Pharmacologic Treatment Options for Insomnia in Patients with Schizophrenia

The relationship between sleep disturbance and aggressive behaviour among community-dwelling schizophrenia patients: a moderated mesomeric effect model

OBJECTIVE

Sleep disturbance is the most common concern of patients with schizophrenia and can lead to a poor prognosis, a low survival rate and aggressive behaviour, posing a significant threat to social security and stability. The aim of this study was to explore the mediating role of depression in the relationship between sleep disturbance and aggressive behaviour in people with schizophrenia living in the community, as well as the regulatory role of family intimacy and adaptability. These findings, in turn, may provide a theoretical basis and constructive suggestions for addressing the physical and mental health problems of these patients.

METHOD

From September 2020 to August 2021, a convenience sampling method was used to select schizophrenia patients from the community attending follow-up appointments at the Fourth People's Hospital of Pengzhou City, China. The researchers conducted a survey in the form of a star questionnaire. The survey included questions about general demographic data and disease-related questionnaires: the Pittsburgh Sleep Quality Index (PSQI), the revised Chinese version of the Modified Over Aggression Scale (MOAS), the Self-Rating Depression Scale (SDS), and the Family Adaptability and Cohesion Scale, Second Edition. FACES-II and SPSS 21.0 were used to organize and analyse the data.

RESULTS

A total of 818 schizophrenia patients living in the community participated in the survey, and 785 valid questionnaires were ultimately collected, for a response rate of 95.97%. The results of multivariate analysis indicated that sex, number of psychiatric medications used, outpatient follow-up, history of hospitalization for mental disorders and sleep disturbances were factors influencing aggressive behaviour. Depression played a partial mediating role between sleep disturbance and aggressive behaviour, and the indirect effect size was 0.043 (57.33% of the total). In addition to sleep disturbance, family intimacy (β=-0.009, P < 0.01) and adaptability (β=-0.145, P < 0.001) can significantly predict depression.

CONCLUSION

The findings indicate that sleep disturbance in schizophrenia patients in the community is a risk factor for aggressive behaviour, and depression plays a partial mediating role in the relationship among sleep disturbance, aggressive behaviour and family intimacy. In addition, adaptability plays a regulatory role in the relationship between depression and sleep disturbance.

Sleep Problems, Suicidal Ideation, and Psychopathology in First-Episode Psychosis

BACKGROUND AND HYPOTHESIS

Insomnia occurs frequently in the clinical course of schizophrenia. A growing literature has found associations between insomnia, suicidal ideation and behavior, and psychopathology in schizophrenia. We explored associations between sleep problems, suicidal ideation, and psychopathology in a cohort of patients with first-episode psychosis.

STUDY DESIGN

We performed a secondary analysis of data for n = 403 subjects with data from the Recovery After an Initial Schizophrenia Episode study using regression models.

STUDY RESULTS

The prevalence of sleep problems and suicidal ideation at baseline was 57% and 15%, respectively. After controlling for potential confounders, in the study baseline sleep problems were associated with increased odds of suicidal ideation with evidence of a dose-dependent relationship (OR = 2.25, 95% CI 1.15-4.41, P = .018). Over 24 months, sleep problems at any time point were associated with an over 3-fold increased odds of concurrent suicidal ideation (OR = 3.21, 95% CI 1.45-7.14, P = .004). Subjects with persistent sleep problems were almost 14 times more likely to endorse suicidal ideation at least once over the study than those without sleep problems (OR = 13.8, 95% CI 6.5-53.4, P < .001). Sleep problems were also a predictor of higher Positive and Negative Syndrome Scale total (β = 0.13-0.22), positive (β = 0.14-0.25), and general (β = 0.16-0.27) subscale scores at baseline and multiple follow-up visits (P < .01 for each).

CONCLUSIONS

Sleep problems are highly prevalent and associated with suicidal ideation and greater psychopathology in first-episode psychosis. Formal assessment and treatment of insomnia appear relevant to the clinical care of patients with psychosis as a predictor of suicidal ideation and symptom severity.

Adverse effects of antipsychotics on sleep in patients with schizophrenia. Systematic review and meta-analysis

Introduction

Our objective was to conduct a systematic review and meta-analysis of adverse effects on sleep in patients with schizophrenia receiving antipsychotic treatment.

Methods

A systematic search was performed in PubMed, Cochrane Central, Embase, Toxline, Ebsco, Virtual Health Library, Web of Science, SpringerLink, and in Database of abstracts of Reviews of Effects of Randomized Clinical Trials to identify eligible studies published from January 1990 to October 2021. The methodological quality of the studies was evaluated using the CONSORT list, and the Cochrane bias tool. Network meta-analysis was performed using the Bayesian random-effects model, with multivariate meta-regression to assess the association of interest.

Results

87 randomized clinical trials were identified that met the inclusion criteria, and 70 articles were included in the network meta-analysis. Regarding the methodological quality of the studies, 47 had a low or moderate bias risk. The most common adverse effects on sleep reported in the studies were insomnia, somnolence, and sedation. The results of the network meta-analysis showed that ziprasidone was associated with an increased risk of insomnia (OR, 1.56; 95% credible interval CrI, 1.18-2.06). Several of the included antipsychotics were associated with a significantly increased risk of somnolence; haloperidol (OR, 1.90; 95% CrI, 1.12-3.22), lurasidone (OR, 2.25; 95% CrI, 1.28-3.97) and ziprasidone (OR, 1.79; 95% CrI, 1.06-3.02) had the narrowest confidence intervals. In addition, perphenazine (OR, 5.33; 95% CrI, 1.92-14.83), haloperidol (OR, 2.61; 95% CrI, 1.14-5.99), and risperidone (OR, 2.41; 95% CrI, 1.21-4.80) were associated with an increased risk of sedation compared with placebo, and other antipsychotics did not differ. According to the SUCRAs for insomnia, chlorpromazine was ranked as the lowest risk of insomnia (57%), followed by clozapine (20%), while flupentixol (26 %) and perospirone (22.5%) were associated with a lower risk of somnolence. On the other hand, amisulpride (89.9%) was the safest option to reduce the risk of sedation.

Discussion

Insomnia, sedation, and somnolence were the most frequent adverse effects on sleep among the different antipsychotics administered. The evidence shows that chlorpromazine, clozapine, flupentixol, perospirone, and amisulpride had favorable safety profiles. In contrast, ziprasidone, perphenazine, haloperidol, and risperidone were the least safe for sleep.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017078052, identifier: PROSPERO 2017 CRD42017078052.

Meta-analysis of insomnia, suicide, and psychopathology in schizophrenia

PURPOSE OF REVIEW

Insomnia is common in schizophrenia. Insomnia has been associated with suicidal ideation and behavior, as well as greater severity of psychopathology, in schizophrenia. This review performs a meta-analysis of associations between insomnia, suicide, and psychopathology in patients with schizophrenia.

RECENT FINDINGS

We searched major electronic databases from inception until November 2022 for studies of insomnia, suicide, and psychopathology in patients with schizophrenia. Random effects meta-analysis calculating odds ratios (ORs, for suicide) and effect sizes (ESs, for psychopathology) and 95% confidence intervals (CIs) were performed. Ten studies met the inclusion criteria, comprising 3428 patients with schizophrenia. Insomnia was associated with a significant increased odds of suicidal ideation (OR = 1.84, 95% CI 1.28-2.65, P  < 0.01) and suicide attempt or death (OR = 5.83, 95% CI 1.61-2.96, P  < 0.01). Insomnia was also associated with total (ES = 0.16, 95% CI 0.09-0.23, P  < 0.01), positive (ES = 0.14, 95% CI 0.08-0.20, P  = 0.02), and general (ES = 0.17, 95% CI 0.08-0.27, P  < 0.01) psychopathology. In meta-regression analyses, BMI was negatively associated with suicidal ideation. Otherwise, age, sex, and study year were all unrelated to the associations.

SUMMARY

Insomnia is associated with suicide and psychopathology in schizophrenia. Formal assessment and treatment of insomnia appears relevant to the clinical care of schizophrenia.

Psychiatric and non-psychiatric polypharmacy among older adults with schizophrenia: Trends from a population-based study between 2000 and 2016

Background: Schizophrenia is a severe psychiatric disorder associated with multiple psychiatric and non-psychiatric comorbidities. As adults with schizophrenia age, they may use many medications, i.e., have polypharmacy. While psychiatric polypharmacy is well documented, little is known about trends and patterns of global polypharmacy. This study aimed to draw a portrait of polypharmacy among older adults with schizophrenia from 2000 to 2016. Methods: This population-based cohort study was conducted using the data of the Quebec Integrated Chronic Disease Surveillance System of the National Institute of Public Health of Quebec to characterize recent trends and patterns of medication use according to age and sex. We identified all Quebec residents over 65 years with an ICD-9 or ICD-10 diagnosis of schizophrenia between 2000 and 2016. We calculated the total number of medications used by every individual each year and the age-standardized proportion of individuals with polypharmacy, as defined by the usage of 5+, 10+, 15+, and 20+ different medications yearly. We identified the clinical and socio-demographic factors associated with polypharmacy using robust Poisson regression models considering the correlation of the responses between subjects and analyzed trends in the prevalence of different degrees of polypharmacy. Results: From 2000 to 2016, the median number of medications consumed yearly rose from 8 in 2000 to 11 in 2016. The age-standardized proportion of people exposed to different degrees of polypharmacy also increased from 2000 to 2016: 5+ drugs: 76.6%-89.3%; 10+ drugs: 36.9%-62.2%; 15+: 13.3%-34.4%; 20+: 3.9%-14.4%. Non-antipsychotic drugs essentially drove the rise in polypharmacy since the number of antipsychotics remained stable (mean number of antipsychotics consumed: 1.51 in 2000 vs. 1.67 in 2016). In the multivariate regression, one of the main clinically significant factor associated with polypharmacy was the number of comorbidities (e.g., Polypharmacy-10+: RR_{[2 VS. 0-1]} = 1.4; 99% IC:1.3-1.4, RR_[3-4] = 1.7 (1.7-1.8); RR_[5+] = 2.1 (2.1-2.2); Polypharmacy-15+: RR_{[2 VS 0-1]} = 1.6; 99% IC:1.5-1.7, RR_[3-4] = 2.5 (2.3-2.7); RR_[5+] = 4.1 (3.8-4.5). Conclusion: There was a noticeable increase in polypharmacy exposure among older adults with schizophrenia in recent years, mainly driven by non-antipsychotic medications. This raises concerns about the growing risks for adverse effects and drug-drug interactions in this vulnerable population.

Hormone Targets for the Treatment of Sleep Disorders in Postmenopausal Women with Schizophrenia: A Narrative Review

While the early identification of insomnia in patients with schizophrenia is of clinical relevance, the use of specific compounds to treat insomnia has been studied less in postmenopausal women with schizophrenia. We aimed to explore the effects of melatonin, sex hormones, and raloxifene for the treatment of insomnia in these populations. Although melatonin treatment improved the quality and efficiency of the sleep of patients with schizophrenia, few studies have explored its use in postmenopausal women with schizophrenia. The estrogen and progesterone pathways are dysregulated in major psychiatric disorders, such as in schizophrenia. While, in the context of menopause, a high testosterone-to-estradiol ratio is associated with higher frequencies of depressive symptoms, the effects of estradiol and other sex hormones on sleep disorders in postmenopausal women with schizophrenia has not been sufficiently investigated. Raloxifene, a selective estrogen receptor modulator, has shown positive effects on sleep disorders in postmenopausal women. Future studies should investigate the effectiveness of hormonal compounds on insomnia in postmenopausal women with schizophrenia.

Insomnia, suicidal ideation, and psychopathology in Chinese patients with chronic schizophrenia

OBJECTIVES

Insomnia occurs frequently in the clinical course of schizophrenia. A growing literature has found associations between insomnia, suicidal ideation, and psychopathology in patients with schizophrenia. We explored these associations in a cross-sectional study of a large sample of patients with chronic schizophrenia in China. We hypothesized that insomnia would be associated with an increased odds of current suicidal ideation and higher current psychopathology scores.

METHODS

We recruited 328 inpatients with chronic schizophrenia, all of whom were prescribed psychotropics. We investigated relationships between current insomnia, suicidal ideation over the past two weeks, and current psychopathology for subjects using regression models.

RESULTS

After controlling for multiple potential confounding factors, current insomnia was an indicator of a significant, 2.5-fold increased odds of suicidal ideation (OR = 2.56, 95% CI 1.10-5.95, p = 0.029). Insomnia was also a significant indicator of lifetime suicide attempt (OR = 1.07) as well as higher Positive and Negative Syndrome Scale total (β = 0.134, p = 0.017), positive (β = 0.154, p = 0.006) and general (β = 0.145, p = 0.010) subscale scores.

CONCLUSION

Insomnia is associated with suicidal ideation, lifetime suicide attempt, and higher psychopathology scores in inpatients with chronic schizophrenia. Formal assessment of insomnia appears relevant to the clinical care of patients with schizophrenia as an indicator of suicidal thinking and behavior, depression, and symptom severity.

The Causal Effects of Insomnia on Bipolar Disorder, Depression, and Schizophrenia: A Two-Sample Mendelian Randomization Study

Psychiatric disorder, including bipolar disorder (BD), major depression (MDD), and schizophrenia (SCZ), affects millions of persons around the world. Understanding the disease causal mechanism underlying the three diseases and identifying the modifiable risk factors for them hold the key for the development of effective preventative and treatment strategies. We used a two-sample Mendelian randomization method to assess the causal effect of insomnia on the risk of BD, MDD, and SCZ in a European population. We collected one dataset of insomnia, three of BD, one of MDD, and three of SCZ and performed a meta-analysis for each trait, further verifying the analysis through extensive complementarity and sensitivity analysis. Among the three psychiatric disorders, we found that only insomnia is causally associated with MDD and that higher insomnia increases the risk of MDD. Specifically, the odds ratio of MDD increase of insomnia is estimated to be 1.408 [95% confidence interval (CI): 1.210–1.640, p = 1.03E-05] in the European population. The identified causal relationship between insomnia and MDD is robust with respect to the choice of statistical methods and is validated through extensive sensitivity analyses that guard against various model assumption violations. Our results provide new evidence to support the causal effect of insomnia on MDD and pave ways for reducing the psychiatric disorder burden.

Sleep Interventions in the Treatment of Schizophrenia and Bipolar Disorder

Due to the effects of sleep on the central nervous system, it is thought that sleep disorders have a special importance in the onset, course and treatment of psychiatric diseases. Although the negative effects of sleep problems on the occurrence, recurrence and clinical course of psychiatric disorders are well known, it is reported that clinicians do not spend enough time for sleep problems in practice. This may be related to the fact that patients underreport their complaints for various reasons, insufficient examination time, and clinicians' lack of knowledge about the importance of the subject. Pharmacotherapy, psychological and behavioral interventions are options among the therapeutic approaches to sleep problems. But, it seems that clinicians tend to prefer pharmacological approaches for the treatment of sleep problems. However, it is important to choose the appropriate treatment option with considering the method preferred by the patients, who already use many and high doses of pharmacological agents, the nature of the psychiatric disorder and the sleep problem. In this context, chronotherapeutic approaches such as bright light, sleep deprivation, interpersonal relations and social rhythm therapy, and cognitive behavioral therapy techniques adapted for patients with bipolar disorder can be used in the treatment of suitable patients. In this article, the current literature about sleep-related problems observed in patients with schizophrenia and bipolar disorder is reviewed comprehensively with presenting clinical phenotypes and treatment approaches.

Antipsychotic Polypharmacy for the Management of Schizophrenia: Evidence and Recommendations

Schizophrenia is a debilitating illness with a lifetime prevalence estimate of 0.6% and consists of symptoms from the positive, negative, and cognitive domains. Social support, therapy, psychoeducation, and overall case management are very important aspects of the treatment of schizophrenia. However, as abnormalities in neurotransmission are one of the key findings of schizophrenia pathology, pharmacotherapies are cornerstones of the management of schizophrenia. Antipsychotics have been used as the primary pharmacological treatment of schizophrenia. These agents often have a good effect on reducing positive symptoms, but may not markedly improve negative symptoms or cognitive defects. However, at least 20% of individuals with schizophrenia do not experience a substantial response from monotherapy with antipsychotics. Further, despite evolving treatment protocols and advances in early recognition of the disorder, 70% of patients with schizophrenia require long-term, even lifetime, medication to control their symptoms and do not achieve complete recovery. To address these shortcomings, clinicians and research scientists have explored different combinations of treatments, polypharmacy, to improve the treatment of patients. Antipsychotic polypharmacy has been shown to cause more side effects than monotherapy, which is the main reason why most treatment guidelines caution against it. Antipsychotic monotherapy should be strived for and clozapine should be tried at the latest if two monotherapy trials with other antipsychotics have failed and no absolute contraindications exist. If residual symptoms exist despite trials of adequate dose and duration, other reasons that may reduce treatment effect should be ruled out. Long-acting injectables or blood concentration measurements should be considered to affirm compliance and proper serum levels. Antipsychotic polypharmacy should be considered and discussed with patients from whom the aforementioned procedures do not produce a satisfactory treatment result. In some cases, antipsychotic polypharmacy may produce better results than other forms of treatment augmentation, such as benzodiazepines. In particular, combining aripiprazole with clozapine may be effective in reducing treatment side effects or residual symptoms, and this is likely to hold true for combining other partial dopamine D₂ agonists with clozapine as well, although currently scant data exist. More research is needed, both in controlled but also real-world settings, to define optimal antipsychotic polypharmacy and/or other psychotropic treatment augmentation strategies for specific patient groups and situations.

International Expert Opinions and Recommendations on the Use of Melatonin in the Treatment of Insomnia and Circadian Sleep Disturbances in Adult Neuropsychiatric Disorders

Introduction: Insomnia and circadian rhythm disorders, such as the delayed sleep phase syndrome, are frequent in psychiatric disorders and their evaluation and management in early stages should be a priority. The aim of this paper was to express recommendations on the use of exogenous melatonin, which exhibits both chronobiotic and sleep-promoting actions, for the treatment of these sleep disturbances in psychiatric disorders. Methods: To this aim, we conducted a systematic review according to PRISMA on the use of melatonin for the treatment of insomnia and circadian sleep disorders in neuropsychiatry. We expressed recommendations for the use of melatonin in psychiatric clinical practice for each disorder using the RAND/UCLA appropriateness method. Results: We selected 41 studies, which included mood disorders, schizophrenia, substance use disorders, attention deficit hyperactivity disorders, autism spectrum disorders, neurocognitive disorders, and delirium; no studies were found for both anxiety and eating disorders. Conclusion: The administration of prolonged release melatonin at 2-10 mg, 1-2 h before bedtime, might be used in the treatment of insomnia symptoms or comorbid insomnia in mood disorders, schizophrenia, in adults with autism spectrum disorders, neurocognitive disorders and during sedative-hypnotics discontinuation. Immediate release melatonin at <1 mg might be useful in the treatment of circadian sleep disturbances of neuropsychiatric disorders.

The association between hormones and antipsychotic use: a focus on postpartum and menopausal women

During the postpartum and menopausal periods of women's lives, there is a well-established and significant drop of circulating estrogens. This may be the reason why both these periods are associated with an increased risk for onset or exacerbation of psychiatric disorders. Whether symptoms are mainly affective or mainly psychotic, these disorders are frequently treated with antipsychotic medications, which calls for an examination of the relationship between hormone replacement and antipsychotic agents at these time periods. The aim of this narrative review is to summarize what is known about the association of hormones and antipsychotics in the postnatal period and at menopause. In the review, we focus on estrogen and oxytocin hormones and include, for the most part, only papers published within the last 10 years. Both estradiol and oxytocin have at various times been implicated in the etiology of postpartum disorders, and estrogens, sometimes combined with progesterone, have been tested as potential treatments for these conditions. The role of estradiol as an adjunct to antipsychotics in the prevention of postpartum relapses is currently controversial. With respect to oxytocin, studies are lacking. Psychosis in menopausal and postmenopausal women has been successfully treated with estrogens and selective estrogen-receptor modulators, mainly raloxifene, in addition to antipsychotics. Some symptoms appear to respond better than others. No oxytocin study has specifically targeted postmenopausal women. Because of feedback mechanisms, there is a theoretical danger of therapy with exogenous hormones interfering with endogenous secretion and disturbing the balance among inter-related hormones. When used with antipsychotics, hormones may also affect the metabolism and, hence, the brain level of specific antipsychotics. This makes treatment with antipsychotics plus hormones complicated. Dose, timing and route of intervention may all prove critical to efficacy. While much remains unknown, this literature review indicates that, within standard dose ranges, the combination of hormones and antipsychotics for postnatal and menopausal women suffering severe mental distress can be beneficial, and is safe.

Schizophrenia and Sleep Disorders: An Introduction

This editorial is an introduction to the special issue 'Schizophrenia and Sleep Disorders'.[…].