Nightmares are positively correlated with and a risk factor for suicidality in psychiatric patients, with some evidence showing an association independent of insomnia and depressive symptoms. Given this linkage, nurses should be aware of the association and integrate an evaluation of nightmares into their assessments of psychiatric patients. Jane Mahoney, PhD, RN, Bethany Sphar, BSN, RN, and Audrey Pyle, BSN, RN, Menninger Clinic, Houston, Texas, USA, systematically reviewed the literature as part of an evidence-based practice approach to understand the association between nightmares and suicide in psychiatric patients.

BACKGROUND

The session opened with a brief primer on studies and theories that have looked at and considered the importance of sleep, and conversely, insomnia on multiple physiologic and psychological functions. Dr Mahoney highlighted data from the Substance Abuse and Mental Health Services Administration (SAMHSA) that now lists significant changes in sleep as one of the top 10 warning signs of suicide [SAMHSA. CMHS-SVP-0126. 2005] and described studies showing a link between sleep disorders and general sleep complaints with greater levels of suicidal ideation, attempted suicides, and deaths by suicides along with greater levels of depression.

Dr Mahoney discussed several theories of why poor sleep quality is linked to suicide and cited one study that showed that suicidal patients averaged more time in rapid eye movement (REM) sleep compared with nonsuicidal people [Agargun MY, Cartwright R. Psychiatry Res. 2003]. Properties of REM, she said, include vivid dreams with high emotional content as well as a dramatic increase in sympathetic activity that leads to increases in heart rate, blood pressure, and dysregulation of body temperature.

Citing studies from the 1990s showing an association between nightmares and psychological problems in patients with depressive or anxiety disorders or both, she highlighted that until recently only a few studies have looked at whether nightmares are linked to suicidal ideation and behaviors independent of psychiatric illness.

The current study was undertaken to address how nightmares influence suicidality in people with psychiatric symptoms. To answer this primary question, the investigators used an evidence-based practice approach to first collect and evaluate published studies that addressed this primary question. From this systematic review of the literature, they selected 7 key studies that were the most valid and applicable to their project.

WHAT THE EVIDENCE SHOWED

The studies were culled from a number of databases, including the Cochrane Library, CINAHL, PubMed, and the National Guidelines Clearinghouse. Table 1 lists the key findings of the studies.

TREATMENT OPTIONS

Citing evidence from a best practice guide for treatment of nightmare disorder in adults [Aurora RN et al. J Clin Sleep Med. 2010], the researchers provided a brief overview of the pharmacologic and nonpharmacologic treatment options for nightmares in adults (Table 2).

APPLYING THE RESEARCH TO DAILY PRACTICE

Along with providing a review of the evidence, the investigators discussed ways to apply the research to daily practice. Ms Pyle highlighted the imperative to educate nurses on the significance of the link between suicidality and nightmares, and stressed the importance for nurses to consistently assess patients for the severity, frequency, and duration of nightmares.

She also highlighted the need for nurses to integrate the assessment of nightmares in the treatment plan for each patient and to act as a team advocate for addressing nightmares in a comprehensive manner.

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The editors would like to thank the many members of the APNA 2014 presenting faculty who generously gave their time to ensure the accuracy and quality of the articles in this publication.