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

Abstract and Introduction


Sleep disturbance is known to be associated with psychosis, but sleep disorders (eg, insomnia, nightmare disorder, sleep apnea) have rarely been investigated. We aimed to provide the first detailed assessment of sleep disorders and their correlates in patients with early psychosis. Sixty outpatients aged between 18 and 30 with nonaffective psychosis were assessed for sleep disorder presence, severity, and treatment using a structured diagnostic interview, sleep diaries, and actigraphy. Psychotic experiences, mood, and psychological wellbeing were also measured. Forty-eight patients (80%) had at least one sleep disorder, with insomnia and nightmare disorder being the most common. Comorbidity of sleep disorders within this group was high, with an average of 3.3 sleep disorders per patient. Over half of the sleep disorders had been discussed with a clinician but almost three-quarters had received no treatment. Treatment according to clinical guidelines was rare, occurring in only 8% of cases (n = 13). Sleep disorders were significantly associated with increased psychotic experiences, depression, anxiety, fatigue, and lower quality of life. Sleep disorders are very common in patients with psychosis, may have wide-ranging negative effects, and merit routine assessment and treatment in psychiatric practice.


Over recent years, there has been a growing recognition of the potential importance of disrupted sleep in psychosis.[1,2] Sleep disturbance is a primary motivation for many patients to seek mental health treatment,[3,4] and there is an awareness among both professionals and patients of an interaction between poor sleep and worsening mental health.[5,6] Many studies have found that sleep disturbance (eg, shorter sleep time, lowered sleep quality) is associated with increased psychotic experiences in clinical,[7] nonclinical,[8] and at-risk[9,10] populations.[1,2] Yet relatively few studies have investigated clinical sleep disorders (eg, insomnia, nightmare disorder, sleep apnea) in psychosis, which clearly cause sleep disturbance and therefore present targets for intervention.[1,11] This study sought to carry out the first detailed assessment of clinical sleep disorders in patients experiencing early psychosis.

The evidence to date does indicate that sleep disorders are an important clinical issue in psychosis. Insomnia, by far the most researched sleep disorder, has been shown to be common, severe, and—importantly—treatable in patients with psychosis.[12,13]There are also indications that other sleep disorders, for instance, nightmares and circadian disruption, may be more common in psychosis.[11,14,15] Only one study identified had assessed multiple sleep disorders, finding that comorbid insomnia and nightmares in schizophrenia was associated with a greatly elevated suicide risk above either sleep disorder individually.[16] To date, therefore, the range of potential sleep disorder comorbidity in psychosis has not been fully elucidated, despite its possible clinical importance.

Taking sleep disorders in psychosis seriously may have important benefits. Recent manipulation studies have demonstrated that simulating insomnia increases psychotic experiences,[17] and, conversely, treating insomnia reduces psychotic experiences.[18] Therefore, independently of the importance of treating sleep disorders in their own right,[19] treating sleep represents a new therapeutic target for psychosis itself. Yet a recent survey of clinicians found that the use of formal sleep assessments with patients with psychosis is rare, as is provision of evidence-based sleep treatments.[5]

We set out to report on the presence, severity, and treatment of a wide range of sleep disorders in patients with nonaffective psychosis attending outpatient clinical services. The focus was on patients with early psychosis, to limit the impact of age and long-term medication usage. The association between sleep disorders, psychiatric symptoms, and wellbeing was tested as a secondary objective. We hypothesized that: sleep disorders are common, severe, and often unassessed and untreated among patients with psychosis; and that patients with sleep disorders in the context of psychosis have more severe psychotic experiences, lowered mood, and reduced wellbeing compared with those without sleep disorders. The results can help guide clinicians' expectations of patient presentations in early psychosis clinical services.