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Is Insomnia Associated With Suicidality in Stroke?

      Abstract

      Tang W-K, Lu J-Y, Liang H, Chan T-T, Mok V, Ungvari GS, Wong K-S. Is insomnia associated with suicidality in stroke?

      Objective

      To evaluate the relationship between insomnia and suicidality (SI) in Chinese patients with first or recurrent stroke.

      Design

      Cross-sectional survey.

      Setting

      Acute stroke unit of a general hospital.

      Participants

      Patients (N=787) with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong.

      Interventions

      Not applicable.

      Main Outcome Measures

      Suicidality (SI) was assessed with the Geriatric Mental State Examination at 3 months after subjects' index stroke. Insomnia symptoms were evaluated with a standard insomnia questionnaire. The association between insomnia symptoms and SI was examined and adjusted for potential confounders, including age, sex, marital status, previous stroke, depression, fatigue, Mini-Mental State Examination score, and neurologic deficits measured with the National Institutes of Health Stroke Scale.

      Results

      Eighty-seven patients (11.1%) were found to have SI (SI group). Frequent awakening was significantly more common in the SI group than in the non-SI group and remained a significant predictor of SI in forward logistic regression analysis (odds ratio, 1.7) after adjusting for possible confounders.

      Conclusions

      These findings should alert clinicians to the potential danger of insomnia and the importance of its early identification and treatment in stroke patients.

      Key Words

      List of Abbreviations:

      DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition), FSS (Fatigue Severity Scale), MMSE (Mini-Mental State Examination), OR (odds ratio), SI (suicidality)
      BOTH INSOMNIA AND SUICIDALITY (SI) have been observed in stroke survivors,
      • Palomäki H.
      • Berg A.
      • Meririnne E.
      • et al.
      Complaints of poststroke insomnia and its treatment with mianserin.
      • Pohjasvaara T.
      • Vataja R.
      • Leppavuori A.
      • Kaste M.
      • Erkinjuntti T.
      Suicidal ideas in stroke patients 3 and 15 months after stroke.
      with the frequency of insomnia in these patients ranging from 68% on admission,
      • Palomäki H.
      • Berg A.
      • Meririnne E.
      • et al.
      Complaints of poststroke insomnia and its treatment with mianserin.
      37% to 57% at 3 to 4 months' follow-up,
      • Leppävuori A.
      • Pohjasvaara T.
      • Vataja R.
      • Kaste M.
      • Erkinjuntti T.
      Insomnia in ischemic stroke patients.
      • Chen Y.K.
      • Lu J.Y.
      • Mok V.C.
      • et al.
      Clinical and radiologic correlates of insomnia symptoms in ischemic stroke patients.
      to 49% at 18-month follow-up.
      • Palomäki H.
      • Berg A.
      • Meririnne E.
      • et al.
      Complaints of poststroke insomnia and its treatment with mianserin.
      Insomnia subsumes difficulties in initiating or maintaining sleep, or early awakening with the inability to fall asleep again.
      • Estivill E.
      • Bové A.
      • García-Borreguero D.
      • et al.
      Consensus on drug treatment, definition and diagnosis for insomnia.
      As insomnia may affect stroke prognosis and quality of life, it should be taken into consideration in stroke patients' treatment and rehabilitation.
      • Leppävuori A.
      • Pohjasvaara T.
      • Vataja R.
      • Kaste M.
      • Erkinjuntti T.
      Insomnia in ischemic stroke patients.
      However, there is a paucity of studies on insomnia in stroke, and the issue tends to be neglected by health care providers.
      • Eaton W.W.
      • Badawi M.
      • Melton B.
      Prodromes and precursors: epidemiologic data for primary prevention of disorders with slow onset.
      The prevalence of SI in stroke patients ranges from 6.6% in the acute stage,
      • Kishi Y.
      • Kosier J.T.
      • Robinson R.G.
      Suicidal plans in patients with acute stroke.
      to 10% at 3-month follow-up,
      • Pohjasvaara T.
      • Vataja R.
      • Leppavuori A.
      • Kaste M.
      • Erkinjuntti T.
      Suicidal ideas in stroke patients 3 and 15 months after stroke.
      and to 14% at 15-month follow-up.
      • Pohjasvaara T.
      • Vataja R.
      • Leppavuori A.
      • Kaste M.
      • Erkinjuntti T.
      Suicidal ideas in stroke patients 3 and 15 months after stroke.
      The clinical correlates of SI include a younger age,
      • Kishi Y.
      • Kosier J.T.
      • Robinson R.G.
      Suicidal plans in patients with acute stroke.
      unmarried status,
      • Kishi Y.
      • Kosier J.T.
      • Robinson R.G.
      Suicidal plans in patients with acute stroke.
      disabling and recurrent strokes,
      • Pohjasvaara T.
      • Vataja R.
      • Leppavuori A.
      • Kaste M.
      • Erkinjuntti T.
      Suicidal ideas in stroke patients 3 and 15 months after stroke.
      cognitive impairment,
      • Kishi Y.
      • Kosier J.T.
      • Robinson R.G.
      Suicidal plans in patients with acute stroke.
      and depressive symptoms.
      • Pohjasvaara T.
      • Vataja R.
      • Leppavuori A.
      • Kaste M.
      • Erkinjuntti T.
      Suicidal ideas in stroke patients 3 and 15 months after stroke.
      Insomnia is a known risk factor for suicide in the general population
      • Goldstein T.R.
      • Bridge J.A.
      • Brent D.A.
      Sleep disturbance preceding completed suicide in adolescents.
      and is associated with depression
      • Olgiati P.
      • Serretti A.
      • Colombo C.
      Retrospective analysis of psychomotor agitation, hypomanic symptoms, and suicidal ideation in unipolar depression.
      and chronic pain.
      • Tang N.K.
      • Crane C.
      Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links.
      A single case report has suggested that insomnia may also be a risk factor for suicide in stroke,
      • Garden F.H.
      • Garrison S.J.
      • Jain A.
      Assessing suicide risk in stroke patients: review of two cases.
      although systematic examination of the possible impact of insomnia on SI in stroke remains lacking. The aim of the study was thus to evaluate the relationship between insomnia and SI in a large cohort of Chinese stroke patients.

      Methods

      A total of 1363 patients with acute ischemic stroke were screened for entering the study; 339 declined to participate, and another 237 did not meet the study criteria, leaving a final sample of 787 patients admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong from April 2005 to May 2010. The inclusion criteria for the study were (1) aged 18 years or greater, and (2) well-documented first or recurrent acute stroke occurring within the 7 days before admission. Exclusion criteria were (1) transient ischemic attack, cerebral hemorrhage, subdural hematoma, or subarachnoid hemorrhage; (2) history of a central nervous system disease, sleep apnea, or hypothyroidism; (3) severe cognitive impairment, as defined by a Mini-Mental State Examination (MMSE)
      • Chiu H.
      • Lee H.
      • Chung D.
      Reliability and validity of the Cantonese version of the Mini-Mental State Examination: a preliminary study.
      score of less than 20; and (4) aphasia.
      The study protocol was approved by the Clinical Research Ethics Committee of the Chinese University of Hong Kong.
      SI was assessed with the corresponding items in the Geriatric Mental State Examination–Version A13 at 3 months after stroke. SI was diagnosed if the patient “felt suicidal or had wished to be dead sometime in the past month.”
      • Copeland J.R.
      • Dewey M.E.
      • Henderson A.S.
      • et al.
      The Geriatric Mental State (GMS) used in the community: replication studies of the computerized diagnosis AGECAT.
      (p222)
      An insomnia questionnaire
      • Chen Y.K.
      • Lu J.Y.
      • Mok V.C.
      • et al.
      Clinical and radiologic correlates of insomnia symptoms in ischemic stroke patients.
      • Chiu H.F.
      • Leung T.
      • Lam L.C.
      • et al.
      Sleep problems in Chinese elderly in Hong Kong.
      comprising the following items concerning sleep patterns in the past month was administered:
      • 1
        On average, how many hours do you spend asleep per night?
      • 2
        How many hours of sleep per night do you think you need?
      • 3
        Do you have difficulty falling asleep?
      • 4
        Do you experience frequent awakening during the night?
      • 5
        Do you wake up very early in the morning and have difficulty going back to sleep?
      • 6
        Do you consider yourself to have insomnia?
      • 7
        How many days of insomnia per week do you think you have?
      This insomnia questionnaire has previously been used among the Chinese elderly in Hong Kong.
      • Chiu H.F.
      • Leung T.
      • Lam L.C.
      • et al.
      Sleep problems in Chinese elderly in Hong Kong.
      The responses to questions 3 through 6 were coded as “never/rarely,” “sometimes,” and “frequently/all of the time.”
      Fatigue was evaluated using the Fatigue Severity Scale (FSS),
      • Chen S.X.
      • Yu F.M.
      Syndrome differentiation and treatment of post-stroke fatigue.
      • Schwartz J.E.
      • Jandorf L.
      • Krupp L.B.
      The measurement of fatigue: a new instrument.
      which contains 9 items ranked on a 7-point Likert scale (eg, “My motivation is lower when I am fatigued,” “Exercise brings on my fatigue,” and “I am easily fatigued”), with a higher score indicating a greater degree of fatigue. The answers to these items were then averaged, resulting in a global fatigue score. A qualified psychiatrist administered the Chinese version of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)
      • Kam I.W.K.
      Development of the bilingual (Chinese/English) SCID-I (Structured Clinical Interview for DSM-IV Axis I disorder): a study of its reliability and validity in an in-patient population.
      to diagnose depressive disorders (major or minor depression or dysthymia) according to the DSM-IV criteria.
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      All statistical tests were performed using SPSS for Windows.a The demographic and clinical variables of the SI group (age, sex, marital status, previous stroke, concurrent depressive disorder, insomnia symptoms, and FSS, National Institutes of Health Stroke Scale, and MMSE scores) were analyzed with a full model multivariate logistic regression. The odds ratio (OR) of any independent risk factor was interpreted as the risk of subsequent SI when all other risk factors were held constant. The level of significance was set at .05.

      Results

      Eighty-seven patients (11.1%) reported SI (SI group). In the regression model, frequent awakening was a significant predictor of SI in the subsequent forward logistic regression (OR=1.704) after adjusting for possible confounders (table 1).
      Table 1Relationship Between Insomnia and SI in Stroke: Results of Multivariate Analysis
      VariableORCIP
      Insomnia symptoms
       Frequent awakening1.7041.101–2.637.017
       No. of hours spent asleep per nightNANA.091
       No. of days of insomnia in 1 weekNANA.241
       Difficulty in going back to sleepNANA.290
       No. of hours of sleep per night neededNANA.445
       Difficulty in falling asleepNANA.545
       Considered oneself having insomniaNANA.603
      Other variables
       Depression4.5652.315–8.999<.001
       FSS1.3541.098–1.671.005
       NIHSS1.1271.042–1.219.003
       MMSENANA.320
       Previous strokeNANA.348
       FemaleNANA.360
       MarriedNANA.628
       AgeNANA.796
      Abbreviations: CI, confidence interval; NA, not applicable; NIHSS, National Institutes of Health Stroke Scale.

      Discussion

      To our knowledge, this is the first large cross-sectional study to examine the association between insomnia and SI in stroke. The SI frequency in this population group was 11.2%, which is comparable to the figure reported by Pohjasvaara et al.
      • Pohjasvaara T.
      • Vataja R.
      • Leppavuori A.
      • Kaste M.
      • Erkinjuntti T.
      Suicidal ideas in stroke patients 3 and 15 months after stroke.
      The association between insomnia (frequent awakening) and SI was significant and also independent of depression and fatigue. The second part of this finding is particularly important because insomnia is a common symptom of depression,
      • Sunderajan P.
      • Gaynes B.N.
      • Wisniewski S.R.
      • et al.
      Insomnia in patients with depression: a STARlow asteriskD report.
      and depression is also frequent in patients with insomnia.
      • Staner L.
      Comorbidity of insomnia and depression.
      Frequent awakening, or middle insomnia, was associated with SI in the present study. A recent study
      • Nrugham L.
      • Larsson B.
      • Sund A.M.
      Specific depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence.
      also suggested that middle insomnia predicted suicidal acts in adolescence. Another study
      • Agargun M.Y.
      • Besiroglu L.
      • Cilli A.S.
      • et al.
      Nightmares, suicide attempts, and melancholic features in patients with unipolar major depression.
      reported that middle and late insomnia increase the risk of suicidal attempts in adult patients with depression. The reasons for the link between middle insomnia and suicidal ideation remain unclear and warrant further investigation.
      The mechanism underlying the link between insomnia and SI remains to be established. From a biological perspective, SI and sleep disturbance may be interrelated because of partly shared pathophysiology. One possible explanation for this connection is the overlap between lesion location and insomnia and SI in stroke patients. A recent study
      • Chen Y.K.
      • Lu J.Y.
      • Mok V.C.
      • et al.
      Clinical and radiologic correlates of insomnia symptoms in ischemic stroke patients.
      found insomnia in stroke to be associated with acute frontal lobe infarcts. Another study
      • Desmyter S.
      • van Heeringen C.
      • Audenaert K.
      Structural and functional neuroimaging studies of the suicidal brain.
      reported nonstroke suicide victims to have white and gray matter hyperintensities, gray matter volume reduction, and perfusion deficits in the frontal regions associated with a predisposition to suicidal behavior. Postmortem studies have found lower concentrations of serotonin in the brainstems of suicide victims,
      • Jouvet M.
      Sleep and serotonin: an unfinished story.
      and serotonin plays a major role in the regulation of sleep.
      • Jouvet M.
      Sleep and serotonin: an unfinished story.
      Large-scale imaging studies simultaneously measuring lesion location, serotonin receptor function, insomnia, and SI could shed light on this issue.
      There may also be psychological explanations for our findings, such as impaired judgment
      • Liu X.
      Sleep and adolescent suicidal behavior.
      and feelings of hopelessness and a loss of control, constructs that have been associated with suicidal behavior and insomnia.
      • Joiner Jr, T.E.
      • Brown J.
      • Wingate L.R.
      The psychobiology and neurobiology of suicidal behavior.
      For many, sleep is a refuge from the problems of the day. Individuals with severe pain during the day and then finding no respite in sleep may be particularly vulnerable to suicidal ideation as a means of escape.
      Insomnia treatment may include the aggressive treatment of poststroke depression. Treatment options include sedative antidepressants such as mianserin
      • Palomäki H.
      • Berg A.
      • Meririnne E.
      • et al.
      Complaints of poststroke insomnia and its treatment with mianserin.
      and mirtazapine, hypnotics and anxiolytics such as zopiclone and lorazepam,
      • Li Pi Shan R.S.
      • Ashworth N.L.
      Comparison of lorazepam and zopiclone for insomnia in patients with stroke and brain injury: a randomized, crossover, double-blinded trial.
      acupuncture,
      • Lee S.Y.
      • Baek Y.H.
      • Park S.U.
      • et al.
      Intradermal acupuncture on shen-men and nei-kuan acupoints improves insomnia in stroke patients by reducing the sympathetic nervous activity: a randomized clinical trial.
      improving sleep hygiene, and cognitive behavioral techniques.
      • Brown G.K.
      • Ten Have T.
      • Henriques G.R.
      • Xie S.X.
      • Hollander J.E.
      • Beck A.T.
      Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial.
      Cognitive therapy may also be useful in treating SI
      • Brown G.K.
      • Ten Have T.
      • Henriques G.R.
      • Xie S.X.
      • Hollander J.E.
      • Beck A.T.
      Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial.
      and poststroke depression. Prospective clinical trials are warranted to examine whether successful treatment of insomnia may indeed reduce the SI in stroke survivors.
      Other correlates of SI in stroke included depression and the extent of fatigue and neurologic deficits. Indeed, depression is the strongest predictor of SI in the present investigation. A population-based study
      • Forsström E.
      • Hakko H.
      • Nordström T.
      • Räsänen P.
      • Mainio A.
      Suicide in patients with stroke: a population-based study of suicide victims during the years 1988-2007 in northern Finland.
      suggested that depression in stroke patients increased the hazard of suicide up to 2-fold. The association between depression and neurologic deficits and SI in stroke has also been reported by other researchers.
      • Pohjasvaara T.
      • Vataja R.
      • Leppavuori A.
      • Kaste M.
      • Erkinjuntti T.
      Suicidal ideas in stroke patients 3 and 15 months after stroke.
      • Kishi Y.
      • Kosier J.T.
      • Robinson R.G.
      Suicidal plans in patients with acute stroke.

      Study Limitations

      The main limitation of this study is the recruitment of a hospital-based sample. Hence, the findings may not be applicable to patients treated in other settings. In addition, patients in the SI group may only have a “wish to be dead” rather than having a “suicidal plan” or “action,” which represents a milder level of suicidal intent. Nevertheless, in publications measuring SI with Geriatric Mental State, patients with a “wish to be dead” are commonly regarded as “suicidal.”
      • Linden M.
      • Barnow S.
      1997 IPA/Bayer Research Awards in Psychogeriatrics The wish to die in very old persons near the end of life: a psychiatric problem? Results from the Berlin Aging Study.
      • Barnow S.
      • Linden M.
      Epidemiology and psychiatric morbidity of suicidal ideation among the elderly.
      The category of “wish to die” is also present in the Hamilton Depression Rating Scale,
      • Hamilton M.
      A rating scale for depression.
      another common measure of SI.
      • Berlin I.
      • Chen H.
      • Covey L.S.
      Depressive mood, suicide ideation and anxiety in smokers who do and smokers who do not manage to stop smoking after a target quit day.
      • Rucci P.
      • Frank E.
      • Scocco P.
      • et al.
      Treatment-emergent suicidal ideation during 4 months of acute management of unipolar major depression with SSRI pharmacotherapy or interpersonal psychotherapy in a randomized clinical trial.
      Further limitation is that the measure of insomnia and SI were both based on self-report; hence, there is a possibility that the association found is due to a trend of reporting multiple symptoms, which can be ruled out only by an objective sleep assessment such as a polysomnography examination. Future studies with community-based samples and objective sleep assessment are warranted to confirm our findings. Finally, patients with bipolar disorder were not included in this study, as this form of mood disorder is extremely rare in stroke survivors.
      • Tang W.K.
      • Ungvari G.S.
      • Chiu H.F.
      • Sze K.H.
      • Woo J.
      Psychiatric morbidity in first time stroke patients in Hong Kong: a pilot study in a rehabilitation unit.

      Conclusions

      Regardless of the nature of the association between insomnia and SI, the present findings should alert clinicians to the importance of the early identification and treatment of insomnia in stroke patients. Future research aimed at determining whether sleep disturbances constitute a modifiable risk factor for suicidal ideation in stroke is warranted.
      • a
        Release 14.0; SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

      References

        • Palomäki H.
        • Berg A.
        • Meririnne E.
        • et al.
        Complaints of poststroke insomnia and its treatment with mianserin.
        Cerebrovasc Dis. 2003; 15: 56-62
        • Pohjasvaara T.
        • Vataja R.
        • Leppavuori A.
        • Kaste M.
        • Erkinjuntti T.
        Suicidal ideas in stroke patients 3 and 15 months after stroke.
        Cerebrovasc Dis. 2001; 12: 21-26
        • Leppävuori A.
        • Pohjasvaara T.
        • Vataja R.
        • Kaste M.
        • Erkinjuntti T.
        Insomnia in ischemic stroke patients.
        Cerebrovasc Dis. 2002; 14: 90-97
        • Chen Y.K.
        • Lu J.Y.
        • Mok V.C.
        • et al.
        Clinical and radiologic correlates of insomnia symptoms in ischemic stroke patients.
        Int J Geriatr Psychiatry. 2011; 26: 451-457
        • Estivill E.
        • Bové A.
        • García-Borreguero D.
        • et al.
        Consensus on drug treatment, definition and diagnosis for insomnia.
        Clin Drug Investig. 2003; 23: 351-385
        • Eaton W.W.
        • Badawi M.
        • Melton B.
        Prodromes and precursors: epidemiologic data for primary prevention of disorders with slow onset.
        Am J Psychiatry. 1995; 152: 967-972
        • Kishi Y.
        • Kosier J.T.
        • Robinson R.G.
        Suicidal plans in patients with acute stroke.
        J Nerv Ment Dis. 1996; 184: 274-280
        • Goldstein T.R.
        • Bridge J.A.
        • Brent D.A.
        Sleep disturbance preceding completed suicide in adolescents.
        J Consult Clin Psychol. 2008; 76: 84-91
        • Olgiati P.
        • Serretti A.
        • Colombo C.
        Retrospective analysis of psychomotor agitation, hypomanic symptoms, and suicidal ideation in unipolar depression.
        Depress Anxiety. 2006; 23: 389-397
        • Tang N.K.
        • Crane C.
        Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links.
        Psychol Med. 2006; 36: 575-586
        • Garden F.H.
        • Garrison S.J.
        • Jain A.
        Assessing suicide risk in stroke patients: review of two cases.
        Arch Phys Med Rehabil. 1990; 71: 1003-1005
        • Chiu H.
        • Lee H.
        • Chung D.
        Reliability and validity of the Cantonese version of the Mini-Mental State Examination: a preliminary study.
        Hong Kong J Psychiatry. 1994; 4: 25-28
        • Copeland J.R.
        • Dewey M.E.
        • Henderson A.S.
        • et al.
        The Geriatric Mental State (GMS) used in the community: replication studies of the computerized diagnosis AGECAT.
        Psychol Med. 1988; 18: 219-223
        • Chiu H.F.
        • Leung T.
        • Lam L.C.
        • et al.
        Sleep problems in Chinese elderly in Hong Kong.
        Sleep. 1999; 22: 717-726
        • Chen S.X.
        • Yu F.M.
        Syndrome differentiation and treatment of post-stroke fatigue.
        J Pract Tradit Chin Int Med. 2008; 22: 17-19
        • Schwartz J.E.
        • Jandorf L.
        • Krupp L.B.
        The measurement of fatigue: a new instrument.
        J Psychosom Res. 1993; 37: 753-762
        • Kam I.W.K.
        Development of the bilingual (Chinese/English) SCID-I (Structured Clinical Interview for DSM-IV Axis I disorder): a study of its reliability and validity in an in-patient population.
        Hong Kong College of Psychiatrist, Hong Kong2000
        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders.
        4th ed. American Psychiatric Association, Washington, DC1994
        • Sunderajan P.
        • Gaynes B.N.
        • Wisniewski S.R.
        • et al.
        Insomnia in patients with depression: a STARlow asteriskD report.
        CNS Spectr. 2010; 15: 394-404
        • Staner L.
        Comorbidity of insomnia and depression.
        Sleep Med Rev. 2010; 14: 35-46
        • Nrugham L.
        • Larsson B.
        • Sund A.M.
        Specific depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence.
        J Affect Disord. 2008; 111: 83-93
        • Agargun M.Y.
        • Besiroglu L.
        • Cilli A.S.
        • et al.
        Nightmares, suicide attempts, and melancholic features in patients with unipolar major depression.
        J Affect Disord. 2007; 98: 267-270
        • Desmyter S.
        • van Heeringen C.
        • Audenaert K.
        Structural and functional neuroimaging studies of the suicidal brain.
        Prog Neuropsychopharmacol Biol Psychiatry. 2011; 35: 796-808
        • Jouvet M.
        Sleep and serotonin: an unfinished story.
        Neuropsychopharmacology. 1999; 21: 24S-27S
        • Liu X.
        Sleep and adolescent suicidal behavior.
        Sleep. 2004; 27: 1351-1358
        • Joiner Jr, T.E.
        • Brown J.
        • Wingate L.R.
        The psychobiology and neurobiology of suicidal behavior.
        Annu Rev Psychol. 2005; 56: 287-314
        • Li Pi Shan R.S.
        • Ashworth N.L.
        Comparison of lorazepam and zopiclone for insomnia in patients with stroke and brain injury: a randomized, crossover, double-blinded trial.
        Am J Phys Med Rehabil. 2004; 83: 421-427
        • Lee S.Y.
        • Baek Y.H.
        • Park S.U.
        • et al.
        Intradermal acupuncture on shen-men and nei-kuan acupoints improves insomnia in stroke patients by reducing the sympathetic nervous activity: a randomized clinical trial.
        Am J Chin Med. 2009; 37: 1013-1021
        • Brown G.K.
        • Ten Have T.
        • Henriques G.R.
        • Xie S.X.
        • Hollander J.E.
        • Beck A.T.
        Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial.
        JAMA. 2005; 294: 563-570
        • Forsström E.
        • Hakko H.
        • Nordström T.
        • Räsänen P.
        • Mainio A.
        Suicide in patients with stroke: a population-based study of suicide victims during the years 1988-2007 in northern Finland.
        J Neuropsychiatry Clin Neurosci. 2010; 22: 182-187
        • Linden M.
        • Barnow S.
        1997 IPA/Bayer Research Awards in Psychogeriatrics.
        Int Psychogeriatr. 1997; 9: 291-307
        • Barnow S.
        • Linden M.
        Epidemiology and psychiatric morbidity of suicidal ideation among the elderly.
        Crisis. 2000; 21: 171-180
        • Hamilton M.
        A rating scale for depression.
        J Neurol Neurosurg Psychiatry. 1960; 23: 56-62
        • Berlin I.
        • Chen H.
        • Covey L.S.
        Depressive mood, suicide ideation and anxiety in smokers who do and smokers who do not manage to stop smoking after a target quit day.
        Addiction. 2010; 105: 2209-2216
        • Rucci P.
        • Frank E.
        • Scocco P.
        • et al.
        Treatment-emergent suicidal ideation during 4 months of acute management of unipolar major depression with SSRI pharmacotherapy or interpersonal psychotherapy in a randomized clinical trial.
        Depress Anxiety. 2011; 28: 303-309
        • Tang W.K.
        • Ungvari G.S.
        • Chiu H.F.
        • Sze K.H.
        • Woo J.
        Psychiatric morbidity in first time stroke patients in Hong Kong: a pilot study in a rehabilitation unit.
        Aust N Z J Psychiatry. 2002; 36: 544-549

      Linked Article

      • Correction
        Archives of Physical Medicine and RehabilitationVol. 93Issue 4
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          In Tang W-K, Lu J-Y, Liang H, Chan T-T, Mok V, Ungvari GS, Wong K-S. Is insomnia associated with suicidality in stroke? Arch Phys Med Rehabil 2011;92:2025-7, coauthor, Tse-Ting Chan's name should read Tsz Ting Chan.
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