Nightmares and suicide risk: why they deserve to be taken seriously

This is a careful article about a serious subject, written for people who have nightmares and for the people who love them. Its message is simple. If your nights are bringing thoughts of ending your life, that is a reason to reach out today, and help works.

If you need help now

If you are in danger, or thinking about harming yourself, please call your local emergency number now (144 or 112 in Switzerland, 112 elsewhere in Europe, 911 in the US), or reach a crisis line. The lines listed there are free, confidential and answered by people. If you can, tell someone near you how you feel, and stay with them.

What the research shows

Researchers have asked whether disturbed sleep is linked to suicidal thoughts and behaviour in its own right, not only as part of depression. Several kinds of study point the same way.

• A follow-up study after hospital care. In Sweden, 165 adults admitted to hospital after a suicide attempt were interviewed about their sleep, and 98 were interviewed again two months later. Hospital records were then checked over two years. Difficulty falling or staying asleep did not predict a repeat attempt, but frequent nightmares did: about three times the odds, and about five times when nightmares were still there at two months. The link held after taking depression, anxiety and psychiatric diagnoses into account.^[1]
• A survey of students. Among 583 undergraduates in the United States, both nightmares and insomnia symptoms were related to suicidal thoughts. Only nightmares stayed linked after accounting for symptoms of depression, anxiety and PTSD.^[2]
• Pooling the evidence. A 2012 meta-analysis of 39 studies, covering more than 147,000 people, found that sleep disturbances in general, and nightmares and insomnia individually, were associated with a higher risk of suicidal thoughts and behaviour.^[3]
• A stricter review. In 2015, a systematic review kept only studies that accounted for depression. Of 82 candidate studies, 18 met that bar, eight of them on nightmares. Despite differences in design, the authors found preliminary but converging evidence that sleep disturbances are a genuine risk factor.^[4]

What this does not mean

These findings are important, and they need to be read carefully.

• An association is not destiny. These studies describe groups of people. A higher average risk says nothing certain about any one person, and because the research is observational, it cannot show that nightmares cause suicidal thoughts.
• The samples differ. Some studies followed people already in hospital; others asked students to fill in questionnaires online. Much of the evidence relies on self-report.
• Nobody yet knows why. The studies show that nightmares and suicidal thoughts are linked, but they cannot yet explain the link.

What the findings do mean is practical. Nightmares are worth asking about, and worth mentioning. Disturbed sleep is listed among the warning signs of suicide in US public health guidance, and the 2015 review describes sleep disturbance as a potentially modifiable risk factor: something that can be changed.^[4]

Nightmares are treatable

This is where there is real hope. The American Academy of Sleep Medicine recommends imagery rehearsal therapy for nightmare disorder and for nightmares linked to PTSD, and lists several other options that may be used.^[5] You can read how imagery rehearsal works, and when bad dreams become a condition.

Whether treating nightmares also eases suicidal thoughts is being studied. In one small open trial, 20 adults staying in a psychiatric hospital took part in four group sessions of imagery rehearsal over three weeks. Their nightmares became less frequent and less intense, their sleep improved, and so did several other measures, including suicidal thoughts.^[6] There was no control group, and everyone was also receiving hospital treatment, so the study cannot show that imagery rehearsal caused the change. Larger trials are needed. Still, the 2015 review sees sleep as a real opportunity for prevention, precisely because it is a risk factor that can be treated.^[4]

What you can do tonight

1. If you feel unsafe, call now. Your local emergency number, or a crisis line. You do not have to be sure it is “bad enough”.
2. Tell one person. A partner, a friend, a family member. You could say: “My nightmares are getting to me, and I’ve been having dark thoughts. Can you stay with me tonight?”
3. Make your space safer. If you can, put distance between yourself and anything you might use to hurt yourself, or ask someone to help with that.
4. If you wake from a nightmare, keep the light low and warm, breathe out for longer than you breathe in, and remind yourself that it was a dream and you are here, now. Cyclic sighing is one way to do this.
5. Book an appointment. Tell your doctor about both the nightmares and the thoughts. Mentioning both helps them see what you are carrying, and nightmares are something they can help with.

For partners and family

If someone you love has frequent nightmares and seems low, it is all right to ask them directly how they are, including whether they have had thoughts of ending their life. A review of the research found no evidence that asking about suicidal thoughts increases them, and talking about it may even help.^[7] Listen, stay with them, and help them contact a doctor or a crisis line. There is more for partners on our page for partners.

Baku is a wellness app, not a crisis service. If you are in danger, please use the numbers above. For the ordinary hard nights in between, Nightlight is there, and it is free.