What is the nature of the relationship between psychosis and sleep disorders?
“Mr Deuce” is a 22-year-old man with no psychiatric history who presents to the emergency department with his family. He is a senior in college and has not been sleeping well. He has been experiencing initial insomnia and has been taking NyQuil for the past 2 weeks with minimal benefit.
According to his sister, the patient has exhibited delusional thinking, stating that he thinks he is a superhero and his roommates at college are plotting to get him kicked out of school. He has also had a paranoid ideation that his dormitory room is wiretapped. Upon admission to the emergency department, he told the interviewer that he would be meeting the president the next day.
The patient also has periods in which his speech is mostly incoherent. His laboratory studies, including a urine drug screen, were unremarkable. He was diagnosed with a first episode of psychosis and stabilized on risperidone, titrated to 3 mg daily, during an inpatient psychiatric hospitalization.
Sleep disorders are highly prevalent in patients with psychotic disorders.1 This comorbidity has a significant impact on the clinical course of illness, including worsening psychotic symptoms and cognitive impairment, as well as poorer functioning and decreased quality of life.2-4
However, the nature of the relationship between psychosis and sleep disorders is unclear; it may be a primary component of the illness itself and/or a secondary consequence of behavioral or iatrogenic factors.5
The Current Study
The Physical Health Assistance in Early Psychosis (PHAstER) study was a randomized clinical trial of a physical health nurse intervention for patients with first-episode psychosis (FEP).6 Gannon and colleagues7 performed a prospective cohort study nested within this trial. Patients aged 15 to 24 years with FEP and < 4 weeks of exposure to antipsychotic medications attending the Early Psychosis Prevention and Intervention Centre service in Melbourne, Australia, were assessed at baseline and at the 6-month follow-up.
Participants were diagnosed using the Structured Clinical Interview for DSM-5. Insomnia was defined by a score of ≥ 15 on the Insomnia Severity Index (ISI). Poor sleep quality was determined by a score of > 5 on the Pittsburgh Sleep Quality Index (PSQI). Psychopathology was assessed with the Brief Psychiatric Rating Scale (BPRS) and the Scale for Assessment of Negative Symptoms (SANS).
Functioning was assessed with the Social and Occupational Functioning Assessment Scale (SOFAS), and the Simple Physical Health Questionnaire (SIMPAQ) was used to measure physical activity. The authors used binary logistic regression models to calculate odds ratios for demographic and clinical predictors of either insomnia or poor sleep quality.
Seventy-seven individuals participated in the PHAstER trial, of whom 70 (91%) had baseline data on insomnia. The mean age was 19.4 years, 53% of participants were male, and 44% had a diagnosis of schizophreniform disorder.
The prevalence of clinical insomnia at study baseline was 43% (n = 30). Individuals with insomnia had more severe total psychopathology (mean BPRS total score, 63 vs 55) and negative symptoms (mean SANS score, 24 vs 14). Positive symptoms, demographic factors, functioning, and physical activity were not associated with baseline clinical insomnia.
At 6 months, ISI data were available for 42 individuals, and the prevalence of insomnia decreased to 21%. Those individuals with insomnia at 6 months had more severe total and positive psychopathology and lower social and occupational functioning.
Poor sleep quality at baseline was present in 87% of the cohort, and there were no associated demographic, clinical, or physical health factors. At 6 months, only 43% of the cohort completed the PSQI, of whom 67% had poor sleep quality. Similar to the data for insomnia, individuals with poor sleep quality at 6 months had more severe total and positive psychopathology and lower social and occupational functioning.
The authors concluded that there was a high prevalence of poor sleep quality and insomnia in patients with FEP. Study strengths included the longitudinal design and that participants had minimal antipsychotic exposure at baseline. The primary study limitation was the appreciable attrition of data on sleep at the 6-month follow-up.
There is some evidence supporting sleep hygiene strategies8 and cognitive behavioral therapy for insomnia in FEP.9 By contrast, there is limited evidence for using specific psychopharmacological agents for insomnia in this patient population.
The Bottom Line
Findings provide evidence that sleep problems are common at the onset of psychotic illness. Sleep disorders represent a potential therapeutic target in psychosis to improve psychopathology and functioning.
Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Georgia. He is a member of the Editorial Board and schizophrenia section chief for Psychiatric Times®. He receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.
1. Reeve S, Sheaves B, Freeman D. Sleep disorders in early psychosis: incidence, severity, and association with clinical symptoms. Schizophr Bull. 2019;45(2):287-295.
2. Poulin J, Daoust AM, Forest G, et al. Sleep architecture and its clinical correlates in first episode and neuroleptic-naive patients with schizophrenia. Schizophr Res. 2003;62(1-2):147-153.
3. Laskemoen JF, Büchmann C, Barrett EA, et al. Do sleep disturbances contribute to cognitive impairments in schizophrenia spectrum and bipolar disorders? Eur Arch Psychiatry Clin Neurosci. 2020;270(6):749-759.
4. Subramaniam M, Abdin E, Shahwan S, et al. Prevalence, correlates and outcomes of insomnia in patients with first episode psychosis from a tertiary psychiatric institution in Singapore. Gen Hosp Psychiatry. 2018;51:15-21.
5. Chiu VW, Harvey RH, Sloan NB, et al. Cognitive and behavioral factors associated with insomnia in inpatients with schizophrenia and related psychoses. J Nerv Ment Dis. 2015;203(10):798-803.
6. O’Donoghue B, Mifsud N, Castagnini E, et al. A single-blind, randomised controlled trial of a physical health nurse intervention to prevent weight gain and metabolic complications in first-episode psychosis: the Physical Health Assistance in Early Psychosis (PHAstER) study. BJPsych Open. 2022;8(6):e189.
7. Gannon L, Pearson N, Tsiglopoulos J, et al. Longitudinal study of the prevalence of sleep disorders in first episode psychosis and its clinical correlates. Schizophr Res. 2023;258:81-83.
8. Griffiths C, Hina F, Pollard L, et al. A qualitative study of early intervention psychosis (EIP) service patient’s experience of sleep, exercise, sleep hygiene advice and Fitbit wearable activity and sleep tracker. Open J Psychiatry. 2021;11(02):91-106.
9. Freeman D, Waite F, Startup H, et al. Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial. Lancet Psychiatry. 2015;2(11):975-983.