The Overlap in Sleep Problems and Psychiatric Disorders

SPECIAL REPORT: SLEEP DISORDERS

Sleep and rhythm disturbances are prevalent in individuals with psychiatric disorders, and sleep complaints are part of the diagnostic criteria or related features in most disorders. Not only are sleep problems worsened by psychiatric illnesses, but sleep disturbances also exacerbate psychiatric symptomatology. This Special Report highlights these important interactions and the need to better identify and treat sleep disturbances and disorders in psychiatric patients.

Insomnia is frequently reported, and objective sleep recordings in groups of individuals with acute episodes of most major psychiatric illnesses tend to show reductions in total sleep amount and sleep efficiency, as well as increased latency to sleep onset.^1,2 Not only does insomnia frequently occur in psychiatric disorders, but it is also predictive of new onset or exacerbation of psychiatric disorders, particularly depression.^3,4 Both insomnia and reduced sleep time are also predictive of increased risk of suicidal behaviors.^5,6 Treatment of insomnia with cognitive behavioral therapy for insomnia has been shown to reduce depressive symptoms or hasten the antidepressant response in individuals with depression.^7,8

Individuals with psychiatric disorders may also have sleep complaints related to comorbid primary sleep disorders. Obstructive sleep apnea (OSA), which is characterized by episodes of upper airway obstruction, commonly occurs in patients with psychiatric disorders. Furthermore, symptoms of OSA overlap with symptoms of many psychiatric disorders, including depressed mood, irritability, sleep disturbance, cognitive impairment, and lack of motivation.⁹ Psychiatric medications that lead to muscle relaxation, decreased upper airway muscle tone, or increase arousal threshold, can worsen OSA; these include benzodiazepines, nonbenzodiazepine hypnotics, and barbiturates. Circadian rhythm disorders—particularly delayed sleep-wake phase disorder, in which individuals fall asleep and wake up much later than desired—are also seen in individuals with psychiatric disorders, particularly bipolar disorder, and are associated with increased risk of developing bipolar disorder.^10,11 Parasomnias, or abnormal behaviors arising from sleep, are also more frequent in individuals with psychiatric disorders.¹² Restless legs syndrome (RLS), in which individuals feel an urge to move their legs in the evening or at rest, is also more commonly seen in individuals with psychiatric disorders in comparison with the general population, and both parasomnias and RLS may be triggered by some psychopharmacologic agents.¹³

The articles in this Special Report review topics related to sleep in psychiatry that are relevant for the practicing clinician. “Beyond the Night: Unraveling the Psychiatric Impact of Sleep Disorders” points out the strong associations between various primary sleep disorders and psychiatric disorders. The importance of addressing insomnia in people with psychiatric disorders and an overview of its management are covered in “Promoting Insomnia Management in the Context of Psychiatric Symptoms” and “Cognitive Behavior Therapy for Insomnia and Hypnotic Deprescribing.”

Sleep problems are common in individuals with psychiatric disorders, but unfortunately, patients are not routinely evaluated for sleep or rhythm disorders. Given the overlap in symptoms between the 2 groups of disorders, a treatment-resistant psychiatric disorder may be a treatment-responsive sleep disorder, and treating sleep problems often leads to improvement in psychiatric symptoms and quality of life.

Dr Benca is the Kate Mills Snider Professor and chair of psychiatry and behavioral medicine at Wake Forest University School of Medicine in Winston-Salem, North Carolina.

References

1. Benca RM, Obermeyer WH, Thisted RA, Gillin JC. Sleep and psychiatric disorders. A meta-analysis. Arch Gen Psychiatry. 1992;49(8):651-668.

2. Baglioni C, Nanovska S, Regen W, et al. Sleep and mental disorders: a meta-analysis of polysomnographic research. Psychol Bull. 2016;142(9):969-990.

3. Baglioni C, Battagliese G, Feige B, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011;135(1-3):10-19.

4. Hertenstein E, Feige B, Gmeiner T, et al. Insomnia as a predictor of mental disorders: a systematic review and meta-analysis. Sleep Med Rev. 2019;43:96-105.

5. Liu RT, Steele SJ, Hamilton JL, et al. Sleep and suicide: a systematic review and meta-analysis of longitudinal studies. Clin Psychol Rev. 2020;81:101895.

6. Bernert RA, Kim JS, Iwata NG, Perlis ML. Sleep disturbances as an evidence-based suicide risk factor. Curr Psychiatry Rep. 2015;17(3):554.

7. Gee B, Orchard F, Clarke E, et al. The effect of non-pharmacological sleep interventions on depression symptoms: a meta-analysis of randomised controlled trials. Sleep Med Rev. 2019;43:118-128.

8. Hertenstein E, Trinca E, Wunderlin M, et al. Cognitive behavioral therapy for insomnia in patients with mental disorders and comorbid insomnia: a systematic review and meta-analysis. Sleep Med Rev. 2022;62:101597.

9. Benca RM, Krystal A, Chepke C, Doghramji K. Recognition and management of obstructive sleep apnea in psychiatric practice. J Clin Psychiatry. 2023;84(2):22r14521.

10. Melo MCA, Abreu RLC, Linhares Neto VB, et al. Chronotype and circadian rhythm in bipolar disorder: a systematic review. Sleep Med Rev. 2017;34:46-58.

11. Scott J, Etain B, Miklowitz D, et al. A systematic review and meta-analysis of sleep and circadian rhythms disturbances in individuals at high-risk of developing or with early onset of bipolar disorders. Neurosci Biobehav Rev. 2022;135:104585.

12. Tomic T, Mombelli S, Oana S, et al. Psychopathology and NREM sleep parasomnias: a systematic review. Sleep Med Rev. 2025;80:102043.

13. Dumont S, Block V, Lillo-Lelouet A, et al. Parasomnias and sleep-related movement disorders induced by drugs in the adult population: a review about iatrogenic medication effects. J Sleep Res. 2025;34(2):e14306.