Sleep Disorders in Early Psychosis: Incidence, Severity, and Association With Clinical Symptoms

Sarah Reeve; Bryony Sheaves; Daniel Freeman


Schizophr Bull. 2019;45(2):287-295. 

In This Article



The participant group comprised a higher proportion of men (n = 39, 65%) than women (n = 21, 35%). The average age was 23.7 years old (SD = 3.2). Twenty-six participants (43.3%) were unemployed. Most participants were referred from early intervention psychosis services (n = 45, 75.0%). The most common diagnoses were psychosis (not otherwise specified) (n = 25, 41.7%) and schizophrenia (n = 17, 28.3%). The majority were prescribed antipsychotic medication (n = 49, 81.7%), and 40% (n = 24) were prescribed antidepressants. A detailed breakdown of demographics is available in Table 2.

Sleep Disorders: Prevalence and Severity

Sleep disorders were common, with 80% (n = 48) of the participants receiving a positive screen or diagnosis for at least one disorder. As can be seen in Table 3, the most common sleep diagnoses were insomnia (n = 30, 50%) and nightmare disorder (n = 29, 48.3%). However, there was a broad range of sleep issues presenting in this group and comorbidity was high, with an average of 3.3 sleep disorders per patient. Notable areas of comorbidity include insomnia and nightmares, with 20 individuals (33%) receiving a diagnosis of both disorders. The majority of all sleep disorders (n = 77, 52%) were severe in their presentation.

A large proportion of participants (n = 54, 90%) endorsed at least one apnea symptom (Supplementary Appendix 3). "Feeling sleepier than others your age" was the most commonly endorsed indicator (n = 42, 70%), although breathing related apnea symptoms were also present, with 17 participants (28.3%) reported waking from sleep not breathing or gasping or choking, and 9 participants (15%) reported stopping breathing or breathing abnormally while asleep.

Sleep Disorders and Sleep Recording Variables

For circadian disorders, sleep recordings were used to confirm shifted sleep times. Two individuals fulfilled the early sleep onset criterion (9 PM or earlier), with average sleep onsets of 19:34 and 20:30. Delayed sleep phase disorder required evidence of a late onset (1AM or later). Three individuals satisfied this criterion with sleep onset averages of 01:36, 02:05, and 03:08. An 11 hour or more sleep duration (in a 24-hour period) was required to satisfy the hypersomnia diagnostic requirement, which was confirmed for 5 participants, with durations ranging from 11 hours 00 minutes to 12 hours 13 minutes. All times reported are from sleep diaries, but were corroborated by actigraphic recording.

Sleep recording differences are not required for a diagnosis of insomnia, but self-reported sleep duration was significantly lower in individuals with insomnia compared with those without insomnia, as measured by sleep diaries (8 h 12 min compared with 9 h 56 min, t = 5.09, P < .001) and actigraphy (7 h 25 min compared with 8 h 20 min; t = 2.57, P = .013). Individuals with insomnia disorder reported a lower sleep efficiency in their sleep diaries than those without insomnia (74.8% of time in bed was spent asleep in those with insomnia, compared with 89.4% in those without insomnia; t = 4.36, P < .001). Differences in actigraphic sleep efficiency were nonsignificant (t = 0.594, P = .556) in those with insomnia (75.3%) compared with those without insomnia (76.5%).

Clinical Service Assessment and Treatment

Approximately half of all sleep disorders had been discussed with a medical professional (n = 60, 53.1%), with insomnia the most frequently discussed (80%, n = 24). The remaining disorders had either not been discussed (n = 43, 38.1%) or the participant was unsure if they had discussed it with a medical professional (n = 10, 8.8%). Night terror, nightmare disorder, and RLS were the disorders least commonly discussed with a clinician (all below 50%). Further information can be found in Supplementary Appendix 4.

Thirty-four sleep disorders had received treatment; this is 30% of all sleep disorders, or 56.7% of those that were discussed with a medical professional. The majority received a nonrecommended treatment (n = 21, 61.8%), typically antipsychotic or antidepressant medication prescribed with intent to aid in sleep. Of the 13 disorders which received recommended treatment, only hypnotic medication for insomnia (5 cases) was accessed through routine mental health care. Four instances of Bruxism were treated by a dentist, an enuresis case by surgery, and 2 nightmare disorder cases and 1 insomnia case received CBT interventions via randomized controlled trials conducted by our specialist research team.

Psychotic Experiences, Affect, and Wellbeing

Compared with not having a sleep disorder diagnosis, having at least one sleep disorder was significantly associated with more severe paranoia, hallucinations, and cognitive disorganization (Table 4). There was no significant relationship between sleep disorder presence and grandiosity.

Individuals with at least one sleep disorder had more severe depression and anxiety. They also reported significantly lower health-related quality of life, and higher fatigue.

Medication and Sleep Disorders

Considering the number of individuals identifying their antipsychotic medication as a treatment for their sleep disorder we performed secondary analyses to test if antipsychotic medication dosage differed between those with and those without the most common sleep disorders (insomnia and nightmares). The defined daily dose (DDD) of antipsychotics in individuals with insomnia (average DDD = 0.72, SD = 0.59) was lower than in individuals without an insomnia diagnosis (1.05, 0.94), however this difference was nonsignificant (t = 1.617, P = .111). There was similarly no significant difference in antipsychotic DDD in individuals with nightmare disorder (average DDD = 0.81, SD = 0.62) compared with those without nightmare disorder (0.95, 0.94; t = 0.675, P = .503).