Sleep problems and suicide associated with emotion dysregulation in the Adult Psychiatric Morbidity Survey, 2007 and 2014.

The University of Surrey (UoS) requires access to NHS England Adult Psychiatric Morbidity Survey (APMS) data for the purpose of studying sleep problems and suicide associated with emotion dysregulation in the Adult Psychiatric Morbidity Survey, 2007 and 2014.

The following is a summary of the aims of the research project provided by the University of Surrey:

Research suggests that the association between poor sleep and suicide attempts and self-harm behaviours is mediated by emotion dysregulation. This investigation seeks to use a representative sample of the general population using data combined from the Adult Psychiatric Morbidity Survey (2007) and the Adult Psychiatric Morbidity Survey (2014) to understand the relationship between sleep problems, self-harm, and emotion dysregulation. Odds ratios will be calculated using logistic regressions to understand the association of sleep problems and suicide, including emotion dysregulation as a mediator. Potential modifiers of the relationship will be measured, such as sedative vs non-sedative medication use and mental health diagnosis.

The hypotheses to be tested are as follows:

1. Sleep problems are positively related to suicidal thoughts

2. Sleep problems are positively related to non-suicidal self-harm

3. Sleep problems are positively related to deliberate self-harm/suicide attempt

4. Emotion dysregulation will moderate the relationship between sleep problems and suicide/self-harm

The following NHS England data will be accessed:

• APMS

The level of the data will be:

• Pseudonymised

The data will be minimised as follows:

• Limited to the APMS 2007 and APMS 2014 datasets which will be processed together to increase statistical power.

• Filtering: The purpose of the research project is to understand a pattern of symptoms over the general population, using a large sample size to increase reliability and validity; the data cannot be narrowed by geography, demographics or clinical factors. Filtering of participants would remove a section of the population needed to carry out the study purpose.

• Episodes: The data was collected at a single time point for each participant, hence all ‘episodes’ are required to achieve the purpose.

• Fields: All pseudonymised fields are necessary to obtain the population data for the study. This includes retrieving any possible confounding variables for the association that has been proposed.

The APMS Dataset has already been minimised and pseudonymised, and disclosure control suppression applied by NHS England’s survey contractors before sending it to the UK Data Service who also did their own checks on the dataset. The dataset has been through NHS England’s Disclosure Control Panel and approved.

The University of Surrey is the data controller who also process the data as the organisation responsible for ensuring that the data will only be processed for the purpose described above.

The lawful basis for processing personal data under the UK GDPR is:

> Article 6(1)(e) - processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller.

The lawful basis for processing special category data under the UK GDPR is:

> Article 9(2)(j) - processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.

The public interest is that adults presenting with poor sleep and emotion dysregulation may benefit from receiving more appropriate care, from the most appropriately trained staff most appropriately able to meet their needs. Interventions are likely to be more effective and efficient and reduction in distress of individuals in contact with those experiencing these difficulties is also expected.

The research is being carried out as part of a funded Clinical Psychology doctorate training programme with the University of Surrey, which commenced in 2021 and ends in September 2024.

Patient/Participant involvement:

There is a plan to speak to a relevant client group, such as those with poor sleep, emotional problems, and self-harm/suicidal ideation. These individuals may help identify possible confounders or moderators that may have not been considered. The purpose of this is to understand perspectives of individuals with lived experience of sleep problems and emotion dysregulation and reflect on initial conclusions that are drawn from the data. Questions such as ‘what do these findings mean to you?’, ‘do you think they make sense and are valid?’, and ‘what do you think they suggest?’ will be asked.

Also, after data analysis and provisional associations drawn, a discussion around the potential application of the findings to clinical practice will be suggested. Potential questions include: ‘Do you feel that if you knew this it would have made a difference to your care or you would have felt more comfortable to ask for specific help regarding your sleep?’, How could this be applied in your service?’ and ‘If it finds sleep has impact – would you rather interventions to target this vs ones for emotional instability?’. The plan is to also speak to clinicians working in relevant areas to see what the findings mean to them.

No data will flow to NHS England for the purposes of this Agreement.

NHS England data will provide the relevant records from the Adult Psychiatric Morbidity Survey (APMS) dataset to the University of Surrey. The data will:

• contain no direct identifying data items. The data will be pseudonymised and individuals cannot be reidentified through linkage with other data in the possession of the recipient.

The data will not be transferred to any other location.

The data will be stored on servers at the University of Surrey. The data will be retained for the purpose of analyses, and thereafter be deleted from the server.

The data will be accessed onsite via password-protected secure system access at the premises of the University of Surrey.

The data will also be accessed by authorised personnel via remote access. The data will remain on the servers at the University of Surrey at all times.

Personnel are not technically capable of downloading or copying data to local devices.

The data will not leave England/Wales at any time.

Access is restricted to substantive employees of the University of Surrey who have authorisation from the Principal Researcher.

All personnel accessing the data have been appropriately trained in data protection and confidentiality.

The data will not be linked with any other data.

There will be no requirement and no attempt to reidentify individuals when using the data.

The study outputs will explicitly state that the findings are associations, and causation cannot be inferred. Therefore, although guiding future research, individuals will not be at risk of learning about a condition or disease where they may have otherwise been unaware.

Analysts from the University of Surrey will analyse the data for the purposes described above.

The outputs will not contain NHS England data and will only contain aggregated information with small numbers suppressed as appropriate in line with the relevant disclosure rules for the dataset(s) from which the information was derived.

The dissemination of results will aim to guide future researchers for further investigation of the subject.

The outputs will be communicated to relevant recipients through the following dissemination channels:

• Journals: Possible journals include but are not limited to, ‘Sleep Medicine Reviews’ and ‘Behavioural Sleep Medicine’, where similar articles have been published.

• Social media, including Twitter and the ‘Mental Elf’ blog.

• Presentations to relevant service user groups, such as individuals with personality disorders. A written summary of results will be presented to relevant clinicians i.e., those in primary care who encounter relevant service users. This may influence their interest and awareness of the subject matter.

• The findings will be presented at the University of Surrey research project forum in the form of a presentation and/or a poster.

• Websites: An accessible summary of the findings will be submitted to the Office of National Statistics blog website.

Target dates:

- Submission to journal article, expected July 2025

- Presentation of findings to UoS research day, expected August 2025

- Publication, expected January 2026

- Blog article submitted to 'Office of National Statistics' and 'Mental Elf', expected February 2026

- Dissemination to relevant clinicians and service users, expected March 2026

APMS low numbers and suppression

In order to protect patient confidentiality in publications resulting from analysis of APMS data users must:

· guarantee that any outputs made available to anyone other than those with whom this agreement is made, will meet required standards, including the guarantee, methods and standards contained in the Code of Practice for Official Statistics (http://www.statisticsauthority.gov.uk/assessment/code-of-practice/index.html) and the ONS Statistical Disclosure Control (https://gss.civilservice.gov.uk/statistics/methodology-2/statistical-disclosure-control/) for tables produced from surveys;

· apply methods and standards specified in the Microdata Handling and Security Guide to Good Practice (http://www.data-archive.ac.uk/media/132701/UKDA171-SS-MicrodataHandling.pdf) for disclosure control for statistical outputs.

The results of this study are expected within a year of the download of the NHS England APMS data. This study will hopefully lead to recommendations which may have an impact on the following categories:

1. Impact on identifying the association, and the factors influencing the association, between self-harm, sleep problems and emotional dysregulation

This study may increase the clarity of understanding how self-harm and suicide, sleep problems, and emotional dysregulation are associated in the general population. Current research is sparce, with limited epidemiological understanding of how these three variables are associated, and any other factors influence the association, such as medication type.

2. Impact on adult mental health

If this study’s work shows an association between these three variables, then it will provide support for the development of more tailored studies to test causal effects over time. This will highlight the benefit of specific intervention targets, which could be piloted to reduce self-harm behaviours, emotion dysregulation, and poor sleep. Adults presenting with poor sleep and emotion dysregulation may benefit from receiving more appropriate care, from the most appropriately trained staff most appropriately able to meet their needs. This will hopefully have positive effects on reducing morbidity and self-harm and/or suicide at a population level over time. If modifiable risk factors for suicide and self-harm are identified, this has the potential to disrupt the course of the mental health illness prior to self-harm behaviours. Since prior self-harm or suicidal ideation is the main factor predicting future self-harm and suicidal behaviours, prevention is paramount.

Since this research will identify factors transcending diagnostic boundaries, the findings could be applied to adult mental health at symptom level, in a range of settings. Findings are likely to be generalisable to other developed countries.

3. Impact on families

A reduction in family distress is expected if individuals suffering with these mental health problems are treated more effectively. Furthermore, individuals who are at high risk of harming themselves, are often looked after by family members, hence with a reduction in this need family members will likely have a better mental health and quality of life. Positive effects are thus compounded in regard to adult mental health.

4. Impact on other care providers

Targeting reducing self-harm is crucial to reducing activity at physical health services, such as hospitals. In forensic settings, this would also reduce the instance of self-harm related cases to officers who are frequently on bedside watch or completing hourly welfare checks. This would increase their time spent on, and hence quality of, their alternative job roles. If further understanding is highlighted as to the effect of sleep medication, this may influence psychiatrists’ prescription choice.

5. Impact on service provision

Understanding better the connections between sleep, self-harm and emotion dysregulation will likely lead to further research or piloting of more structured support for individuals suffering with these symptoms. This may include specific treatment targets or a change in the sequence of treatment, for example starting with poor sleep before emotion dysregulation or vice versa. This will allow for more efficient, effective interventions at service level. For example, if research suggests that one can target sleep to reduce suicide and self-harm, then this may be a more appropriate, effective intervention target than emotion management in individuals with personality disorder, who often have enduring emotional difficulties. Thus, if piloted successfully, changes to the current mental health provision can be made in services that have a high rate of self-harm, including personality disorder units and forensic settings.

6. Impact on commissioning: service and economic benefits for the NHS

This study may reveal a specific association which could spark future research to pilot changes in configuration of care for individuals with self-harm and suicidal behaviours. This could have implications for hospital utilisation and hence capacity. More streamlined services are likely to have economic benefits due to more efficient, effective care. The data from this study will support working towards a situation where individuals with self-harm and suicidal tendencies will be consistently provided the most cost-effective care to reduce mental health problems related to poor sleep, emotion dysregulation, and self-harm behaviours.

More appropriate care may allow Networks and Commissioning teams the opportunity to predict future cost utilisation assumptions more accurately, which could in turn inform commissioning of psychology therapy services, and other resources.

Any recommendations for change resulting from this and other studies will be evidence-based and considered from a health and cost-benefit viewpoint whilst attending to needs of adult mental health and families. Implementation of any changes will require future research to support this study’s findings. It will then need close engagement at a local level with commissioners and care provides, managers, and the general public.

7. Impact on NHS and society

For the NHS, mental health problems, including poor sleep, emotion dysregulation, and self-harm behaviours represent a significant proportion of healthcare activities. Identifying modifiable risk factors for self-harm and suicidal behaviours, including poor sleep, is pertinent because it has the potential to prevent and reduce morbidity and mortality rates. As a result of this research that transcends diagnostic boundaries, the findings have implications for a large application of the findings have applications to the general population, rather than those diagnostically bound.

As a result of better mental health, there will likely be less activity for both mental and physical healthcare providers. Individuals with, and families exposed to, these problems will be more likely to be able to work and contribute meaningfully to society. Therefore, this is likely to influence social integration, education, and employment opportunities with attendant societal consequences and financial costs.

Yielded Benefits is not a requirement for new applications.