parameters, suicide, suicidality, suicidal behaviors, assessment, and management. To assess for commonalities, the authors reviewed guidelines and resource documents across 13 key content categories and assessed whether each document suggested validated assessment measures.The search generated 101 source documents, which included N = 10 clinical practice guidelines and N = 12 additional resource documents (e.g., non-formalized guidelines, tool-kits). All guidelines (100 %) provided detailed recommendations for the use of evidence-based risk factors and protective factors, 80 % provided brief (but not detailed) recommendations for the assessment of suicidal intent, and 70 % recommended risk management strategies. By comparison, only 30 % discussed standardization of risk-level categorizations and other content areas considered central to best practices in suicide prevention (e.g., restricting access to means, ethical considerations, confidentiality/legal issues, training, and postvention practices). Resource documents were largely consistent with these findings.Current guidelines address similar aspects of suicide risk assessment and management, but significant discrepancies exist. A lack of consensus was evident in recommendations across core competencies, which may be improved by increased standardization in practice and training. Additional resources appear useful for supplemental use.

    View details for DOI 10.1007/s40596-014-0180-1

    View details for Web of Science ID 000342172000011

    View details for PubMedCentralID PMC4283785

  • Association of Poor Subjective Sleep Quality With Risk for Death by Suicide During a 10-Year Period A Longitudinal, Population-Based Study of Late Life JAMA PSYCHIATRY Bernert, R. A., Turvey, C. L., Conwell, Y., Joiner, T. E. 2014; 71 (10): 1129-1137

    Abstract

    Older adults have high rates of sleep disturbance, die by suicide at disproportionately higher rates compared with other age groups, and tend to visit their physician in the weeks preceding suicide death. To our knowledge, to date, no study has examined disturbed sleep as an independent risk factor for late-life suicide.To examine the relative independent risk for suicide associated with poor subjective sleep quality in a population-based study of older adults during a 10-year observation period.A longitudinal case-control cohort study of late-life suicide among a multisite, population-based community sample of older adults participating in the Established Populations for Epidemiologic Studies of the Elderly. Of 14 456 community older adults sampled, 400 control subjects were matched (on age, sex, and study site) to 20 suicide decedents.Primary measures included the Sleep Quality Index, the Center for Epidemiologic Studies-Depression Scale, and vital statistics.Hierarchical logistic regressions revealed that poor sleep quality at baseline was significantly associated with increased risk for suicide (odds ratio [OR], 1.39; 95% CI, 1.14-1.69; P < .001) by 10 follow-up years. In addition, 2 sleep items were individually associated with elevated risk for suicide at 10-year follow-up: difficulty falling asleep (OR, 2.24; 95% CI, 1.27-3.93; P < .01) and nonrestorative sleep (OR, 2.17; 95% CI, 1.28-3.67; P < .01). Controlling for depressive symptoms, baseline self-reported sleep quality was associated with increased risk for death by suicide (OR, 1.30; 95% CI, 1.04-1.63; P < .05).Our results indicate that poor subjective sleep quality is associated with increased risk for death by suicide 10 years later, even after adjustment for depressive symptoms. Disturbed sleep appears to confer considerable risk, independent of depressed mood, for the most severe suicidal behaviors and may warrant inclusion in suicide risk assessment frameworks to enhance detection of risk and intervention opportunity in late life.

    View details for DOI 10.1001/jamapsychiatry.2014.1126

    View details for Web of Science ID 000342900200007

  • Sleep Architecture Abnormalities as a Risk Factor for Elevated Suicidal Ideation: A Polysomnographic Investigation of Sleep in Treatment Resistant Unipolar and Bipolar Depression Bernert, R., Luckenbaugh, D., Duncan, W. C., Zarate, C. A. NATURE PUBLISHING GROUP. 2013: S388–S389
  • Eating disorder and obsessive-compulsive symptoms in a sample of bulimic women: Perfectionism as a mediating factor PERSONALITY AND INDIVIDUAL DIFFERENCES Bernert, R. A., Timpano, K. R., Peterson, C. B., Crow, S. J., Bardone-Cone, A. M., Le Grange, D., Klein, M., Crosby, R. D., Mitchell, J. E., Wonderlich, S. A., Joiner, T. E. 2013; 54 (2): 231-235
  • Clinical significance of night-to-night sleep variability in insomnia SLEEP MEDICINE Suh, S., Nowakowski, S., Bernert, R. A., Ong, J. C., Siebern, A. T., Dowdle, C. L., Manber, R. 2012; 13 (5): 469-475

    Abstract

    To evaluate the clinical relevance of night-to-night variability of sleep schedules and insomnia symptoms.The sample consisted of 455 patients (193 men, mean age=48) seeking treatment for insomnia in a sleep medicine clinic. All participants received group cognitive behavioral therapy for insomnia (CBTI). Variability in sleep parameters was assessed using sleep diary data. Two composite scores were computed, a behavioral schedule composite score (BCS) and insomnia symptom composite score (ICS). The Insomnia Severity Index, the Beck Depression Inventory, and the Morningness-Eveningness Composite Scale were administered at baseline and post-treatment.Results revealed that greater BCS scores were significantly associated with younger age, eveningness chronotype, and greater depression severity (p<0.001). Both depression severity and eveningness chronotype independently predicted variability in sleep schedules (p<0.001). Finally, CBTI resulted in reduced sleep variability for all sleep diary variables except bedtime. Post-treatment symptom reductions in depression severity were greater among those with high versus low baseline BCS scores (p<0.001).Results suggest that variability in sleep schedules predict reduction in insomnia and depressive severity following group CBTI. Schedule variability may be particularly important to assess and address among patients with high depression symptoms and those with the evening chronotype.

    View details for DOI 10.1016/j.sleep.2011.10.034

    View details for Web of Science ID 000303346800004

    View details for PubMedID 22357064

  • Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military JOURNAL OF AFFECTIVE DISORDERS Ribeiro, J. D., Pease, J. L., Gutierrez, P. M., Silva, C., Bernert, R. A., Rudd, M. D., Joiner, T. E. 2012; 136 (3): 743-750

    Abstract

    Sleep problems appear to represent an underappreciated and important warning sign and risk factor for suicidal behaviors. Given past research indicating that disturbed sleep may confer such risk independent of depressed mood, in the present report we compared self-reported insomnia symptoms to several more traditional, well-established suicide risk factors: depression severity, hopelessness, PTSD diagnosis, as well as anxiety, drug abuse, and alcohol abuse symptoms.Using multiple regression, we examined the cross-sectional and longitudinal relationships between insomnia symptoms and suicidal ideation and behavior, controlling for depressive symptom severity, hopelessness, PTSD diagnosis, anxiety symptoms, and drug and alcohol abuse symptoms in a sample of military personnel (N=311).In support of a priori hypotheses, self-reported insomnia symptoms were cross-sectionally associated with suicidal ideation, even after accounting for symptoms of depression, hopelessness, PTSD diagnosis, anxiety symptoms and drug and alcohol abuse. Self-reported insomnia symptoms also predicted suicide attempts prospectively at one-month follow up at the level of a non-significant trend, when controlling for baseline self-reported insomnia symptoms, depression, hopelessness, PTSD diagnosis and anxiety, drug and alcohol abuse symptoms. Insomnia symptoms were unique predictors of suicide attempt longitudinally when only baseline self-reported insomnia symptoms, depressive symptoms and hopelessness were controlled.The assessment of insomnia symptoms consisted of only three self-report items. Findings may not generalize outside of populations at severe suicide risk.These findings suggest that insomnia symptoms may be an important target for suicide risk assessment and the treatment development of interventions to prevent suicide.

    View details for DOI 10.1016/j.jad.2011.09.049

    View details for Web of Science ID 000301996000071

    View details for PubMedID 22032872

  • CBT for Insomnia in Patients with High and Low Depressive Symptom Severity: Adherence and Clinical Outcomes JOURNAL OF CLINICAL SLEEP MEDICINE Manber, R., Bernert, R. A., Suh, S., Nowakowski, S., Siebern, A. T., Ong, J. C. 2011; 7 (6): 645-652

    Abstract

    To evaluate whether depressive symptom severity leads to poorer response and perceived adherence to cognitive behavioral therapy for insomnia (CBTI) and to examine the impact of CBTI on well-being, depressive symptom severity, and suicidal ideation.Pre- to posttreatment case replication series comparing low depression (LowDep) and high depression (HiDep) groups (based on a cutoff of 14 on the Beck Depression Inventory [BDI]).127 men and 174 women referred for the treatment of insomnia.Seven sessions of group CBTI.Improvement in the insomnia severity, perceived energy, productivity, self-esteem, other aspects of wellbeing, and overall treatment satisfaction did not differ between the HiDep and LowDep groups (p > 0.14). HiDep patients reported lower adherence to a fixed rise time, restricting time in bed, and changing expectations about sleep (p < 0.05). HiDep participants experienced significant reductions in BDI, after removing the sleep item. Levels of suicidal ideation dropped significantly among patients with pretreatment elevations (p < 0.0001).Results suggest that pre- to post CBTI improvements in insomnia symptoms, perceived energy, productivity, self-esteem, and other aspects of well-being were similar among patients with and without elevation in depressive symptom severity. Thus, the benefits of CBTI extend beyond insomnia and include improvements in non-sleep outcomes, such as overall well-being and depressive symptom severity, including suicidal ideation, among patients with baseline elevations. Results identify aspects of CBTI that may merit additional attention to further improve outcomes among patients with insomnia and elevated depressive symptom severity.

    View details for DOI 10.5664/jcsm.1472

    View details for Web of Science ID 000300161900012

    View details for PubMedID 22171204

    View details for PubMedCentralID PMC3227711