Psychiatry Research 257 (2017) 242–248

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Adolescent insomnia, suicide risk, and the interpersonal theory of suicide MARK
a,b a,b a,b b a
Lucas Zullo , Sarah Horton , Michael Eaddy , Jessica King , Jennifer Hughes ,
⁎
Andrew Diedericha,b, Betsy Kennarda,b, Graham Emsliea,b, Sunita Stewarta,b,
a
Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX, USA
b
Department of Psychiatry, Children's Medical Center of Dallas, Dallas, TX, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Although insomnia has been repeatedly linked with suicide ideation, the reason for the linkage is not clear. The
Suicide Interpersonal Psychological Theory of Suicide (IPTS) proposes that three core variables (thwarted belongingness,
Inpatient perceived burdensomeness, and acquired capability) are the final common pathway for all risk factors for suicide
Clinical sample ideation and behavior. Recent research has suggested that insomnia may be associated with suicide ideation
independently of the IPTS. We examined cross-sectional data from 151 psychiatric inpatients (ages 12–17) to
determine if the association between insomnia symptoms and a continuous measure of suicide risk (measured as
increasingly severe ideation and plan) was explained by the framework of the IPTS. When all IPTS variables and
depressive symptoms were included in the model, insomnia symptoms did not contribute unique variance to
suicide risk. Perceived burdensomeness and depressive symptoms were found to explain the relationship be-
tween insomnia symptoms and suicide risk. Our findings suggest that improved sleep might reduce suicide risk,
that management of interpersonal need cognitions might reduce risk in the presence of insomnia symptoms, and
reinforce the independent role of depressive symptoms in suicide risk in clinical samples of adolescents.

1. Introduction Kann et al., 2014). There are also a multitude of neurobiological

Suicide is a significant problem in the United States, especially
among youth, and is currently the second leading cause of death among
individuals 15–24 years old (CDC, 2014). Recent scholarship has un-
derscored the need for theoretical models of suicide to better explain
what leads to attempts (Prinstein, 2008). This paper will present an
examination of the relationship between insomnia symptoms and con-
current suicide risk in an inpatient adolescent sample, utilizing the
framework of the Interpersonal Psychological Theory of Suicide
(IPTS).1
Suicide phenomena range from passive thoughts about death
through death by suicide and terminology is not consistent across stu-
dies. As a result, clear specification of the outcome is essential to in-
tegrate findings from different studies. For the present study, the term
suicide risk was treated as a continuous variable, and defined as in-
creasing in severity from nonspecific to active suicide ideation, and
further to a plan for suicide.
Developmental differences in regards to how insomnia symptoms
relate to suicide risk in an adolescent sample are expected due to the
several known factors that vary by age (i.e. diagnosis, presence of
previous attempts, ethnic distribution of ideators) (Crosby et al., 2011;
changes during this developmental stage that affect the processes at
play in suicide ideation such as subcortical limbic systems (related to
processing affective stimuli) and the prefrontal cortex (impulse control)
(Casey et al., 2008). Due to these differences, it is unclear whether
findings from adult samples would be replicated in adolescent samples.
Insomnia has been tied to suicide ideation, attempt, and death by
suicide with adult samples (Pigeon et al., 2012; Barraclough and Pallis,
1975). Insomnia has also been studied as a suicide-related behavior
with both adults and adolescents, in a variety of settings (Goldstein
et al., 2008; Krakow et al., 2011; Nadorff et al., 2011; McGlinchey et al.,
2016). Goldstein et al. (2008) found a higher prevalence of insomnia
and hypersomnia for the week prior to a suicide attempt among ado-
lescents who died by suicide when compared to a control group. A large
school-based survey (Roberts et al., 2011) found that insomnia and
hypersomnia were correlated with suicide ideation. In a longitudinal
study by Wong et al. (2011), insomnia present between the ages of
12–14 predicted suicide ideation and “self-harm behavior” (including
suicide attempts) at the ages of 15–17.
Several explanations of why insomnia is related to suicide risk have
been offered, such as the notion that being awake during nighttime
hours results in poor decision making (leading to increased suicide

⁎
Correspondence to: 5323 Harry Hines Blvd., Dallas, TX 75390, USA.
E-mail address: Sunita.Stewart@UTSouthwestern.edu (S. Stewart).
1
IPTS = Interpersonal Psychological Theory of Suicide.

http://dx.doi.org/10.1016/j.psychres.2017.07.054
Received 25 March 2017; Received in revised form 1 July 2017; Accepted 29 July 2017
Available online 29 July 2017
0165-1781/ © 2017 Elsevier B.V. All rights reserved.
L. Zullo et al.
ideation and behavior). Individuals coping with insomnia are at in-
creased risk of experiencing a major depressive episode; depression is a
well-recognized risk factor for suicide ideation (Perlis et al., 2015,
2006). Perlis et al. (2015) described several mechanisms by which sleep
may influence suicide ideation and attempts, including “circadian,
psychosocial, and neuro-cognitive explanations of risk” that contribute
to impaired executive function, thereby making an attempt more likely.
There is also evidence that insomnia constitutes a state of increased
arousal, placing it within a category of behaviors and symptoms (such
as agitation and restlessness), which are believed to increase the risk of
a suicide attempt (Hochard et al., 2016). Weis et al. (2015) reported
that depressive symptoms and rumination explained the relationship
between insomnia and suicide ideation, suggesting that there are cog-
nitive as well as biological factors that might explain the full role of
sleep in suicide ideation.
The Interpersonal Psychological Theory of Suicide (IPTS; Joiner,
2005) offers a framework to explain the association between risk factors
and suicide related outcomes. The theory posits that there are three
main constructs that explain suicide ideation and attempt: thwarted
belongingness, perceived burdensomeness, and acquired capability.
Thwarted belongingness is characterized by having a feeling of being
unable to connect to others. Perceived burdensomeness occurs when an
individual believes that they are burdening others and that it would be
more helpful for them to end their life than continue living. Acquired
capability is the result of a habituation to pain and a decreased fear of
death, which is necessary to overcome biological warnings protecting
against suicide (Van Orden et al., 2010). The theory proposes that a
suicide attempt will occur only when there is simultaneous elevation of
all three constructs, with perceived burdensomeness and thwarted be-
longingness contributing to suicide ideation and acquired capability
translating ideation to attempt (Joiner et al., 2009). An important value
of the framework is that it has the potential to gather and explain the
mechanisms of disparate risk factors under its central constructs. The
IPTS proposes that the three constructs serve as final pathways in the
development of risk for suicide attempts. Although the IPTS has been
most widely studied in adult samples, there is a growing evidence base
for its applicability in adolescents (Horton et al., 2015; Stewart et al.,
2015).
There are mixed findings from past studies regarding insomnia's
independent association with suicide ideation and attempts in the
presence of IPTS variables. A recent study by Nadorff et al. (2014)
found that in a young adult sample of undergraduate students, insomnia
was associated with perceived burdensomeness and thwarted belong-
ingness. However, overall findings supported the notion that the IPTS
may not fully explain the link to suicide attempts as there were still
main effects between insomnia and past suicide attempts even after
controlling for depressive symptoms, thwarted belongingness, and
perceived burdensomeness. Golding et al. (2015) aimed to replicate
Nadorff's study in an older adult community sample. The results in-
dicated that insomnia was not significantly associated with an index of
suicide risk (defined as past ideation and attempts along with thoughts
of future attempts) after accounting for IPTS variables. Hochard et al.
(2016) evaluated the relationship between acquired capability, in-
somnia, and suicide ideation in an adult community sample. The results
indicated that insomnia showed no main effect in its relationship with
ideation. However, insomnia did interact with acquired capability
(assessed with the modified Deliberate Self-Harm Inventory) to predict
higher levels of suicide ideation. Another study (Chu et al., 2016) de-
monstrated that higher levels of insomnia were associated with higher
levels of thwarted belongingness and suicide ideation in several clinical
and community adult samples. Results from this study indicated that
there was no direct effect of insomnia on suicide ideation after con-
trolling for thwarted belongingness. Other IPTS variables were not
considered in this paper.
The gaps in the current literature indicate a need for further studies
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Psychiatry Research 257 (2017) 242–248
on insomnia and the IPTS utilizing adolescent clinical populations.
While the IPTS has rapidly growing empirical support, it is unclear how
the relationship between insomnia symptoms and suicide risk among
adolescents fits into this framework. Although there is mixed evidence
to this end, Nadorff et al. (2014) young adult research suggests that
insomnia's relationship with past suicide attempts is independent of the
IPTS, challenging the IPTS framework.
Tests of the IPTS have not always controlled for depressive symp-
toms. It has been suggested that the IPTS as a new theory has value only
in that it accounts for a phenomenon better than existing explanations
(Stewart et al., 2015), and depression is the most widely held ex-
planation for suicide ideation and attempts. Unless depression is con-
trolled, any findings of direct associations between IPTS variables and
suicide ideation might simply represent the result of their association
more generally with depression and not specifically with suicide idea-
tion. Additionally, recent evidence with clinical samples of adolescents
suggests that depressive symptoms contribute to risk independent of the
IPTS constructs (Horton et al., 2015; King et al., 2017; Miller et al.,
2015). If depression as an independent variable maintains an associa-
tion to suicide ideation in the presence of the core IPTS variables, the
possibility is supported for a parallel mediation, which threatens the
final common pathway clause and therefore the theory.
The overall goal of this study was to examine the association of
insomnia symptoms with suicide risk within the framework of the IPTS
in an adolescent clinical sample. Our first aim was to examine the
concurrent association between insomnia symptoms and suicide risk.
We hypothesized that insomnia symptoms and suicide risk would be
associated. Our second aim was to examine if IPTS variables explain the
association between insomnia symptoms and risk. Acquired capability
is proposed to be specific to suicide attempts (Joiner, 2005) whereas
our study is limited to suicide ideation. However, there is recent evi-
dence that acquired capability contributes both to insomnia (Hochard
et al., 2016), and to suicide ideation in a clinical sample (Rogers et al.,
2016), and so was included among our explanatory variables. We also
tested for the interaction between perceived burdensomeness and
thwarted belongingness as an independent variable, which has been
proposed in the IPTS as contributing to increased levels of suicide
ideation (Van Orden et al., 2010). Given the mixed evidence we had no
basis to predict direct versus indirect relationships between insomnia
symptoms and suicide risk in the presence of IPTS variables.
In addition to controlling for depressive symptoms, we examined
their independent prediction to risk. In light of recent findings (King
et al., 2017) supporting a parallel mediation model, we anticipated that
depressive symptoms would contribute to suicide ideation independent
of the IPTS variables.
2. Methods
2.1. Participants
153 adolescents were recruited from the Inpatient Psychiatry Unit at
Children's Medical Center (CMC), as part of a larger study on risk fac-
tors associated with suicide ideation and attempt. This pediatric in-
patient psychiatry service provides brief hospitalization and stabiliza-
tion to acutely ill children and adolescents. This study was approved by
the university's Institutional Review Board. Written informed consent
and assent were obtained prior to initiation of study procedures.
Inclusion criteria were that participants were between the ages of 12
and 17 and were enrolled in school. Exclusion criteria included: in-
tellectual disability, active psychosis, neurological disorders, acute
substance/alcohol intoxication, and if participant was delayed more
than two years from an age-appropriate grade level. A consort diagram
is provided as Fig. 1. The 151 participants who had complete data on all
variables were the sample used for all analyses.
L. Zullo et al.
2.2. Measures
In addition to the measures listed below, each study participant also
received an interview to determine history of suicide ideation and at-
tempts. This information was then reconciled with the data gathered
during the admission intake and used as the basis for information on
Table 1.
2.2.1. Perceived burdensomeness and thwarted belongingness
Perceived burdensomeness and thwarted belongingness were as-
sessed using the Interpersonal Needs Questionnaire (INQ, Van Orden
et al., 2012.) The 15-item INQ consists of nine items evaluating
thwarted belongingness and six items measuring perceived burden-
someness. The INQ is scored on a Likert Scale from 1 (“not at all true of
me”) to 7 (“very true for me); higher ratings indicate greater levels of
perceived burdensomeness or thwarted belongingness. Horton et al.
(2015) have provided initial evidence for internal reliability and con-
struct validity. In our sample the Cronbach's alphas (α) were .93 and
.88 for perceived burdensomeness and thwarted belongingness re-
spectively.
2.2.2. Acquired capability
Acquired capability was measured using the Acquired Capability for
Suicide Scale-Fearlessness About Death (ACSS-FAD) (Ribeiro et al.,
2014). This consists of seven items from the original 20-item ques-
tionnaire that is meant to measure a participant's fearlessness about
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Psychiatry Research 257 (2017) 242–248
Fig. 1. Consort diagram.
death. Consistent with earlier reports (Horton et al., 2015), internal
consistency was found to be good in our sample (α = .85).
2.2.3. Depressive symptoms
The Quick Inventory of Depressive Symptomatology – Adolescent
Version Self-Report (QIDS-A-SR-17; Rush et al., 2006, 2003) was used
to assess depressive symptoms. This 17-item self-report questionnaire
records the severity of the symptoms of Major Depressive Disorder in
the past week. The item targeting suicidal thoughts was not included
because suicide risk is the primary dependent variable for this study.
Previous research has demonstrated that when covarying suicide
ideation out of a measure of depression, the remaining symptoms still
retained their significant relationships with constructs associated with
depression (Rogers et al., 2016), supporting the idea that removing the
suicide ideation item does not fundamentally alter the measurement of
depressive symptoms. The sleep item was retained in order to preserve
the integrity of the scale though post-hoc analyses were run after re-
moving both suicide and sleep items to explore the effects on the out-
comes. The QIDS-SR has been demonstrated to have good internal
consistency in previous studies (Bernstein et al., 2010) and the relia-
bility was good in our sample as well (α = .80). Mean scores were used
for analysis in order to offset the effects of a missing item.
2.2.4. Insomnia symptoms
The Insomnia Severity Index (ISI; Bastien et al., 2001) was used to
measure symptoms of insomnia for the past two weeks. It is a 7 item
L. Zullo et al. Psychiatry Research 257 (2017) 242–248

Table 1 risk (Trivedi et al., 2011). The scale shows good discriminant validity,
Sample demographics and clinical characteristics (N = 151). with highest associations with the Positive and Negative Suicide Idea-
tion Inventory and the Hamilton Depression Rating Scale, and weak
Variables Mean or N (percent)
associations with a measure of medical comorbidity in a clinical sample
Age 15.05 (1.4) of adults (Trivedi et al., 2011). This sub-scale has been previously used
Admitting diagnosis with clinical adolescent samples, and shows a relationship to depressive
MDD 121 (80.1%)
symptoms and IPTS variables both in cross-section and over time (King
Mood disorder NOS 9 (6%)
OCD 1 (.7%) et al., 2017) providing initial evidence for construct validity.
PTSD 1 (.7%) The sub-scale of this measure used (Active Suicidal Thoughts and
Anorexia nervosa 1 (.7%) Plans) consists of three items that are combined to serve as the outcome
DMDD 2 (1.3%) measure of suicide risk. The three items are: 1) I have had thoughts of
Anxiety disorder NOS 2 (1.3%)
killing myself; 2) I have thoughts about how I might kill myself; and 3) I
Bipolar disorder 2 (1.3%)
Depression NOS 12 (7.9%) have a plan to kill myself. The items are scored on a five point Likert
Girls 124 (82.1%) scale from 0 (“strongly disagree”) to 4 (“strongly agree”). The internal
Boys 27 (17.9%) consistency was found to be excellent in our sample (α=.91).
Ethnicity
Hispanic 18 (11.9%)
Non-hispanic 133 (88.1%) 2.3. Data analysis
Race
Caucasian 126 (83.4%)
African American 14 (9.3%)
One participant was missing two items on the INQ and the items
Asian 3 (2%) were imputed with the mean in computing the total. Another partici-
Other 8 (5.3%) pant was missing an item on the QIDS but since the scale uses a max-
Lifetime suicidal ideation imum score from several items in the scoring procedures, and received
None 6 (4%)
the highest possible score within that group, no adjustments were ne-
Death wishes 9 (6%)
Active ideation 70 (46.3%) cessary. Thus, all participants had complete data on all aggregate
Plan 66 (43.7%) measures. Inspection of the data revealed that there were no outliers.
Lifetime attempt Several variables were not normally distributed. For this reason, the
None 55 (36.4%) first hypothesis proposing an association between insomnia symptoms
1 55 (36.4%)
≥2 41 (27.2%)
and suicide risk was examined with the Spearman's rank correlation
Suicide attempt past two weeks 79 (52.3%) coefficient. Analyses examining the second aim used bootstrapping,
ISI scores ≥ 15 (clinical cutoff) 53 (35.1%) thereby accommodating for the non-normal distribution of the vari-
ables (Ong, 2014).
Note. MDD = major depressive disorder; NOS = not otherwise specified; ISI =
A PROCESS analysis was conducted in SPSS 23, testing a model that
Insomnia Severity Index; OCD = obsessive compulsive disorder; PTSD = post-trau-
specified insomnia symptoms as the predictor, suicide risk as the out-
matic stress disorder; DMDD = disruptive mood dysregulation disorder.
come, and perceived burdensomeness, thwarted belongingness, ac-
quired capability, the interaction between perceived burdensomeness
self-report questionnaire using a Likert Scale ranging from 0 (“none”) to
and thwarted belongingness, and depressive symptoms as explanatory
4 (very severe”) to assess severity of sleep difficulty. The scores from
variables. Age and sex were covariates.
each item are summed for a total score that indicates whether a clinical
level of insomnia is present (scores greater than or equal to 15). Internal
consistency was good in our sample (α = .87). 3. Results

2.2.5. Suicide risk
The Concise Health Risk Tracking scale Self-Report (CHRT SR;
Trivedi et al., 2011) was used to assess suicide risk. In an adult clinical
sample, this scale has shown excellent goodness of fit (.99) for the
three-factor solution, consistent with the authors' design. The three
factors have been used as sub-scales, and internal consistency reliability
for all scales and the total score was reported as good to excellent (α =
.77–.92) in a clinical adolescent sample (Mayes et al., 2017). A sub-
scale of this measure (Active Suicidal Thoughts and Plans) consists of
three items that are combined to serve as a measure of imminent suicide
Table 1 presents sample demographics and clinical characteristics.
The sample was largely female (82.1%) and Caucasian (83.4%), with a
diagnosis of Major Depressive Disorder (80.1%). A large proportion had
made a suicide attempt within the past two weeks (52.3%), as would be
expected given the restricted criteria for admission into a higher level of
care. Approximately a third of the sample (35.1%) reported scores at or
higher than the cut-off for clinical levels of insomnia symptoms
(score > 15).
Insomnia symptoms, depressive symptoms, perceived burdensome-
ness, thwarted belongingness, and acquired capability were all

Table 2
Intercorrelations among variablesa (N = 151).

Variable Suicide risk Insomnia symptoms Depressive symptomsb PB TB AC M (SD)

1. Suicide risk __ __ __ __ __ __ 5.46 (4.17)

2. Insomnia symptoms .34** __ __ __ __ __ 11.88 (6.58)
3. Depressive symptomsb .53** .70** __ __ __ __ 1.56 (.65)
4. PB .56** .44** .61** __ __ __ 20.23 (10.77)
5. TB .50** .44** .60** .62** __ __ 33.99 (13.48)
6. AC .35** .17* .22** .26** .27** __ 2.26 (1.09)

Note. PB = perceived burdensomeness; TB = thwarted belongingness; AC = acquired capability.

** p < .01.
* p < .05.
a
Spearman Rank Correlation Coefficients.
b
Calculated using the Quick Inventory of Depressive Symptomatology (QIDS-SR-A) minus the suicide item.

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number of individuals who have a history of suicide attempts, the re-

lationship of acquired capability to current risk may simply reflect this
history, as individuals who have made a suicide attempt are vulnerable
to another attempt and therefore the development of severe ideation. As
Hochard et al. (2016) found an interaction between symptoms of in-
somnia and acquired capability in predicting suicide ideation, we ex-
amined our data in post-hoc exploratory analyses to determine whether
we would have similar findings. This interaction was not found to be
significant in its direct effect on suicide risk in our study (t = − .28,
p > .05).
In contrast to findings with young adults in Nadorff et al. (2014)
study, insomnia symptoms were not directly associated with suicide
risk after controlling for depression and the IPTS variables in our
clinical adolescent sample. However, the final common pathway aspect
of the IPTS was challenged by the direct effect of depressive symptoms.
A potential reason for the discrepancies between the findings from
Nadorff et al. (2014) and this study is that the role of the IPTS variables
might be moderated by the severity of distress present in our inpatient
sample. Specifically, both insomnia symptoms and IPTS variables could
be more elevated in samples (such as ours) experiencing clinically
Fig. 2. Paths from insomnia symptoms to suicide risk. Significant paths (p < .05) are
shown in bold. Age and sex were covaried. The interaction between perceived burden-
significant distress and the unique role of insomnia symptoms might
someness and thwarted belongingness was included in the model but had no direct re- become negligible. Nadorff et al. (2014) used a community sample of
lationships with insomnia symptoms or suicide risk. aDepressive symptoms were calcu- undergraduate students with low depressive symptoms. In that context,
lated using the Quick Inventory of Depressive Symptomatology (QIDS-A-SR-17) without the role of insomnia symptoms in risk may stand out more clearly.
the suicide item. *p < .1 **p < .05 ***p < .01 ****p < .001 Chu et al. (2016) found that thwarted belongingness accounted for
the relationship between insomnia and suicide risk. In our study,
Table 3 thwarted belongingness was not a significant factor in predicting risk. It
Indirect effect of insomnia symptoms on suicide risk. should be noted that Chu et al. (2016) did not include perceived bur-
densomeness or acquired capability in their study, so it is possible that
Effect SE LLCI ULCI
only when measures of interpersonal needs are included together that
Total .25 .06 .14 .36 thwarted belongingness becomes a non-significant contributor.
Perceived burdensomeness .07 .03 .02 .15 The independent importance of depressive symptoms within the
Thwarted belongingness .04 .03 -.003 .1 framework of the IPTS among this specific population is consistent with
Acquired capability .02 .01 -.002 .05
the literature. A study by Miller et al. (2015) with adolescents enrolled
PBxTB .0004 .005 -.007 .02
Depressive symptoms .12 .05 .01 .22 in a partial hospitalization program demonstrated that thwarted be-
longingness acted through depressive symptoms when predicting future
suicide risk. Horton et al. (2015) also found that depression severity
significantly correlated with suicide risk (Table 2, all p's < .01). The was independently associated with recent intent, in the presence of
results of the PROCESS analysis examining the direct and indirect ef- IPTS variables. Additional data examining change in risk over the
fects of insomnia symptoms on risk are presented in Fig. 2 and Table 3 course of intensive outpatient treatment for suicide ideation and at-
respectively. There was no evidence for a direct relationship between tempts also suggested that both change in IPTS variables and in de-
insomnia symptoms and suicide risk (t = − .74, p > .05); however, pressive symptoms were directly associated with change in risk (King
insomnia symptoms had a significant total indirect effect on suicide risk et al., 2017).
(indirect effect = .25, 95% confidence interval = .14–.35). As would Our findings are also in line with the literature that emphasizes the
be predicted by the IPTS and consistent with our hypothesis, in the strength of perceived burdensomeness over thwarted belongingness
presence of IPTS variables the relationship of insomnia symptoms and (Hill and Pettit, 2014; Ma et al., 2016) when both are included in ex-
suicide risk became nonsignificant, and the relationship of insomnia plaining suicide risk. King et al. (2017) examined patients before and
symptoms to suicide risk was indirect through the association with after intensive outpatient treatment for suicide ideation and attempts.
perceived burdensomeness. Although insomnia symptoms were also They found that change in perceived burdensomeness but not thwarted
associated with thwarted belongingness, the latter variable had only a belongingness was associated with change in suicide ideation when
marginal association with on suicide risk in this model (t = 1.91, p = analyzing all three IPTS variables in a sample of clinical adolescents. In
.06). Acquired capability was not an agent of the relationship between addition, Horton et al. (2015) found that although both interpersonal
insomnia symptoms and suicide risk as insomnia symptoms were not variables contributed to suicide risk, of the two, perceived burden-
associated with acquired capability. Two findings were contrary to someness’ relationship was stronger and explained more variance,
expectations derived from the IPTS. First, acquired capability was as- consistent with findings in other samples (e.g., Hill and Pettit, 2014; Ma
sociated with suicide risk. Second, as hypothesized, depressive symp- et al., 2016). Rumination might be the mechanism by which insomnia,
toms were also directly associated with suicide risk, and also explained interpersonal variables and suicide risk are linked. Several investigators
the relationship between symptoms of insomnia and suicide risk. The (e.g., Takano et al., 2012; Weiss et al., 2015) have suggested that di-
interaction between perceived burdensomeness and thwarted belong- minished sleep is associated with rumination and repetitive negative
ingness was not found to be significant. cognitions. Rumination accompanying insomnia might enhance
thoughts about being a burden or being left out of a reciprocal re-
4. Discussion lationship, which then would increase risk for suicidal behavior.

The finding of an association between acquired capability and risk is 4.1. Limitations
consistent with previous studies (Hochard et al., 2016; Rogers et al.,
2016), but not consistent with the IPTS. Because this sample includes a This study's cross-sectional design precluded examination of the

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L. Zullo et al.
temporal relationship of insomnia symptoms and suicide risk. This
limits the conclusions drawn from this study to a single time-point, and
we cannot say whether changes in insomnia symptoms are accom-
panied by changes in risk. Furthermore, we acknowledge that the cross-
sectional analyses can overestimate the relationships in a model, and
these initial results should be conservatively interpreted and confirmed
in a longitudinal design. The demographics of our participants were not
entirely representative of clinical samples as the majority was
Caucasian, female, and at an acute level of care with high levels of
distress. Research over the longitudinal span and with more diverse
samples is needed before findings can be generalized to a broad range
of youth.
The findings from this study are limited to insomnia and are not
generalizable to related sleep disorders such as hypersomnia. Sleep
patterns in the hospital setting may not be representative of patterns
that preceded hospitalization. Given the acute nature of the hospitali-
zation, virtually every child received some kind of psychotropic medi-
cation to relieve symptoms, making it difficult to examine whether
some of these youth might have reported more insomnia symptoms in
the absence of medication. All data were collected by self-report only;
polysomnography may provide different results. Insomnia symptoms
were treated as a single condition. Refinements that separately examine
for example early morning awakening and difficulty falling asleep
might produce different results. Prospective studies that sample parti-
cipants at different levels of care with and without medications that
make an impact on sleep patterns, and using both objective, subjective,
and refined measures of sleep could address these concerns.
4.2. Conclusions and future directions
The direct relationship between depressive symptoms and risk in the
presence of IPTS constructs challenges the final common pathway
clause of the theory. Interpersonal needs (thwarted belongingness and
perceived burdensomeness) and depressive symptoms each explain
different variance in suicide risk. Investigations that clarify the specific
contributions from depressive symptoms that are independent from
IPTS factors may improve our understanding of risk.
Future longitudinal study of the relationship between symptoms of
insomnia with suicide attempts in the context of the IPTS in adolescent
samples is needed. The literature suggesting that perceived burden-
someness is a particularly strong predictor of risk continues to expand
with the addition of our study. It would also be worthwhile to explore
whether perceived burdensomeness and risk can be managed through
improved sleep.
This study contributes to the literature by examining symptoms of
insomnia as a risk factor for adolescent suicide risk in the framework of
the IPTS, using a clinical sample, and including depressive symptoms
both as a control variable and as a possible explanation of the re-
lationship between insomnia symptoms and suicide ideation. Our
findings suggest that improved sleep might reduce suicide risk, that
management of interpersonal need cognitions might reduce risk in the
presence of insomnia symptoms, and reinforces the role of depressive
symptoms in elevated suicide risk in clinical samples of adolescents.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Ethical approval
All procedures performed in studies involving human participants
were in accordance with the ethical standards of the institutional and/
or national research committee and with the 1964 Helsinki declaration
and its later amendments or comparable ethical standards. This study
was approved by the university's Institutional Review Board.
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Psychiatry Research 257 (2017) 242–248
Informed consent
Informed consent was obtained from all individual participants in-
cluded in the study.
Potential conflicts of interest
Jennifer Hughes:
• American Psychological Association (APA) Division 53, Society for
Clinical Child and Adolescent Psychology (SCCAP; 2013–2015):
Board Member, paid travel for APA Convention in 2013 and 2014.
• California Institute for Mental Health (CIMH; now California
Institute for Behavioral Health Solutions), Sacramento, CA (2014):
Paid consultant providing California county trainings in CBT for
youth depression.
• EDU Health Consulting, LLC, Davis, CA (2014–2015): Paid con-
sultant providing California county trainings in CBT for youth de-
pression.
• Cal Lutheran (2014–2016): Honorarium for guest lecturing on youth
suicide prevention to doctoral students – not included for UTSW as
educational institution.
• Southern California Society of Child and Adolescent Psychiatry (01/
26/2014): Honorarium for lecture on child and adolescent DBT.
• Guilford Press (2016 – ongoing): Published Kennard, B.D., Hughes,
J.L., & Foxwell, A.F. (2016). CBT for Depression in Children and
Adolescents: A Guide to Relapse Prevention. New York, NY: Guilford
Press.
• Dallas Psychological Association (DPA; 2015–2017): Board Member,
unpaid
• Association for Behavioral and Cognitive Therapies (ABCT) Child
and Adolescent Depression Special Interest Group (2017–2019):
Chair, unpaid.
Betsy Kennard:
Grant funding
“Brief Intervention for Suicide Risk Reduction in High Risk
Adolescents”; collaboration with U. of Pittsburgh, 3/01/2014–02/28/
2017. NIMH R34 MH100375-01.
Consultant and CBT for Suicide Prevention (CBT-SP) Trainer: Zero
Suicides in Texas (ZEST) initiative. Department of State Health Services
{DSHS No.] (eff. 10/1/15–9/30/16); PI: Molly Lopez.
“Developing and Implementing an Adolescent Suicide Prevention
Program in a Community Mental Health Setting”; 8/01/2016–7/31/
2018. UT Southwestern Community-Based Pilot Research Grants;
$75,000.
Protocol Vice Chair: IMPAACT 2002 (PI: Brown).
“Combined Cognitive Behavioral Therapy and a Medication
Management Algorithm for Treatment of Depression among Youth
Living with HIV in the United States”, International Maternal Pediatric
Adolescent AIDS Clinical Trials Network (IMPAACT; 11/01/2016–10/
31/2021).
Trustee, Jerry M. Lewis, MD Research Foundation
Honoraria
Kennard, B. Keeping kids well at home and at school: Relapse pre-
vention cognitive behavioral therapy for youth with depression; Invited
Workshop, 49th Banff International Conference on Behavioral Sciences,
March 2017.
Kennard, B. Relapse prevention cognitive behavioral therapy for
youth with depression; Research outcomes, Invited plenary address,
49th Banff International Conference on Behavioral Sciences, March
2017.
Graham Emslie:
Research
Duke University (Pfizer)
Forest Research Institute, Inc. (partner of Merck KgaA, subsidiary of
L. Zullo et al.
Allergan)
Consultant
Allergan
Alkermes
INC Research Inc.
Lundbeck
NCS Pearson
Neuronetics
Otsuka
Pfizer
Texas Department of State Health Services
Sunita Stewart:
UT Southwestern Community-Based Pilot Research Grants
Developing and Implementing and Adolescent Suicide Prevention
Program in a Community Mental Health Setting (PI: B. Kennard)
Co-Investigator: 8/2016–7/2018
Health Care and Promotion Fund
A psychological intervention to enhance resilience in Mainland new
immigrants to Hong Kong. (PI: NX Yu)
Co-investigator, 6/16–11/17
Children's Clinical Research Advisory Committee
Intensive Education in a Residential Camp Setting for Families of
Youth Children with Type 1 Diabetes: a Pilot Study (PI: P. White)
Co-investigator, 7/14–6/16
Hong Kong Jockey Club Charities Trust
The Family Project II (PI: TH Lam)
Co-investigator, 7/14–6/17
Hong Kong Jockey Club Charities Trust
The Family Project (PI: TH Lam)
Co-investigator and PI of the Intervention Arm, 11/07–6/14
All other authors declare that they have no conflicts of interest.
Acknowledgement
We would like to thank the inpatient medical and psychosocial
teams at Children's Medical Center for their support for the collection of
data used in this study. All authors contributed to article preparation
and have approved the final article.
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