“Mr. Deuce,” a 22-year-old man with no previous psychiatric history, visited the emergency department with his family. He is a senior in college. He complains of early insomnia, does not sleep well and has been on NyQuil for the past two weeks with little effect.
According to his sister, the patient displayed paranoid thinking, saying he thought he was a superhero and that his college roommate was plotting to get him expelled. He also had delusions that his dorm room was being bugged. When he was admitted to the emergency department, he told his interviewer that he planned to meet the president the next day.
Patients may also have periods when speech becomes almost incoherent. His laboratory results, including a urine drug screen, were unremarkable. He was diagnosed with a first episode of psychosis and stabilized on risperidone increased to 3 mg daily during his psychiatric admission.
Sleep disturbances are very common in psychiatric patients.1 This comorbidity has a significant impact on the clinical course of the disease, including exacerbation of psychotic symptoms and cognitive impairment, decreased function and quality of life.2-4 However, the nature of the relationship between psychosis and sleep disturbances is unclear, and it may be a major component of the disease itself, and/or a secondary consequence of behavioral or iatrogenic factors. .Five
The Physical Health Assistance in Early Psychosis (PHAstER) study was a randomized clinical trial (RCT) of public health nurse interventions for patients with first-time psychosis (FEP).6 Ganon and Friends7 We performed a nested prospective cohort study within this RCT. Baseline and 6-month follow-up in FEP patients aged 15-24 years with less than 4 weeks of exposure to antipsychotics participating in the services of the Center for Early Psychosis Prevention and Intervention, Melbourne, Australia was evaluated.
Participants were diagnosed using the DSM-5 structured clinical interview. Insomnia was defined as an Insomnia Severity Index (ISI) score of 15 or greater. Poor sleep quality was determined by a Pittsburgh Sleep Quality Index (PSQI) score >5. Psychopathology was assessed using the Brief Psychiatric Rating Scale (BPRS) and the Negative Symptom Assessment Schedule (SANS).
Functioning was assessed with the Scale of Social and Occupational Functioning (SOFAS) and the Simple Physical Health Questionnaire (SIMPAQ) was used to measure physical activity. The authors used binary logistic regression models to calculate odds ratios for demographic and clinical predictors of insomnia or poor sleep quality.
Seventy-seven people participated in the PHAstER trial, of whom 70 (91%) had baseline data on insomnia. Mean age was 19.4 years, 53% of participants were male, and 44% were diagnosed with schizophreniform disorder.
The prevalence of clinical insomnia at study baseline was 43% (n=30). Insomniacs had more severe global psychopathology (BPRS total score mean 63 vs. 55) and negative symptoms (SANS score mean 24 vs. 14). Positive symptoms, demographic factors, function, and physical activity were not associated with baseline clinical insomnia.
At 6 months, 42 ISI data were available and the prevalence of insomnia had decreased to 21%. Those with insomnia at 6 months had more severe global positive psychopathology and decreased social and occupational functioning.
Poor baseline sleep quality was present in 87% of the cohort and had no associated demographic, clinical, or physical health factors. Only 43% of the cohort completed the PSQI at 6 months, 67% of whom had poor sleep quality. Similar to the insomnia data, those with poor sleep quality at 6 months of age had more severe global and positive psychopathology and decreased social and occupational functioning.
Conclusion of the study
The authors concluded that patients with FEP had a higher prevalence of poor sleep quality and insomnia. A strength of the study is that participants had minimal exposure to antipsychotics at baseline and in the long-term plan. The main limitation of the study was the substantial reduction in sleep data at 6 months follow-up.
There is some evidence to support sleep hygiene strategies8 Cognitive behavioral therapy (CBT-I) for insomnia in FEP.9 In contrast, evidence regarding the use of specific psychopharmacological agents for insomnia in this patient population is limited.
Findings provide evidence that sleep disturbances are common during the onset of psychotic illness. Sleep disturbances are potential therapeutic targets in psychosis to improve psychopathology and mental function.
Dr. Miller Professor of Psychiatry and Behavioral Health, Augusta University, Augusta, Georgia. He is on the editorial board and head of the schizophrenia department. Psychiatry Times®. The authors report research support from Augusta University, the National Institute of Mental Health, and the Stanley Institute of Medicine.
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