Insomnia in patients with schizophrenia: current understanding and treatment options

Sleep disruptions and the pathway to psychosis: An in-depth case and literature review

Key Clinical Message

The case highlights an unusual presentation where sleep issues preceded psychotic symptoms, implying link between disrupted sleep and psychosis onset. Earlier symptoms were viewed as depression but may have signaled psychosis exacerbated by insomnia.

Abstract

Sleep disorders, prevalent yet frequently overlooked in individuals with psychotic disorders, have significant associations with the onset and severity of psychosis. Here we describe the case of a patient who first presented with insomnia, but whose condition improved with the use of risperidone and was diagnosed with first-episode psychosis. Multiple studies emphasize the critical relationship between sleep disturbances and psychosis, particularly in the lead-up to first-episode psychosis. Structural abnormalities in the brain, notably the thalamus, combined with neurotransmitter imbalances involving dopamine and acetylcholine, seem pivotal in this interrelation. The connection between dopamine, sleep disturbances, and psychosis, specifically the role of D2 dopamine receptors, highlights a potential pathway bridging sleep irregularities with psychosis. The study underscores the need for further research to delineate the relationship between sleep disturbances and psychosis and to assess the efficacy of various therapeutic interventions targeting both conditions.

The interaction between polygenic risk and environmental influences: A direct test of the 3P model of insomnia in adolescents

BACKGROUND

Stress is a universal phenomenon and one of the most common precipitants of insomnia. However, not everyone develops insomnia after experiencing a stressful life event. This study aims to test aspects of Spielman's '3P model of insomnia' (during adolescence) by exploring the extent to which: (a) insomnia symptoms are predicted by polygenic scores (PGS); (b) life events predict insomnia symptoms; (c) the interaction between PGS and life events contribute to the prediction of insomnia symptoms; (d) gene-environment interaction effects remain after controlling for sex.

METHODS

The sample comprised 4,629 twins aged 16 from the Twin Early Development Study who reported on their insomnia symptoms and life events. PGS for insomnia were calculated. In order to test the main hypothesis of this study (a significant interaction between PGS and negative life events), we fitted a series of mixed effect regressions.

RESULTS

The best fit was provided by the model including sex, PGS for insomnia, negative life events, and their interactions (AIC = 26,158.7). Our results show that the association between insomnia symptoms and negative life events is stronger for those with a higher genetic risk for insomnia.

CONCLUSIONS

This work sheds light on the complex relationship between genetic and environmental factors implicated for insomnia. This study has tested for the first time the interaction between genetic predisposition (PGS) for insomnia and environmental stressors (negative life events) in adolescents. This work represents a direct test of components of Spielman's 3P model for insomnia which is supported by our results.

Circadian rhythmicity in schizophrenia male patients with and without substance use disorder comorbidity

Circadian rhythmicity is associated to clinical variables that play an important role in both schizophrenia (SZ) and substance use disorders (SUD), although the characteristics of the coexistence of these two diagnoses (SZ +) remain mostly unknown. Hence, we studied a sample of 165 male patients divided in three groups each of 55, according to their diagnoses (SZ + , SZ, and SUD), as well as a healthy control (HC; n = 90) group. Alongside with sociodemographic and clinical variables, circadian rhythms were registered through a sleep-wake data structured interview, a circadian typology questionnaire, and distal skin temperature (DST) using the Thermochron iButton every 2 min during 48 h. Analyses showed that SZ + and SZ patients presented a longer sleep (delay in wake-up time) and mostly an intermediate circadian typology, while SUD patients slept less hours, displaying a morning typology. The DST showed the highest daily activation and stability for the SUD group, even when compared with the HC group. The presence of schizophrenia (SZ + and SZ) was related to a DST pattern with a reduced amplitude determined by a wakefulness impairment, which was more pronounced for SZ patients whose sleep period was adequate. The assessment of circadian rhythms in under treatment male patients with SZ should be focused on the diurnal period as a possible marker of either treatment adherence or patient's recovery, irrespective of the presence of a comorbid SUD. Further research with additional objective measures may provide knowledge transferable to therapeutic strategies and could be useful to establish possible endophenotypes in the future.

Inter-relationships of insomnia and psychiatric symptoms with suicidal ideation among patients with chronic schizophrenia: A network perspective

BACKGROUND

Insomnia is common in patients with schizophrenia, which contributes to worsening psychiatric symptoms and suicidality. We aimed to assess the inter-relationships of insomnia and psychopathology with suicidal ideation (SI) among 1407 Chinese patients with chronic schizophrenia via the network approach.

METHOD

We used Positive and Negative Syndrome Scale, Insomnia Severity Index, and Beck Scale for Suicidal Ideation to assess psychiatric symptoms, insomnia, and SI, respectively. Lifetime suicidal attempts (SA) were collected.

RESULTS

(1) The incidence of insomnia, lifetime SI, lifetime SA, and current SI was 13.5% (n = 190), 22.8% (n = 321), 13.5% (n = 190), and 9.7% (n = 136), respectively. (2) Patients with insomnia had worse clinical symptoms and higher suicidal risk. (3) Daytime dysfunction, sleep-related distress, conceptual disorganization, delusions, anxiety, and poor rapport were the core symptoms, while late sleep onset and sleep dissatisfaction emerged as bridge symptoms connecting insomnia and psychopathology. (4) Depressive mood, hallucinations, poor impulse control, guilty feelings, insomnia-related impaired quality of life, and sleep dissatisfaction were directly associated with SI.

CONCLUSION

Our findings called for formal assessment of insomnia in patients with schizophrenia, which should cover both nocturnal and daytime insomnia symptoms. Targeted interventions for key symptoms may help reduce insomnia, psychiatric symptoms, and SI in patients with schizophrenia.

Correlation analysis between insomnia symptoms and language function in patients with schizophrenia

Objective

To explore the correlation between insomnia and language ability in patients with schizophrenia.

Methods

120 patients with schizophrenia admitted to our hospital from June 2020 to January 2022 were enrolled as the research objects. According to the total score of the Pittsburgh Sleep Index (PSQI), they were divided into the insomnia group (PSQI total score > 10 points) and the non-insomnia group (PSQI total score ≤ 10 points). To compare the difference in verbal fluency scale between insomnia and non-insomnia groups and to understand the correlation between insomnia symptoms and language ability in patients with schizophrenia.

Results

There were no significant differences in age, gender, and years of education between the insomnia group and the non-insomnia group (P > 0.05). The total score of the verbal fluency test (VFT) in the insomnia group was significantly different from that in the non-insomnia group (P < 0.01). The total score of the insomnia group was lower than that of the non-insomnia group, and the factors (fluency animal, fluency fruit and vegetable, speech fluency, motor fluency) were lower than that of the non-insomnia group. Logistic regression analysis showed that the total verbal fluency score in schizophrenia patients was negatively correlated with insomnia symptoms (P < 0.05). Schizophrenia patients with insomnia symptoms had worse language ability than those without.

Conclusion

There is a significant difference in language ability between schizophrenia patients with insomnia and those without insomnia symptoms. This suggests that schizophrenia patients with insomnia have a greater probability of language ability disorder.

Machine learning techniques in diagnostics and prediction of the clinical features of schizophrenia: a narrative review

BACKGROUND

Schizophrenia is a severe psychiatric disorder associated with a significant negative impact. Early diagnosis and treatment of schizophrenia has a favorable effect on the clinical outcome and patients quality of life. In this context, machine learning techniques open up new opportunities for a more accurate diagnosis and prediction of the clinical features of this illness.

AIM

This literature review is aimed to search for information on the use of machine learning techniques in the prediction and diagnosis of schizophrenia and the determination of its clinical features.

METHODS

The Google Scholar, PubMed, and eLIBRARY.ru databases were used to search for relevant data. The review included articles that had been published not earlier than January 1, 2010, and not later than March 31, 2023. Combinations of the following keywords were applied for search queries: machine learning, deep learning, schizophrenia, neural network, predictors, artificial intelligence, diagnostics, suicide, depressive, insomnia, and cognitive. Original articles regardless of their design were included in the review. Descriptive analysis was used to summarize the retrieved data.

RESULTS

Machine learning techniques are widely used in the functional assessment of patients with schizophrenia. They are used for interpretation of MRI, EEG, and actigraphy findings. Also, models created using machine learning algorithms can analyze speech, behavior, and the creativity of people and these data can be used for the diagnosis of psychiatric disorders. It has been found that different machine learning-based models can help specialists predict and diagnose schizophrenia based on medical history and genetic data, as well as epigenetic information. Machine learning techniques can also be used to build effective models that can help specialists diagnose and predict clinical manifestations and complications of schizophrenia, such as insomnia, depressive symptoms, suicide risk, aggressive behavior, and changes in cognitive functions over time.

CONCLUSION

Machine learning techniques play an important role in psychiatry, as they have been used in models that help specialists in the diagnosis of schizophrenia and determination of its clinical features. The use of machine learning algorithms is one of the most promising direction in psychiatry, and it can significantly improve the effectiveness of the diagnosis and treatment of schizophrenia.

Sleep Disturbances in At-Risk Mental States and First Episode of Psychosis: A Narrative Review on Interventions

Sleep disturbances are a common yet often overlooked symptom of psychosis that can drastically affect the quality of life and well-being of those living with the condition. Sleep disorders are common in people diagnosed with schizophrenia and have significant negative effects on the clinical course of the illness and the functional outcomes and quality of life of patients. There is a limited number of studies addressing this question in first-episode psychosis (FEP). In this narrative review, we aimed to provide an overview of sleep disorders in populations with FEP and at-risk mental states (ARMS). The review was focused on the various treatments currently used for sleep disorders, including both non-pharmacological and pharmacological treatments. A total of 48 studies were included. We found that sleep disturbances are associated with attenuated psychotic symptoms and other psychopathological symptoms in ARMSs. The association of sleep disturbances with the transition to psychosis has been poorly investigated. Sleep disturbances have an impact on the quality of life and the psychopathological symptoms of people suffering from FEP. The non-pharmacological treatments include cognitive behavioral therapy for insomnia, bright light therapy, cognitive restructuring techniques, sleep restriction therapy, basic sleep hygiene education, and the provision of portable sleep trackers. Other treatments include antipsychotics in acute phases and melatonin. The early intervention in sleep disturbances may improve overall prognosis in emerging psychosis populations.

The Feature of Sleep Spindle Deficits in Patients With Schizophrenia With and Without Auditory Verbal Hallucinations

BACKGROUND

Previous sleep electroencephalography studies have detected abnormalities in sleep architecture and sleep spindle deficits in schizophrenia (SCZ), but the consistency of these results was not robust, which might be due to the small sample size and the influence of clinical factors such as the various medication therapies and symptom heterogeneity. This study aimed to regard auditory verbal hallucinations (AVHs) as a pointcut to downscale the heterogeneity of SCZ and explore whether some sleep architecture and spindle parameters were more severely impaired in SCZ patients with AVHs compared with those without AVHs.

METHODS

A total of 90 SCZ patients with AVHs, 92 SCZ patients without AVHs, and 91 healthy control subjects were recruited, and parameters of sleep architecture and spindle activities were compared between groups. The correlation between significant sleep parameters and clinical indicators was analyzed.

RESULTS

Deficits of sleep spindle activities at prefrontal electrodes and intrahemispheric spindle coherence were observed in both AVH and non-AVH groups, several of which were more serious in the AVH group. In addition, deficits of spindle activities at central and occipital electrodes and interhemispheric spindle coherence mainly manifested accompanying AVH symptoms, most of which were retained in the medication-naive first-episode patients, and were associated with Auditory Hallucination Rating Scale scores.

CONCLUSIONS

Our results suggest that the underlying mechanism of spindle deficits might be different between SCZ patients with and without AVHs. In the future, the sleep feature of SCZ patients with different symptoms and the influence of clinical factors, such as medication therapy, should be further illustrated.

Exploring the association between lifetime traumatic experiences and positive psychotic symptoms in a group of long-stay patients with schizophrenia: the mediating effect of depression, anxiety, and distress

BACKGROUND

Positive psychotic symptoms of schizophrenia are generally characterized by hallucinations and delusions. We propose to assess the relationship between total composite trauma and positive psychotic symptoms, along with the mediation effect of cognition, fear of COVID-19, insomnia, anxiety, distress, and depression of Lebanese patients with schizophrenia.

METHODS

A cross-sectional study was carried out, between June and July 2021, by deriving data from 155 long-stay in-patients diagnosed with schizophrenia.

RESULTS

Depression, anxiety, and distress but not cognitive impairment, insomnia, and fear of COVID-19) mediated the association between lifetime traumatic experiences and positive psychotic symptoms. Higher traumatic experiences were associated with greater depression, anxiety, and distress, indicating a significant positive total effect on positive psychotic scores. Moreover, higher depression, anxiety, and distress were significantly associated with higher positive psychotic symptoms.

CONCLUSION

Our results contribute to the existing knowledge by suggesting other possible intervention paths through mediating factors. Interventions that improve anxiety, depression, and distress severity may be effective in reducing positive psychotic symptoms among patients with schizophrenia having experienced lifetime trauma.

Circadian functioning and quality of life in substance use disorder patients with and without comorbid schizophrenia

Sleep disturbances are strongly linked with mental diseases such as substance use disorder (SUD) or schizophrenia (SZ) which can have a detrimental impact on quality of life (QOL), especially when both disorders are comorbid (dual disorder). In absence of studies about both circadian characteristics and QOL in patients with SUD and comorbid SZ (SUD + SZ), we examined a sample of 155 male under treatment, 75 with SUD + SZ and 80 only with SUD. Circadian functioning was evaluated by chronotype, social jet-lag and sleep quality (using the Pittsburgh Sleep Quality Index, PSQI), while the QOL was obtained by the World Health Organization's Quality of Life Questionnaire (WHOQOL)-BREF. SUD + SZ patients were more evening type than SUD, and this chronotype was linked to polydrug use in total sample and SUD + SZ group. We observed that the comorbidity did not lead to worse sleep quality in the SUD and SUD + SZ patients. QOL was poorer in SUD + SZ patients, who showed a negative association of Physical health, Psychological health and Social relationship with suicide attempts and severity of SZ. Lastly, patients with worse QOL also reported poorer sleep quality suggesting that treatment could include circadian adjustments along with a focused approach to lifestyle improvement.

Weight Gain, Mental Symptoms and Self-Esteem in Patients with Schizophrenia

The aim of this study is to examine the weight gain, mental symptoms and self-esteem in patients with schizophrenia undergoing treatment at a community mental health center (CMHC). The study is conducted with 103 schizophrenic patients between 01.08.2021 – 01.02.2022. The data was collected with Personal Information Form, Rosenberg Self-esteem Scale, and Positive and Negative Syndrome Scale (PANSS). 35% of the patients are women, 43.7% are single, and 48.5% are between the ages of 45-64. There was no significant increase between the patients’ weigh measurement value in the first month (x̄=81.185) and the measurement value at the end of six months (x̄=81.320). The decrease in the self-esteem scale mean score at the end of six months (x̄=1.317) was not found significant, when compared to the self-esteem scale mean score in the first month (x̄=1452). The PANSS General Psychopathology subscale mean score was found to be statistically lower at the end of the six-month follow-up (x̄=26.418), compared to the first month mean score (x̄=27.136). There was no significant difference between weight gain, self-esteem, and PANSS positive/negative symptoms in the six-month follow-up of patients with schizophrenia enrolled in CMHC. A significant difference was discovered between the first and sixth-month measurements in PANSS general psychopathology symptoms. It is detected that gender, working status, atypical and mixed antipsychotics use, smoking status, and changes in daytime sleeping habits affect mental symptoms.

The characteristics of discharge prescriptions including pro re nata psychotropic medications for patients with schizophrenia and major depressive disorder from the survey of the "Effectiveness of guidelines for dissemination and education in psychiatric treatment (EGUIDE)" project

BACKGROUND

Several guidelines recommend monotherapy in pharmacotherapy for schizophrenia and major depressive disorder. The content of regular prescriptions has been reported in several studies, but not enough research has been conducted on the content of pharmacotherapy, including pro re nata (PRN) medications. The purpose of this study was to evaluate the content of pharmacotherapy, including PRN medications, and to clarify the relationship with regular prescriptions.

METHODS

We used data from the "Effectiveness of Guidelines for Dissemination And Education in psychiatric treatment" (EGUIDE) project to investigate the presence or absence of PRN psychotropic medications at discharge for each drug category. We compared the PRN psychotropic prescription ratio at discharge by diagnosis for each drug category. The antipsychotic monotherapy ratio and no prescription ratio of other psychotropics for schizophrenia at discharge and the antidepressant monotherapy ratio and no prescription ratio of other psychotropics for major depressive disorder at discharge were calculated for each regular prescription, including PRN psychotropic medications, as quality indicators (QIs). Spearman's rank correlation test was performed for QI values of regular prescriptions and the QI ratio between regular prescriptions and prescriptions including PRN medications for each diagnosis.

RESULTS

The PRN psychotropic prescription ratio at discharge was 28.7% for schizophrenia and 30.4% for major depressive disorder, with no significant differences by diagnosis. The prescription ratios of PRN antipsychotic medications and PRN antiparkinsonian medications were significantly higher for schizophrenia. The prescription ratios of PRN anxiolytic and hypnotic and PRN antidepressant medications were significantly higher for patients with major depressive disorder. For both schizophrenia and major depressive disorder, the QI was lower for discharge prescriptions, including PRN medications, than for regular prescriptions. QI values for regular prescriptions and the QI ratio were positively correlated.

CONCLUSIONS

Considering PRN psychotropic medications, the monotherapy ratio and no prescription ratio of other psychotropics at discharge decreased in pharmacotherapy for schizophrenia and major depressive disorder. A higher ratio of monotherapy and no prescription of other psychotropics on regular prescriptions may result in less concomitant use of PRN psychotropic medications. Further studies are needed to optimize PRN psychotropic prescriptions.

Comparisons of resting-state brain activity between insomnia and schizophrenia: a coordinate-based meta-analysis

Growing evidence shows that insomnia is closely associated with schizophrenia (SCZ), but the neural mechanism under the association remains unclear. A direct comparison of the patterns of resting-state brain activities would help understand the above question. Using meta-analytic approach, 11 studies of insomnia vs. healthy controls (HC) and 39 studies of SCZ vs. HC were included to illuminate the common and distinct patterns between insomnia and SCZ. Results showed that SCZ and insomnia shared increased resting-state brain activities in frontolimbic structures including the right medial prefrontal gyrus (mPFC) and left parahippocampal gyrus. SCZ additionally revealed greater increased activities in subcortical areas including bilateral putamen, caudate and right insula and greater decreased activities in precentral gyrus and orbitofrontal gyrus. Our study reveals both shared and distinct activation patterns in SCZ and insomnia, which may provide novel insights for understanding the neural basis of the two disorders and enlighten the possibility of the development of treatment strategies for insomnia in SCZ in the future.

Exploring potential mechanism of ciwujia tablets for insomnia by UPLC-Q-TOF-MS/MS, network pharmacology, and experimental validation

Insomnia, whether chronic or intermittent, is a common central nervous system disease. Ciwujia Tablet (CWT) is a well-known traditional Chinese medicine (TCM) made from the extract of Eleutherococcus senticosus (Rupr. & Maxim.) Maxim. This medication is commonly used for treating insomnia in China, but the lack of in-depth research focused on the chemical ingredients of CWT creates a gap in knowledge regarding its effective constituents against insomnia. Considering that the therapeutic material basis, targets, and pathways related to this drug have not been fully investigated by scholars in the field, the focus of this study is on identifying the chemical ingredients or structural characteristics of CWT by the UPLC-Q-TOF-MS/MS technique. Besides, concepts of network pharmacology were also used to investigate the targets and pathways of CWT. An insomnia rat model was established by intraperitoneal injection of p-chlorophenylalanine, and the results were verified through various experiments. A total of 46 ingredients were identified in CWT, such as eleutheroside B, eleutheroside E, isofraxidin, and chlorogenic acid. Among them, 17 ingredients with good solubility, favorable gastrointestinal absorption, and high bioavailability were selected for network pharmacological analysis. It was concluded that CWT participated in the regulation of neurotransmitter levels, modulation of ion transport, neurotransmitter receptor activity, synaptic transmission, dopaminergic transmission and other essential processes. Results from the animal experiments showed that CWT can increase the content of inhibitory neurotransmitters 5-HT and GABA in the brain, reduce the synthesis of excitatory escalating transmitters DA and NE, shorten the sleep latency and prolong the sleep duration of insomnia rats. Furthermore, CWT could significantly alleviate the symptoms of insomnia in model rats. Identifying the chemical ingredients of CWT in this experiment is of great significance for exploring its potential curative effects, which provides a solid basis for further understanding the therapeutic value of this medication.

Genetic evidence for a potential causal relationship between insomnia symptoms and suicidal behavior: a Mendelian randomization study

Insomnia and restless leg syndrome (RLS) are associated with increased risk for suicidal behavior (SB), which is often comorbid with mood or thought disorders; however, it is unclear whether these relationships are causal. We performed a two-sample Mendelian randomization study using summary-level genetic associations with insomnia symptoms and RLS against the outcomes of risk of major depressive disorder (MDD), bipolar disorder (BP), schizophrenia (SCZ), and SB. The inverse-variance weighted method was used in the main analysis. We performed replication and sensitivity analyses to examine the robustness of the results. We identified outcome cohorts for MDD (n = 170,756 cases/329,443 controls), BP (n = 20,352/31,358), SCZ (n = 69,369/236,642), SB-Cohort-2019 (n = 6569/14,996 all with MDD, BP or SCZ; and SB within individual disease categories), and SB-Cohort-2020 (n = 29,782/519,961). Genetically proxied liability to insomnia symptoms significantly associated with increased risk of MDD (odds ratio (OR) = 1.23, 95% confidence interval (CI) = 1.2-1.26, P = 1.37 × 10-61), BP (OR = 1.15, 95% CI = 1.07-1.23, P = 5.11 × 10-5), SB-Cohort-2019 (OR = 1.17, 95% CI = 1.07-1.27, P = 2.30 × 10-4), SB-Cohort-2019 in depressed patients (OR = 1.34, 95% CI = 1.16-1.54, P = 5.97 × 10-5), and SB-Cohort-2020 (OR = 1.24, 95% CI = 1.18-1.3, P = 1.47 × 10-18). Genetically proxied liability to RLS did not significantly influence the risk of any of the outcomes (all corrected P > 0.05). Results were replicated for insomnia with MDD and SB in Mass General Brigham Biobank and were consistent in multiple lines of sensitivity analyses. In conclusion, human genetic evidence supports for the first time a potentially independent and causal effect of insomnia on SB and encourages further clinical investigation of treatment of insomnia for prevention or treatment of SB.

Sleep in Psychotic Disorders: Results From Nationwide SUPER Finland Study

Objective

Characterizing sleep in patients with schizophrenia, schizoaffective disorder, bipolar disorder, and psychotic depression.

Methods

This cross-sectional questionnaire study is based on the SUPER study sample, which is part of the Stanley Global Neuropsychiatric Genomics Initiative. The study is a multicentre, nationwide Finnish study consisting of patients (N = 8 623) both in primary and specialized health care. The main measurements were sleep duration, difficulties initiating sleep, early morning awakenings, and fatigue. These results were compared with a nationally representative sample of the Finnish population from the Health 2000 survey (N = 7 167) with frequency and logistic regression analyses.

Results

Patients had more sleep problems compared with the general population, especially young and middle-aged patients (Difficulties initiating sleep in young patients odds ratio = 12.3, 95% CI 9.8-15.4). Long sleep duration was the most deviating property of the sleep characteristics, being particularly common among young patients with schizophrenia (odds ratio = 27.9, 95% CI 22.1-35.2, 47.4% vs 3.3% prevalence). All sleep problems were associated with worse subjective health. We also conducted a latent class analysis, resulting in a cluster relatively free of sleep problems (58% of patients), an insomnia symptom cluster (26%), and a hypersomnia symptom cluster (15%).

Conclusions

In our sample, patients with psychotic disorders have more sleep problems-especially long sleep duration but also insomnia symptoms-compared with the general population. The patients can in a latent class analysis of their sleep symptoms be divided into groups with differing sleep profiles.

Risk factors for violent behaviors in patients with schizophrenia: 2-year follow-up study in primary mental health care in China

OBJECTIVE

The consequences and impact of violent behavior in schizophrenia are often serious, and identification of risk factors is of great importance to achieve early identification and effective management.

METHODS

This follow-up study sampled adult patients with schizophrenia in primary mental health care in a rural area of southern China, in which 491 participants completed a comprehensive questionnaire at baseline and the 2-year follow-up. Sociodemographic, clinical and psychological assessment data were collected from all participants. Paired sample T-Tests and the McNemar Test were performed to examine changes over the follow-up period. Generalized Estimating Equations (GEE) were used to analyze the risk factors for violent behavior.

RESULTS

The results showed that about two in five community-dwelling patients with schizophrenia reported violent behavior in the past year. At follow-up, participants were significantly less employed, had more times of hospitalization, more psychotropic medication, and severer depressive symptoms, but had better health-related quality of life than at baseline. Use of clozapine and better insight into medication decreased the possibility of violent behavior, while more severe positive symptoms, insomnia, as well as use of second-generation antipsychotics other than clozapine, antidepressants and mood stabilizers increased the possibility of violent behavior.

CONCLUSIONS

Risk evaluation, prevention and management of violence in patients with schizophrenia are demanded in primary mental health care.

Hypotic medication use among inpatients with schizophrenia and major depressive disorder: results of a nationwide study

STUDY OBJECTIVES

To investigate the proportion of inpatients with schizophrenia and major depressive disorder prescribed hypnotic medication, and the association between such medication and the use of other antipsychotic agents.

METHODS

This was a nationwide cross-sectional study performed as part of the 'Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment' (EGUIDE) project. Data from 2146 inpatients with schizophrenia and 1031 inpatients with major depressive disorder were analyzed. All types and dosages of psychotropic drugs were recorded and the data at the time of discharge were analyzed. Associations between the use of hypnotic medication and other antipsychotic agents were evaluated using multivariate logistic regression analyses.

RESULTS

The proportions of schizophrenia patients who were prescribed any and two or more hypnotic agents were 55.7% and 17.6%, respectively, and the corresponding proportions for patients with major depressive disorder were 63.6% and 22.6%, respectively. In schizophrenia patients, multivariate logistic regression analyses showed that two or more antipsychotics, anticholinergic drugs, anxiolytics, and mood stabilizers/antiepileptic drugs were positively associated with the use of any hypnotic agent. In patients with major depressive disorder, multivariate logistic regression analyses revealed that two or more antidepressants, two or more antipsychotics, anxiolytics, and mood stabilizers/antiepileptic drugs were positively associated with the use of any hypnotic agent.

CONCLUSIONS

Prescription of hypnotic agents was found to be highly frequent among inpatients with psychiatric disorders. Prescription of two or more main antipsychotic agents was commonly associated with the use of hypnotic medication for both schizophrenia and major depressive disorder.

COVID-related psychological distress fully mediates the association from social impact to sleep disturbance among patients with chronic schizophrenia

The aims of the current study were to identify factors associated with sleep disturbance and Coronavirus disease-19 related psychological distress (CPD), and to develop a conceptual model to verify the mediating effect of CPD on the association between social impact and sleep disturbance. This study recruited patients with schizophrenia. Factors associated with the level of sleep disturbance and CPD were identified using univariate linear regression, and further selected into a stepwise multivariate linear regression model. Using structural equation modeling, a mediation model was developed to test the mediating effect of CPD on the association between social impact and sleep disturbance. After estimating with the stepwise and bootstrap regression, higher levels of CPD were associated with higher levels of social anxiety and subjects without a regular diet. Sleep disturbance was associated with a higher level of social anxiety, a history of psychological trauma, chronic disease, and those who did not smoke. The final model confirmed the mediating effects of CPD; whereas, the direct effect from social impact to sleep disturbance did not reach statistical significance. The current study manifests the crucial role of CPD on the association between social impact and sleep disturbance, and timely intervention for CPD is warranted.

The association between sleep quality and attenuated psychotic symptoms

AIM

To determine if poor sleep makes a unique contribution in predicting the likelihood of experiencing six or more attenuated psychotic symptoms and associated distress, after examining and controlling for sociodemographic factors, depression and drug/alcohol use.

METHOD

An online survey was conducted using Amazon's online crowdsourcing service Mechanical Turk (MTurk). The sample was 1013 adults (18 to 36 years) from the general population in the United States. The survey consisted of the Prodromal Questionnaire 16 (PQ-16), the Pittsburgh Sleep Quality Index, the Patient Health Questionnaire 9, the Drug Abuse Screening Test 10 and the Alcohol Use Disorders Identification Test. Regression analyses were performed with the PQ-16 as the dependent variable, and sleep quality as the predictor variable, holding constant sociodemographic variables, depression, and alcohol/drug abuse.

RESULTS

37% of the sample endorsed six or more PQ-16 items, which may be suggestive of an at-risk mental state, with sleep disturbance significantly increasing the likelihood (Odds ratio 2.09 < .001) of endorsing six or more PQ-16 items. After controlling for sociodemographic variables, depression and drug/alcohol abuse, poor sleep quality made a unique contribution of 5.8% of the variance accounted for in level of distress experienced by attenuated psychotic symptoms.

CONCLUSION

Effective treatment of sleep disturbance may reduce the likelihood ofexperiencing attenuated psychotic symptoms and associated distress.

Features of age-related response to sleep deprivation: in vivo experimental studies

Insomnia is currently considered one of the potential triggers of accelerated aging. The frequency of registered sleep-wake cycle complaints increases with age and correlates with the quality of life of elderly people. Nevertheless, whether insomnia is actually an age-associated process or whether it acts as an independent stress-factor that activates pathological processes, remains controversial. In this study, we analyzed the effects of long-term sleep deprivation modeling on the locomotor and orienting-exploratory activity, spatial learning abilities and working memory of C57BL/6 female mice of different ages. We also evaluated the modeled stress influence on morphological changes in brain tissue, the functional activity of the mitochondrial apparatus of nerve cells, and the level of DNA methylation and mRNA expression levels of the transcription factor HIF-1α (Hif1) and age-associated molecular marker PLIN2. Our findings point to the age-related adaptive capacity of female mice to the long-term sleep deprivation influence. For young (1.5 months) mice, the modeled sleep deprivation acts as a stress factor leading to weight loss against the background of increased food intake, the activation of animals' locomotor and exploratory activity, their mnestic functions, and molecular and cellular adaptive processes ensuring animal resistance both to stress and risk of accelerated aging development. Sleep deprivation in adult (7-9 months) mice is accompanied by an increase in body weight against the background of active food intake, increased locomotor and exploratory activity, gross disturbances in mnestic functions, and decreased adaptive capacity of brain cells, that potentially increasing the risk of pathological reactions and neurodegenerative processes.

Shift work disorder and related influential factors among shift workers in China

BACKGROUND

Shift work may cause insomnia and sleepiness in individuals. The present study aimed to exam shift work disorder (SWD), and to investigate their associations with individual characteristics.

METHODS

A total of 1833 shift workers were assessed using the Pittsburg Sleep Quality Index, Epworth Sleepiness Scale (ESS), Composite Scale of Morningness (CSM), Circadian Type Inventory (CTI), Center for Epidemiologic Studies-Depression Scale (CES-D), Beck Anxiety Inventory (BAI) and other self-compiled socio-demographic questionnaires.

RESULTS

In the current sample, 17.1% shift workers have experienced insomnia symptoms, 20.9% were tested for daytime sleepiness, and 19.9% were categorized as having SWD. Logistics regressions revealed that history of mental disorders (OR = 2.04, 95% CI = 1.30-3.21), chronic physical illness (OR = 1.53, 95% CI = 1.17-1.99), CES-D scores (OR = 1.03, 95% CI = 1.02-1.05), BAI scores (OR = 1.04, 95% CI = 1.03-1.06), languid/vigorous tendencies (OR = 1.06, 95% CI = 1.03-1.10) were positively associated with the onset of SWD, while morningness (OR = 0.97, 95% CI = 0.94-0.99) decreased the odds of SWD onset.

CONCLUSIONS

These findings suggested that attention should be drawn to individuals with mental and chronic diseases in when scheduling work shifts. While SWD and its associates should be considered when providing psychological services to shift workers.

Genomic perspectives on the circadian clock hypothesis of psychiatric disorders

Circadian rhythm disturbances are frequently described in psychiatric disorders such as major depressive disorder, bipolar disorder, and schizophrenia. Growing evidence suggests a biological connection between mental health and circadian rhythmicity, including the circadian influence on brain function and mood and the requirement for circadian entrainment by external factors, which is often impaired in mental illness. Mental (as well as physical) health is also adversely affected by circadian misalignment. The marked interindividual differences in this combined susceptibility, in addition to the phenotypic spectrum in traits related both to circadian rhythms and mental health, suggested the possibility of a shared genetic background and that circadian clock genes may also be candidate genes for psychiatric disorders. This hypothesis was further strengthened by observations in animal models where clock genes had been knocked out or mutated. The introduction of genome-wide association studies (GWAS) enabled hypothesis-free testing. GWAS analysis of chronotype confirmed the prominent role of circadian genes in these phenotypes and their extensive polygenicity. However, in GWAS on psychiatric traits, only one clock gene, ARNTL (BMAL1) was identified as one of the few loci differentiating bipolar disorder from schizophrenia, and macaque monkeys where the ARNTL gene has been knocked out display symptoms similar to schizophrenia. Another lesson from genomic analyses is that chronotype has an important genetic correlation with several psychiatric disorders and that this effect is unidirectional. We conclude that the effect of circadian disturbances on psychiatric disorders probably relates to modulation of rhythm parameters and extend beyond the core clock genes themselves.

Sleep spindle and slow wave abnormalities in schizophrenia and other psychotic disorders: Recent findings and future directions

Sleep spindles and slow waves are the two main oscillatory activities occurring during NREM sleep. Slow waves are ∼1 Hz, high amplitude, negative-positive deflections that are primarily generated and coordinated within the cortex, whereas sleep spindles are 12-16 Hz, waxing and waning oscillations that are initiated within the thalamus and regulated by thalamo-cortical circuits. In healthy subjects, these oscillations are thought to be responsible for the restorative aspects of sleep and have been increasingly shown to be involved in learning, memory and plasticity. Furthermore, deficits in sleep spindles and, to lesser extent, slow waves have been reported in both chronic schizophrenia (SCZ) and early course psychosis patients. In this article, we will first describe sleep spindle and slow wave characteristics, including their putative functional roles in the healthy brain. We will then review electrophysiological, genetic, and cognitive studies demonstrating spindle and slow wave impairments in SCZ and other psychotic disorders, with particularly emphasis on recent findings in early course patients. Finally, we will discuss how future work, including sleep studies in individuals at clinical high risk for psychosis, may help position spindles and slow waves as candidate biomarkers, as well as novel treatment targets, for SCZ and related psychotic disorders.

Neuromodulation of sleep rhythms in schizophrenia: Towards the rational design of non-invasive brain stimulation

Brain function critically depends on oscillatory synchronization of neuronal populations both during wake and sleep. Originally, neural oscillations have been discounted as an epiphenomenon. More recently, specific deficits in the structure of brain oscillations have been linked to psychiatric diseases. For example, schizophrenia is hallmarked by abnormalities in different brain oscillations. Key sleep rhythms during NEM sleep such as sleep spindles, which are implicated in memory consolidation and are related to cognitive functions, are strongly diminished in these patients compared to healthy controls. To date, it remains unclear whether these reductions in sleep oscillations are causal for the functional impairments observed in schizophrenia. The application of non-invasive brain stimulation permits the causal examination of brain network dynamics and will help to establish the causal association of sleep oscillations and symptoms of schizophrenia. To accomplish this, stimulation paradigms that selectively engage specific network targets such as sleep spindles or slow waves are needed. We propose that the successful development and application of these non-invasive brain stimulation approaches will require rational design that takes network dynamics and neuroanatomical information into account. The purpose of this article is to prepare the grounds for the next steps towards such rational design of non-invasive stimulation, with a special focus on electrical and auditory stimulation. First, we briefly summarize the deficits in network dynamics during sleep in schizophrenia. Then, we discuss today's and tomorrow's non-invasive brain stimulation modalities to engage these network targets.

Sleep disturbances in schizophrenia: what we know, what still needs to be done

Sleep disturbances are commonly observed in schizophrenia (SCZ) and are associated with worse psychotic symptoms and poorer clinical outcomes. Early polysomnography studies have focused on characterizing differences in sleep architecture between patients with SCZ and healthy controls. More recently, research has focused on sleep-specific EEG oscillations, such as sleep spindles and slow waves, which reflect the integrity of underlying thalamo-cortical networks. Furthermore, high-density (hd)-EEG (≥64 channels), which affords enhanced spatial resolution, has been employed to better localize abnormalities in sleep characteristics and related thalamo-cortical circuits in patients with SCZ and related disorders. In this article, we will review the most relevant sleep abnormalities reported in SCZ, with an emphasis on recent findings, and propose directions for future research.