Treating residual insomnia in schizophrenia: examining the options

Pharmacologic Treatment Options for Insomnia in Patients with Schizophrenia

Background: Symptoms of sleep disorders, such as disturbances in sleep initiation and continuity, are commonly reported in patients with schizophrenia, especially in the acute phase of illness. Studies have shown that up to 80% of patients diagnosed with schizophrenia report symptoms of insomnia. Sleep disturbances have been shown to increase the risk of cognitive dysfunction and relapse in patients with schizophrenia. Currently, there are no medications approved specifically for the treatment of insomnia in patients with schizophrenia. Methods: A literature search was performed through OVID and PubMed to compile publications of pharmacotherapy options studied to treat insomnia in patients with schizophrenia. Articles were reviewed from 1 January 2000 through 1 March 2018 with some additional earlier articles selected if deemed by the authors to be particularly relevant. Results: Pharmacotherapies collected from the search results that were reviewed and evaluated included melatonin, eszopiclone, sodium oxybate, and antipsychotics. Conclusions: Overall, this review confirmed that there are a few evidence-based options to treat insomnia in patients with schizophrenia, including selecting a more sedating second-generation antipsychotic such as paliperidone, or adding melatonin or eszopiclone. Further randomized controlled trials are needed.

Targets for the Treatment of Insomnia in Veterans With Serious Mental Illness

STUDY OBJECTIVES

Insomnia is pervasive among people with serious mental illnesses (SMI) and has a profound negative impact on their psychiatric symptom management and recovery. However, little is known about the factors that affect severity of insomnia in those with SMI. In addition, very few studies have explored whether evidence-based interventions developed for those without SMI are appropriate for or applicable to individuals with SMI. The purpose of this study was to test the role of arousal, dysfunctional cognitions about sleep, and sleep-related behaviors in predicting severity of insomnia in a sample of 60 Veterans who were receiving care in Veterans Health Administration mental health and psychosocial rehabilitation programs and who reported subjective insomnia. In addition, information was collected regarding the types of insomnia treatments provided to these Veterans.

METHODS

Participants completed assessments of insomnia severity and sleep-related arousal, behaviors, and cognitions. Medical records were reviewed to determine whether participants had been screened/assessed for insomnia and whether treatments for insomnia were provided before the date of referral to the study. Multiple regression was used to predict insomnia severity on the basis of these factors.

RESULTS

Most participants (81.7%) reported moderate to severe insomnia, although only 3.3% had a diagnosis of insomnia in their medical records. Worry and helplessness about sleep were predictive of insomnia severity; better self-reported sleep hygiene and higher levels of arousal were also associated with greater severity of insomnia. Education about sleep hygiene and medication were the only types of insomnia treatment received.

CONCLUSIONS

Similar to insomnia among individuals without SMI, insomnia in Veterans with SMI is associated with dysfunctional sleep-related behaviors and cognitions. Many of the Veterans also lacked access to settings and resources conducive to healthy sleep. Veterans with SMI should be regularly assessed for insomnia. Research is needed concerning optimal evidence-based insomnia interventions for addressing behaviors and cognitions in this population in the context of these challenges.

Sleep Disturbances and Suicide Risk in an 8-Year Longitudinal Study of Schizophrenia-Spectrum Disorders

STUDY OBJECTIVES

Disrupted sleep is one of the prominent but often overlooked presenting symptoms in the clinical course of psychotic disorders. The aims of this study were to examine the prevalence of sleep disturbances, particularly insomnia and nightmares, and their prospective associations with the risk of suicide attempts in patients with schizophrenia-spectrum disorders.

METHODS

A naturalistic longitudinal study was conducted in outpatients diagnosed with schizophrenia-spectrum disorders recruited from the psychiatric outpatient clinic of a regional university-affiliated public hospital in Hong Kong. A detailed sleep questionnaire was completed by 388 patients at baseline in May-June 2006. Relevant clinical information was extracted from clinical case notes from June 2007-October 2014.

RESULTS

Prevalence of frequent insomnia and frequent nightmares was 19% and 9%, respectively. Baseline frequent insomnia was significantly associated with an increased incidence of suicide attempts during the follow-up period (adjusted hazard ratio = 4.63, 95% confidence interval 1.40-15.36, P < 0.05). Nightmare complaint alone did not predict the occurrence of suicide attempts, but the comorbidity of nightmares and insomnia was associated with the risk of suicide attempt over follow-up (adjusted HR = 11.10, 95% confidence interval: 1.68-73.43, P < 0.05).

CONCLUSIONS

Sleep disturbances are common in patients with schizophrenia-spectrum disorders. The association between sleep disturbances and suicidal risk underscores the need for enhanced clinical attention and intervention on sleep disturbances in patients with schizophrenia.

Sleep Disturbances in Schizophrenia

Sleep disturbances are prevalent in patients with schizophrenia and play a critical role in the morbidity and mortality associated with the illness. Subjective and objective assessments of sleep in patients with schizophrenia have identified certain consistent findings. Findings related to the sleep structure abnormalities have shown correlations with important clinical aspects of the illness. Disruption of specific neurotransmitter systems and dysregulation of clock genes may play a role in the pathophysiology of schizophrenia-related sleep disturbances. Antipsychotic medications play an important role in the treatment of sleep disturbances in these patients and have an impact on their sleep structure.

Sleep Disorders Among People With Schizophrenia: Emerging Research

Up to 80 % of individuals with schizophrenia spectrum disorders experience sleep disturbances, which impact physical and mental health, as well as quality of life. In this paper, we review and integrate emerging literature, published between 2012 and 2014, regarding approaches to diagnosis and treatment of major sleep disorders for people with schizophrenia spectrum disorders, including insomnia, obstructive sleep apnea (OSA), circadian rhythm dysfunction, and restless legs syndrome (RLS). We advocate for (1) the need to evaluate the utility of nonpharmacological approaches in people with schizophrenia spectrum disorders; (2) documentation of guidelines to assist providers in clinically tailoring such interventions when their clients experience positive, negative, and/or cognitive symptoms; (3) research on the best ways providers can capitalize on clients' self-identified needs and motivation to engage in sleep treatments through shared decision making; and (4) the importance of investigating whether and how mental health and sleep treatment services should be better connected to facilitate access for people with schizophrenia spectrum disorders. Assessment and tailored treatment of sleep disorders within mental health treatment settings has the potential to reduce sleep problems and improve functioning, quality of life, and recovery of this population.

Insomnia comorbid to severe psychiatric illness

In psychiatric illness, there is a growing body of evidence indicating that sleep disturbances exert a detrimental influence on the course of these disorders and contribute to impaired function. Even when psychiatric disorders are successfully treated or stabilized, insomnia and other sleep disturbances often fail to remit. The present review focuses on sleep in two severe mental illnesses, namely bipolar disorder and schizophrenia. This article discusses the role of sleep disturbances and altered sleep architecture in relation to symptom status, functional impairment, quality of life, and the course of these disorders. Current evidence regarding pharmacological and psychological treatment approaches for insomnia in these populations is presented. This review also notes considerations for adapting Cognitive Behavioral Therapy for insomnia (CBT-I) procedures for severe mental illness and proposes directions for future research.