Sleep Problems, Suicidal Ideation, and Psychopathology in First-Episode Psychosis


Researchers investigated relationships between sleep problems, suicidal ideation, and psychopathology in patients with first-episode psychosis.




“Mr Deuce” is 22-year-old male with no previous psychiatric history who presents to the emergency department with his family. He is a senior in college. He has not been sleeping well, with complaints of initial insomnia, and has been taking NyQuil to aid sleep.

Per his sister, the patient has exhibited delusional thinking that he is a superhero and that his roommates at college are talking about him. He has also had paranoid ideation that his room at college was being wire tapped. He told the interviewer on admission that he would be meeting the president the next day. The patient also has periods where 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 3 mg daily during an inpatient psychiatric hospitalization.

Although not part of the diagnostic criteria for psychotic disorders, insomnia is common in the clinical course of schizophrenia, affecting one-quarter to one-half of patients.1 Insomnia is robustly associated with suicidal ideation and behavior in psychiatric disorders, including schizophrenia.2

This association with relevant, given a lifetime prevalence of 27% for suicidal attempt3 and 5% for suicide death in the disorder.4 Several studies have also found an association between insomnia and greater symptom severity, including total, positive, and general psychopathology.2

The Current Study

Ayers and colleagues5 examined associations between sleep problems, suicidal ideation, and psychopathology in a longitudinal study of a well-characterized sample of patients with early psychosis. Publicly available data from the National Institute of Mental Health Data Archive were obtained from the Recovery After an Initial Schizophrenia Episode—Early Treatment Program (RAISE) early psychosis trial (n=404).6

Participants were aged 15 to 40 years and had the presence of definite psychotic symptoms and evidence of DSM-IV diagnoses of either schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, or psychotic disorder not otherwise specified. All participants had experienced only 1 lifetime episode of psychosis (ie, individuals with a psychotic episode followed by full symptom remission and relapse to another psychotic episode were excluded) and had taken ≤6 months of lifetime antipsychotics. Participants were followed for 24 months.

In the present study, the authors investigated relationships between sleep problems over the past 2 to 4 weeks, suicidal ideation over the past 2 weeks, and psychopathology over the past week for participants from the RAISE trial at baseline and 6, 12, 18, and 24 months. Sleep problems at each time point were defined as the presence of terminal insomnia (assessed using the Calgary Depression Scale for Schizophrenia [CDSS] and/or endorsing sleep problems on the adverse effects scale. Hypersomnia and daytime sleepiness, which were addressed in separate questions, were excluded.

Suicidal ideation at each time point was assessed using the CDSS and was dichotomized as present/absent. Psychopathology was measured with the Positive and Negative Syndrome Scale (PANSS) total and subscale scores at each time point. At baseline, 83.4% of participants were taking antipsychotics.

The authors investigated the association between problems and suicidal ideation at each time point (baseline and 6, 12, 18, and 24 months) using logistic regression models. They also investigated baseline sleep problems as a predictor of suicidal ideation at 6, 12, 18, and 24 months. Finally, they investigated whether persistent sleep problems (yes versus no at all study visits) predicted suicidal ideation at any point during the study.

Age, sex, race, smoking, education, body mass index (BMI), alcohol and cannabis use, PANSS total scores, and depressive symptoms (CDSS total score minus the insomnia and suicide items) were considered as potential confounding and/or moderating factors in the analyses. The authors also investigated associations between sleep problems and PANSS total and subscale scores in linear regression models, controlling for age, sex, race, smoking education, BMI, and substance use.

From the RAISE trial, 403 participants had data on baseline sleep problems and suicidal ideation. Similar data were also available for 291 participants at 6 months, 256 at 12 months, 221 at 18 months, and 205 at 24 months. The mean participant age was 23.5 years, 72% were male, 54% were Caucasian, and 53% had a diagnosis of schizophrenia. Participants with (versus without) sleep problems had higher depression (CDSS) scores with a large effect size (Cohen’s d=0.80), and PANSS total, positive, and general scores with a small to medium effect sizes (Cohen’s d=0.29–0.32).

The prevalence of sleep problems was 57% at baseline and ranged from 40% to 48% at the follow-up visits. The prevalence of suicidal ideation was 15% at baseline and ranged from 5% to 11% at the follow-up visits. Five participants reported a suicide attempt during the study, and all of those participants also reported concurrent sleep problems.

Sleep problems were associated with a significant increased odds of suicidal ideation at baseline (OR=2.25, 95% CI 1.15–4.41, P =.018) and 18 months (OR=4.64, 95% CI 1.1–19.6, P=.037). These associations were no longer significant after controlling for depressive symptoms. Over the 24-month study, sleep problems at any point were associated with a more than 3-fold increased odds of concurrent suicidal ideation (OR=3.21, 95% CI 1.45–7.14, P=.014). These associations were attenuated after controlling for depressive symptom.

Baseline sleep problems did not predict suicidal ideation at any individual follow-up visit. However, participants with persistent sleep problems (“yes” at all visits, n = 50) were almost 14 times more likely to endorse suicidal ideation at least once over the study than those without sleep problems (“no” at all visits, n = 61) (prevalence of suicidal ideation 50% vs 8%, OR=13.8, 95% CI 6.5–53.4, P<.001). This association remained significant after controlling for baseline depressive symptoms (OR=7.7, 95% CI 1.8–33.5, P = .007).

Baseline sleep problems were also a significant predictor of higher baseline PANSS total (β=0.13, P=.010), positive subscale (β=0.18, P<.001), and general subscale (β=0.20, P<.001) scores, but not negative subscale scores. Concurrent sleep problems were a significant predictor of PANSS total and general scores at 6, 12, 18, and 24 months, and PANSS positive scores at 6, 12, and 18 months.

In linear regression analyses, after controlling for potential confounders baseline sleep problems were associated with significantly greater levels of hallucinations, hostility, anxiety, guilt, tension, depression, impulse control, and active social avoidance at baseline (P≤.04 for each).

The strength of these associations with most individual PANSS items were small (β=0.11–0.16), although effects were slightly greater for hallucinations (β=0.20), anxiety (β=0.20), and depression (β=0.28), all 3of which remained significant after Bonferroni correction for multiple (23) comparisons (P<.001 for each).

Study Conclusions

The authors concluded that sleep problems were a common symptom in a large study of patients with first-episode psychosis, affecting more than half of participants at baseline. Over a 2-year period, the prevalence of sleep problems ranged from 40% to 57%, and the prevalence of suicidal ideation ranged from 5% to 15%. After controlling for potential confounders:

  • Sleep problems were associated with significantly increased odds of concurrent suicidal ideation at baseline and 18 months.
  • Sleep problems at any point were associated with a more than 3-fold increased odds of concurrent suicidal ideation.
  • Baseline sleep problems were not a predictor of incident suicidal ideation at follow-up visits.
  • Participants with persistent sleep problems were almost 14 times more likely to endorse suicidal ideation at least once over the study than those without sleep problems.
  • Sleep problems were associated with higher concurrent PANSS total, positive, and general psychopathology scores at baseline and all follow-up visits, also with a dose-dependent relationship.
  • At an individual symptom level, sleep problems were most strongly associated with levels of hallucinations, anxiety, and depression.

Study strengths include the large sample size, the minimization of potential residual confounding by other illness and treatment factors in patients with early psychosis, the availability of longitudinal data over a 2-year period, and consideration of multiple potential confounding factors. Study limitations include the self-reported measures of insomnia and sleep problems and suicidal thinking and behavior.

The Bottom Line

These findings provide additional evidence that formal assessment and treatment of insomnia and sleep disturbance is relevant to the clinical care of patients with early psychosis as a predictor of suicidal ideation and symptom severity. They also underscore the need for comprehensive suicide risk assessment in patients with early psychosis.

Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric Times®. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.


1. Batalla-Martín D, Belzunegui-Eraso A, Miralles Garijo E, et al. Insomnia in schizophrenia patients: prevalence and quality of lifeInt J Environ Res Public Health. 2020;17(4):1350.

2. Miller BJ, McCall WV. Meta-analysis of insomnia, suicide, and psychopathology in schizophreniaCurr Opin Psychiatry. 2023;36(3):156-165.

3. Lu L, Dong M, Zhang L, et al. Prevalence of suicide attempts in individuals with schizophrenia: a meta-analysis of observational studiesEpidemiol Psychiatr Sci. 2019;29:e39.

4. Hor K, Taylor M. Suicide and schizophrenia: a systematic review of rates and risk factorsJ Psychopharmacol. 2010;24(4 Suppl):81-90.

5. Ayers N, McCall WV, Miller BJ. Sleep problems, suicidal ideation, and psychopathology in first-episode psychosis [published online ahead of print, 2023 Apr 22]. Schizophr Bull. 2023;sbad045.

6. Kane JM, Schooler NR, Marcy P, et al. The RAISE early treatment program for first-episode psychosis: background, rationale, and study designJ Clin Psychiatry. 2015;76(3):240-246.

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