Insomnia and other sleep disturbances have deleterious impacts on symptoms, suicidal ideation, cognitive function, functional outcomes, and quality of life in patients with schizophrenia.1–3 The association between sleep disturbances and schizophrenia has been observed since the beginning of the 20th century, when the pioneering German psychiatrist Emil Kraepelin noted that “rest in bed, supervision, care for sleep and food, are here the most important requisites” in the treatment of dementia praecox, the diagnostic precursor of schizophrenia.4 Symptoms of insomnia, such as the inability to fall or stay asleep and daytime sleepiness, affect 80% of patients diagnosed with schizophrenia, and frequently coincide with the prodromal stage, periods of relapse, and experience of positive symptoms, such as hallucinations and delusions.5–7 Insomnia in patients with schizophrenia is frequently overlooked,7 and is not addressed by current schizophrenia treatment guidelines.8

The optimal treatment for insomnia in patients with schizophrenia is unknown. Only a few clinical trials have specifically evaluated insomnia treatments in patients with schizophrenia: Patients with psychiatric disorders such as schizophrenia typically are not included in wider clinical trials for insomnia therapies.9 Two recent systematic reviews of clinical trials investigating the effect of pharmacotherapies for insomnia in patients with schizophrenia similarly concluded that paliperidone, melatonin, and eszopiclone had the strongest evidence for their use. Authors of both reviews emphasize the need for further research.8,10

For perspectives on the treatment of insomnia in patients with schizophrenia, Psychiatry Advisor spoke with 3 experts in the field: Vivian Chiu, PhD, a research psychologist specializing in sleep and psychosis at the University of Western Australia in Perth and facilitator of a sleep program for clients of the public mental health system; Pedro Oliveira, MD, a psychiatrist at the University of Coimbra in Portugal and author of a review about treatment options for insomnia in patients with schizophrenia; and Fabio Ferrarelli, MD, PhD, psychiatry professor and director of the Sleep and Schizophrenia program at the University of Pittsburgh in Pennsylvania.

Psychiatry Advisor: What approach should psychiatrists take to the assessment of sleep disorders in patients with schizophrenia? Should patients with schizophrenia be proactively screened for sleep disorders, given their prevalence in this population?

Dr Chiu: For a long time, sleep problems have been perceived as a byproduct or another symptom of schizophrenia. However, they are now increasingly recognized as disorders in their own right, with their own underlying mechanisms and independent perpetuating factors. There are a range of different sleep disorders, and it is important to ask clients about the specific sleep difficulties they experience and the impact it may have over the course of their mental illness. People with schizophrenia often report that their sleep difficulties fluctuate over time, so it can be helpful to track when sleep changes have occurred and to identify potential triggers for these changes. For example, sometimes sleep problems may be related to medications, medical issues, or changes in activity levels or routine. We are now in a time where devices such as Fitbit watches and mobile phone apps can also be used to help assess and start the conversation about sleep, in conjunction with traditional sleep assessment methods, such as sleep diaries, sleep interview, validated questionnaires, and polysomnography. Given that sleep disturbance is associated with a range of negative health and functional consequences, as well as increased severity of psychopathology, it is beneficial that patients are proactively screened. Treating sleep disorders can aid the recovery journey and may also protect against mental health relapse.

Dr Oliveira: We should actively question patients with psychosis regarding their sleep. When facing clinical suspicion, screening instruments and further sleep evaluation should be considered. The contribution of poor sleep in exacerbating or even precipitating symptoms, not only hallucinations and delusions but also mood changes and concentration, should be acknowledged. The assessment of circadian rhythms, including the presence of insomnia, should happen in every appointment with patients with schizophrenia.

Dr Ferrarelli: In a review that was recently published,11 we reported that patients with schizophrenia often have a comorbid sleep disorder, including insomnia, obstructive sleep apnea, restless leg syndrome, or periodic limb movement disorder. However, although comorbid sleep disorders carry their own unique risks, including worsening of psychotic symptoms and poorer quality of life, sleep disturbances are rarely assessed in patients with schizophrenia in a clinical setting. Thus, it is very important that psychiatrists assess for the presence of sleep disorders in patients with schizophrenia.

A first step would be to ask simple questions about their sleep, such as:

  • Do you have trouble falling or staying asleep?
  • Do you wake up in the middle of the night gasping for air?
  • Do you feel tired or exhausted after waking up in the morning?

It would also be important to periodically screen, in a more systematic way, patients with schizophrenia for sleep disturbances. For example, self-reported questionnaires, such as the Pittsburgh Sleep Quality Index or the Epworth Sleepiness Scale, can be used to assess general sleep quality. Furthermore, some questionnaires can be used to determine risk for specific sleep disorders, such as the STOP-BANG for obstructive sleep apnea. Collecting this information periodically could help identify sleep disturbances in patients with schizophrenia early on, thus leading to more effective interventions in these patients.

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Psychiatry Advisor: Do insomnia treatment strategies for patients with schizophrenia differ from those used in patients without schizophrenia? What are the distinctions?

Dr Chiu: Every person is different, so, as with patients without schizophrenia, it is about catering strategies to the client’s specific profile of insomnia after a thorough assessment. Insomnia in schizophrenia can often co-occur with other sleep problems, such as night-eating syndrome, hypersomnia (excessive daytime sleepiness), sleep apnea, circadian sleep-wake rhythm disturbance (delayed sleep phase, irregular cycle, or sleep-wake reversal), and nightmares. Therefore, it is important to also assess for and address these when they occur, particularly as these conditions may form part of the triggers or maintenance factors for insomnia. Another consideration in treating insomnia for people with schizophrenia is the impact of their psychiatric medications on sleep, so part of treatment may include improving medication compliance or looking at the timing and dosing of medications.

Dr Oliveira: Current schizophrenia treatment guidelines do not address insomnia. In clinical practice, 1 of the following options is commonly chosen:

  • increasing the dose of the current antipsychotic,
  • switching to a sedative antipsychotic,
  • adding a low dose of a sedating antipsychotic, or
  • using anxiolytics, hypnotics, or other non-antipsychotic-sedative drugs as adjuvant therapy.

There is no single ideal approach for every patient. A chosen treatment should take into account the patient’s profile. The main factors are the patient’s current medication, the type of insomnia, its likely cause, sleep hygiene, and drug or alcohol abuse.

Dr Ferrarelli: There are both commonalities and differences for insomnia treatment strategies among patients with and without schizophrenia. A common goal is to ameliorate the sleep of all these patients, regardless of their diagnosis, using both pharmacological and nonpharmacological interventions. However, in patients with schizophrenia, insomnia may be related to the severity of psychotic symptoms, which tend to improve with antipsychotic medications. Also, antipsychotic medications often have a sedative, sleep-inducing effect. It is therefore more likely that 1 of these compounds will be used to treat or ameliorate insomnia in patients with schizophrenia, whereas in patients without schizophrenia, a benzodiazepine or a hypnotic medication may be chosen. Regarding nonpharmacological treatments, cognitive behavioral therapy for insomnia (CBT-I) is the most common, and currently the most effective, treatment intervention. Although CBT-I can be applied to anybody affected by insomnia, it was recently found that patients with schizophrenia with different sleep profiles, including classic insomnia with reduced total sleep time, insomnia with normal sleep duration, and insomnia with longer sleep time, differed in their response to CBT-I treatment, thus suggesting that treatment strategies should be personalized to obtain maximum benefit in these patients.

Psychiatry Advisor: Please feel free to add anything else about insomnia and schizophrenia that would be of interest to a clinical audience.

Dr Chiu: In our past research, conducting focus groups with people with schizophrenia, we found that many individuals report a desire to engage in psychological sleep therapies. When given the choice, many view CBT-I as a more acceptable long-term option in the treatment of their sleep disturbances over standard pharmacotherapy. All too often, however, people with schizophrenia lack awareness or access to these treatment options, despite recommendations by the American Academy of Sleep Medicine that CBT-I is the gold standard treatment for insomnia. This appears to be a significant missed opportunity, as, from an intervention perspective, disturbances in sleep may be simpler to treat than other clinical features of psychosis, such as distressing hallucinations and cognitive deficits.

Dr Oliveira: One aspect that we must always bear in mind is that insomnia in patients with schizophrenia may be iatrogenic. Atypical antipsychotics can lead to weight gain, including obesity. Obesity is 1 of the major risk factors for the development of obstructive sleep apnea syndrome. Obstructive sleep apnea is 1 of the most common causes of intermediate insomnia not only in patients with schizophrenia but also in the general population. Antipsychotics can also lead to insomnia by blocking dopaminergic receptors, leading to restless leg syndrome, a common cause of early insomnia.

Dr Ferrarelli: Do not underestimate the negative effects of insomnia and sleep disturbances on the clinical symptoms of patients with schizophrenia. Sleeping well can significantly improve the functioning and quality of life of individuals affected by this devastating mental illness.

References

1. Klingaman EA, Palmer-Bacon J, Bennett ME, Rowland LM. Sleep disorders among people with schizophrenia: emerging research. Curr Psychiatry Rep. 2015;17(10):79.

2. Malik S, Kanwar A, Sim LA, et al. The association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses: a systematic review and meta-analysis. Syst Rev. 2014;3(1):18.

3. Chiu VW, Ree M, Janca A, Waters F. Sleep in schizophrenia: exploring subjective experiences of sleep problems, and implications for treatment. Psychiatr Q. 2016;87(4):633-648.

4. Reeve S, Sheaves B, Freeman D. The role of sleep dysfunction in the occurrence of delusions and hallucinations: a systematic review. Clin Psychol Rev. 2015;42:96-115.

5. Benson KL. Sleep in schizophrenia: pathology and treatment. Sleep Medicine Clinics. 2015;10(1):49-55.

6. Robertson I, Cheung A, Fan X. Insomnia in patients with schizophrenia: current understanding and treatment options. Prog Neuropsychopharmacol Biol Psychiatry. 2019;92:235-242.

7. Faulkner S, Bee P. Experiences, perspectives and priorities of people with schizophrenia spectrum disorders regarding sleep disturbance and its treatment: a qualitative study. BMC Psychiatry. 2017;17(1):158.

8. Oliveira P, Coroa M, Madeira N. Treatment options for insomnia in schizophrenia: a systematic review. Pharmacopsychiatry [published online July 30, 2018]. doi: 10.1055/a-0658-1645

9. Roehrs T, Verster JC, Koshorek G, Withrow D, Roth T. How representative are insomnia clinical trials? Sleep Med. 2018;51:118-123.

10. Stummer L, Markovic M, Maroney ME. Pharmacologic treatment options for insomnia in patients with schizophrenia. Medicines (Basel). 2018;5(3):88.

11. Kaskie RE, Graziano B, Ferrarelli F. Schizophrenia and sleep disorders: links, risks, and management challenges. Nat Sci Sleep. 2017;9:227-239.