Sleep problems commonly co-occur with serious mental illnesses (SMI) and are associated with negative outcomes, though may be underrecognized and undertreated. This study examined whether clinical services for sleep disorders among Veterans with and without SMI changed during the past decade. The sample included Veterans with a diagnosed sleep disorder in VA VISN 4 (Pennsylvania and sections of Ohio, New Jersey and Delaware) electronic health record data from 2011 to 2019 (N = 77,898). Results revealed that, across 9 years of data, half of Veterans received no sleep services, but among those that did, sleep medications were most common., Notably, Veterans with SMI and sleep disorders were more likely than those without SMI to receive any sleep services, but the proportion of all Veterans receiving sleep services declined across the study period. Results from this study demonstrate that the needs of Veterans with SMI and sleep disorders are met equally well as those of Veterans without SMI, but there remains a large unmet need for all Veterans with sleep disorders, half of whom did not receive any services. Future work should investigate provider and patient perspectives regarding barriers and facilitators to engaging with sleep services, particularly services other than medication.

It is common in mental health care to ask about people's days but comparatively rare to ask about their nights. Most patients diagnosed with schizophrenia struggle at nighttime. The next-day effects can include a worsening of psychotic experiences, affective disturbances, and inactivity, which in turn affect the next night's sleep. Objective and subjective cognitive abilities may be affected too. Patients commonly experience a mix of sleep difficulties in a night and across a week. These difficulties include trouble falling asleep, staying asleep, or sleeping at all; nightmares and other awakenings; poor-quality sleep; oversleeping; tiredness; sleeping at the wrong times; and problems establishing a regular sleep pattern. The patient group is also more vulnerable to obstructive sleep apnea and restless legs syndrome. We describe in this article how the complex presentation of non-respiratory sleep difficulties arises from variation across five factors: timing, mental state, need for sleep, self-care, and environment. We set out 10 illustrative patterns of such difficulties experienced by patients with non-affective psychosis. These sleep problems are eminently treatable with intensive psychological therapy delivered over approximately eight sessions. We describe key techniques and their typical order of implementation by presentation. Sleep problems are an important issue for patients. Giving them the therapeutic attention patients often desire brings both real clinical benefits and improves views of services. Treatment is also very likely to lessen psychotic experiences and mood disturbances while improving daytime functioning and quality of life. Tackling sleep difficulties can be a route toward the successful treatment of psychosis.

This study investigates the prospective associations between short sleep duration, insomnia symptoms, and psychotic-like experiences (PLEs) in a large sample of Chinese adolescents. This study utilized a three-timepoint repeated cross-sectional survey with two nested longitudinal subsamples. A total of 17,722 adolescents were assessed at baseline (April 21 to May 12, 2021) and six months later (December 17 to 26, 2021). Out of these, 15,694 adolescents provided complete responses to the questions at baseline and one year later (May 17 - June 6, 2022). A self-administered questionnaire was used to measure sample characteristics (at baseline), sleep duration, insomnia symptoms, and PLEs (at each assessment), and negative life events (at two follow-ups). Baseline short sleep duration and insomnia symptoms predicted frequent PLEs at both follow-up assessments. Additionally, baseline frequent PLEs also predicted insomnia symptoms at six months and one year later. However, when controlling for confounders, PLEs at baseline only predicted short sleep duration at six months, and not at one year. This study reveals bidirectional prospective relationships between short sleep duration, insomnia symptoms, and PLEs, even after controlling for covariates. Therefore, it is crucial to assess both sleep patterns and PLEs in order to promote optimal sleep and mental health among adolescents.

Pre-diagnostic stages of psychotic illnesses, including 'clinical high risk' (CHR), are marked by sleep disturbances. These sleep disturbances appear to represent a key aspect in the etiology and maintenance of psychotic disorders. We aimed to examine the relationship between self-reported sleep dysfunction and attenuated psychotic symptoms (APS) on a day-to-day basis.

Seventy-six CHR young people completed the Experience Sampling Methodology (ESM) component of the European Union Gene-Environment Interaction Study, collected through PsyMate® devices, prompting sleep and symptom questionnaires 10 times daily for 6 days. Bayesian multilevel mixed linear regression analyses were performed on time-variant ESM data using the brms package in R. We investigated the day-to-day associations between sleep and psychotic experiences bidirectionally on an item level. Sleep items included sleep onset latency, fragmentation, and quality. Psychosis items assessed a range of perceptual, cognitive, and bizarre thought content common in the CHR population.

Two of the seven psychosis variables were unidirectionally predicted by previous night's number of awakenings: every unit increase in number of nightly awakenings predicted a 0.27 and 0.28 unit increase in feeling unreal or paranoid the next day, respectively. No other sleep variables credibly predicted next-day psychotic symptoms or vice-versa.

In this study, the relationship between sleep disturbance and APS appears specific to the item in question. However, some APS, including perceptual disturbances, had low levels of endorsement amongst this sample. Nonetheless, these results provide evidence for a unidirectional relationship between sleep and some APS in this population.

Bipolar disorder (BD) and schizophrenia (SCZ) may exhibit functional abnormalities in several brain areas, including the medial temporal and prefrontal cortex and hippocampus; however, a less explored topic is how brain connectivity is linked to premorbid trauma experiences and clinical features in non-Caucasian samples of SCZ and BD.

Sixty-two individuals with SCZ (n = 20), BD (n = 21), and healthy controls (HC, n = 21) from indigenous and African ethnicity were submitted to clinical screening (Di-PAD), traumata experiences (ETISR-SF), cognitive and functional MRI assessment. The item psychosis/hallucinations in SCZ patients showed a negative correlation with the global efficiency (GE) in the right dorsal attention network. The items mania, irritable mood, and racing thoughts in the Di-PAD scale had a significant negative correlation with the GE in the parietal right default mode network.

Differences in the activation of specific networks were associated with earlier disease onset, history of physical abuse, and more severe psychotic and mood symptoms in SCZ and BD subjects of indigenous and black ethnicity. Findings provide further evidence on SZ and BD's brain connectivity disturbances, and their clinical significance, in non-Caucasian samples.

People with a diagnosis of schizophrenia often have poor sleep, even when their psychotic symptoms are relatively well managed. This includes insomnia, sleep apnoea, hypersomnia, and irregular or non-24 h sleep-wake timing. Improving sleep would better support recovery, yet few evidence-based sleep treatments are offered to this group. This paper presents a mixed methods feasibility and acceptability study of Light-Dark and Activity Rhythm Therapy (L-DART). L-DART is delivered by an occupational therapist over 12 weeks. It is highly personalisable to sleep phenotypes and circumstances. Ten participants with schizophrenia spectrum diagnoses and sleep problems received L-DART; their sleep problems and therapy goals were diverse. We measured recruitment, attrition, session attendance, and adverse effects, and qualitatively explored acceptability, engagement, component delivery, adherence, activity patterns, dynamic light exposure, self-reported sleep, wellbeing, and functioning. Recruitment was ahead of target, there was no attrition, and all participants received the minimum 'dose' of sessions. Acceptability assessed via qualitative reports and satisfaction ratings was good. Adherence to individual intervention components varied, despite high participant motivation. All made some potentially helpful behaviour changes. Positive sleep and functioning outcomes were reported qualitatively as well as in outcome measures. The findings above support testing the intervention in a larger randomised trial ISRCTN11998005.

Individuals with Schizophrenia Spectrum Disorders (SSDs) have significantly higher rates of suicidal thoughts, attempts, and death by suicide in comparison to the general population. Sleep disturbances (reduced duration, timing and quality of sleep) are risk factors for suicidality in the general population, with research indicating the relationship is both immediate and accumulative. Sleep disturbances are also considered to be implicated in the onset and exacerbation of psychotic symptoms in SSDs. Reducing the risk of suicidality in SSDs remains an important public health priority, thus exploration of contributing risk factors is warranted. Sleep monitoring may also offer an adjunct risk monitoring method to suicidality assessments in SSDs, and a potential treatment target for psychotic symptoms. This review aimed to explore proximal and longitudinal relationships between self-reported and objectively measured sleep and suicidality in SSDs and other psychotic disorders. A comprehensive search of four databases was conducted. Eleven studies met the inclusion criteria (10 cross sectional and 1 longitudinal). Narrative synthesis indicated that self-reported sleep disturbances and sleep disorders (e.g. insomnia) were associated with increased risk of suicidal ideation and attempt. However, one study employing polysomnography did not find sleep to be associated with suicidality. Methodological limitations of the evidence base include: i) little experimental or longitudinal evidence, (ii) self-report and/or single item assessment of sleep disturbance, (iii) limited use of validated measures of suicidality, (iv) considerable research in long-term schizophrenia but sparse evidence in early psychosis. Future research should explore (i) cross-sectional and longitudinal relationships between specific aspects of suicidality and objective sleep parameters, (ii) use qualitative or mixed-methods designs to disentangle the nuances and bidirectionality in the sleep-suicide relationship, (iii) explore the psychological processes underpinning or mediating the sleep-suicide relationship in SSDs.

Excessive fatigue in adolescents is a growing concern as it impacts various aspects of their lives. Research on its prevalence and contributing factors in specific populations, especially in developing countries, is scarce. This study examines the prevalence of excessive fatigue among Moroccan adolescents and its association with demographic characteristics, parasomnias, depressive symptoms, and academic performance. In this cross-sectional study, we assessed excessive fatigue among 800 Moroccan adolescents (aged 12-20 years) in Settat province, using a comprehensive questionnaire including Pichot's Fatigue Scale (PFS), Patient Health Questionnaire 9 (PHQ-9), parasomnia questionnaire, and demographic questionnaire. The primary outcome was excessive fatigue, while covariates included demographic factors, physical health, regular exercise, depressive symptoms, and specific parasomnias. Associations were analyzed using cross-tabulation analysis, chi-squared tests, and correlation analysis. Excessive fatigue was prevalent in 8.4% of participants. Female adolescents had significantly higher adjusted odds of experiencing excessive fatigue than male adolescents, with an adjusted odds ratio (AOR) of 3.07 [95% CI (1.48, 6.37), P=0.003]. Excessive fatigue was significantly associated with nightmares, sleep paralysis, and hypnagogic hallucinations. A strong positive linear correlation was observed between fatigue and depressive symptoms (r=0.746, P#x003C;0.001). This study highlights the prevalence of excessive fatigue among Moroccan adolescents, emphasizing the importance of addressing gender-specific issues, sleep habits, and mental health support. Further research is needed to understand the underlying mechanisms and explore the role of lifestyle and socio-cultural contexts.

This study aimed to estimate the 12-month prevalence of diagnosed sleep disorders among veterans with and without serious mental illnesses (SMI) in Veterans Affairs health record data in 2019. We also examined diagnosed sleep disorders across a 9-year period and explored associations with demographic and health factors.

This study used health record data from VISN 4 of the Veterans Health Administration from 2011 to 2019. SMI diagnoses included schizophrenia and bipolar spectrum diagnoses as well as major depression with psychosis. Sleep diagnoses included insomnias, hypersomnias, sleep-related breathing disorders, circadian rhythm sleep-wake disorders, and sleep-related movement disorders. Demographic and health-related factors were also collected from the record.

In 2019, 21.8% of veterans with SMI were diagnosed with a sleep disorder. This is a significantly higher proportion than for veterans without SMI, 15.1% of whom were diagnosed with a sleep disorder. Sleep disorder rates were highest in veterans with a chart diagnosis of major depression with psychosis. From 2011 to 2019, the overall prevalence of sleep disorders in veterans with SMI more than doubled (10.2%-21.8%), suggesting improvements in the detection and diagnosis of sleep concerns for this group.

Our findings suggest that identification and diagnosis of sleep disorders for veterans with SMI has improved over the past decade, though diagnoses still likely underrepresent actual prevalence of clinically relevant sleep concerns. Sleep concerns may be at particularly high risk of going untreated in veterans with schizophrenia-spectrum disorders.

Bonfils KA, Longenecker JM, Soreca I, et al. Sleep disorders in veterans with serious mental illnesses: prevalence in Veterans Affairs health record data. J Clin Sleep Med. 2023;19(9):1651-1660.

Sleep problems are common in mental health service users, but few non-pharmacological therapies are offered. Therapies are being developed and tested, but there may be barriers to these therapies reaching those who need them.

Light-Dark and Activity Rhythm Therapy (L-DART), is a new sleep therapy delivered by an occupational therapist, which has been feasibility tested in people with schizophrenia spectrum diagnoses. This paper presents two surveys, conducted with mental health staff and service users, on sleep problems, treatment wishes; and barriers and facilitators to uptake of L-DART or similar therapies. Descriptive statistics, single-level and multi-level ordinal logistic regression were used to examine factors associated with sleep problems and referral intentions.

Sleep problems were commonly identified by staff and service users, there was demand for non-pharmacological intervention across diagnostic and demographic categories, but staff readiness to refer differed according to NHS Trust and service user diagnosis. Staff and service user reports differed in awareness of sleep disordered breathing and parasomnias, and wish for referral. Staff were more confident identifying sleep problems than addressing them, but more training was associated with greater confidence concerning both assessment and treatment.

A range of sleep problems are prevalent and recognised in mental health service users, and there is an unmet need for non-pharmacological sleep interventions. Improving suitable resources to support self-management in this group may help; Staff and service users also reported a high readiness to refer or be referred for sleep interventions. Staff training to improve identification of sleep problems, and differentiation between types of sleep problems, would support access to the most appropriate treatments.

Early psychosis may be a critical time at which clinical trajectories are still evolving, and sleep interventions hold promise to improve outcomes at this stage. Although cognitive behavioural therapy (CBT) for insomnia shows promise in psychosis, there has been limited evaluation of delivery within current care. This study aims to evaluate the feasibility and acceptability of providing fully-automated digital CBT for insomnia (CBT-I) within an early intervention in psychosis service.

We will conduct a single-arm feasibility trial within an early psychosis intervention service, and up to 40 individuals experiencing a first episode of psychosis and with evidence of insomnia can be enrolled (May 2021 - August 2022). Additional service user inclusion criteria are capacity to consent and access to a suitable technological device to access digital CBT. Participants will be offered access to a fully-automated digital CBT-I program (Sleepio) delivered using web and/or mobile app. The study comprises pre- and post- intervention questionnaire assessments and interviews with service users and staff to provide initial outcome signals.

Quantitative questionnaire data will be analysed descriptively, alongside rates of eligibility, consent, uptake and completion. Qualitative data will be analysed using thematic analysis. Results will be used to develop a logic model describing feasibility and implementation.

From this study, we hope to better understand how to deliver digital CBT for insomnia within an early intervention in psychosis service. This study will help inform further research, including how best to support staff in using Sleepio, and inform the design of subsequent trials in this area.

People with schizophrenia spectrum disorder diagnoses commonly have poor sleep, which predicts various negative outcomes. The problems are diverse, including substantial circadian dysregulation, sleep-wake timing issues, hypersomnia (excessive sleep), and more classic insomnia.

This paper reports on a mixed methods expert opinion study based on the principles of Delphi methodology. The study examines and explores opinion on the optimal contents and format for an occupational therapy intervention to improve poor sleep in this population. Views of clinical and academic topic experts (n = 56), were elicited, examined and explored in three rounds, views from previous rounds being presented back to participants in subsequent rounds. Participants with relevant personal experience (n = 26) then rated and commented on suggestions, with a focus on acceptability. Descriptive statistics and graphs of ratings were triangulated with qualitative content analysis of free-text.

Participants emphasised the central importance of intervention personalisation, although the manner and extent of personalisation suggested varied. Many components and domains were acknowledged as important, with the challenge being how to keep such an intervention simple, brief, and feasible for end-users, for sustainable implementation. The strongest consensus was to address evening routine, daytime activity, and environmental interventions. Relaxation, mindfulness, thermoregulation, sensory factors, and cognitive or psychological approaches were rated as less important. There was disagreement on whether to include time in bed restriction, and how to address napping, as well as how far to address medication timing. Clinicians and researchers advocated some version of stimulus control, but participants with personal experience reported low levels of acceptability for this, describing entirely negative experiences using 'the 15-minute rule' (part of stimulus control).

These results are informative for clinicians treating sleep problems in people with schizophrenia and related conditions, as well as for decision makers considering the potential contribution of the profession of occupational therapy toward sleep treatment.

To examine whether depressive symptoms predict receipt of cognitive-behavioural therapy for psychosis (CBTp) in individuals with psychosis.

Retrospective cross-sectional analysis of electronic health records (EHRs) of a clinical cohort.

A secondary National Health Service mental healthcare service serving four boroughs of south London, UK.

20 078 patients diagnosed with an International Classification of Diseases, version 10 (ICD-10) code between F20 and 29 extracted from an EHR database.

Primary: Whether recorded depressive symptoms predicted CBTp session receipt, defined as at least one session of CBTp identified from structured EHR fields supplemented by a natural language processing algorithm. Secondary: Whether age, gender, ethnicity, symptom profiles (positive, negative, manic and disorganisation symptoms), a comorbid diagnosis of depression, anxiety or bipolar disorder, general CBT receipt prior to the primary psychosis diagnosis date or type of psychosis diagnosis predicted CBTp receipt.

Of patients with a psychotic disorder, only 8.2% received CBTp. Individuals with at least one depressive symptom recorded, depression symptom severity and 12 out of 15 of the individual depressive symptoms independently predicted CBTp receipt. Female gender, White ethnicity and presence of a comorbid affective disorder or primary schizoaffective diagnosis were independently positively associated with CBTp receipt within the whole sample and the top 25% of mentioned depressive symptoms.

Individuals with a psychotic disorder who had recorded depressive symptoms were significantly more likely to receive CBTp sessions, aligning with CBTp guidelines of managing depressive symptoms related to a psychotic experience. However, overall receipt of CBTp is low and more common in certain demographic groups, and needs to be increased.

The extent to which sleep is causally related to mental health is unclear. One way to test the causal link is to evaluate the extent to which interventions that improve sleep quality also improve mental health. We conducted a meta-analysis of randomised controlled trials that reported the effects of an intervention that improved sleep on composite mental health, as well as on seven specific mental health difficulties. 65 trials comprising 72 interventions and N = 8608 participants were included. Improving sleep led to a significant medium-sized effect on composite mental health (g+ = -0.53), depression (g+ = -0.63), anxiety (g+ = -0.51), and rumination (g+ = -0.49), as well as significant small-to-medium sized effects on stress (g+ = -0.42), and finally small significant effects on positive psychosis symptoms (g+ = -0.26). We also found a dose response relationship, in that greater improvements in sleep quality led to greater improvements in mental health. Our findings suggest that sleep is causally related to the experience of mental health difficulties. Future research might consider how interventions that improve sleep could be incorporated into mental health services, as well as the mechanisms of action that explain how sleep exerts an effect on mental health.

Sleep disturbances in schizophrenia are common throughout its course including in the prodrome, and have been mainly attributed to severity of symptoms and antipsychotic use. We aimed to investigate whether early course patients with schizophrenia and young non-psychotic siblings of patients with schizophrenia also show sleep disturbances and whether sleep correlates with symptoms and functioning.

Three study groups, that is, adults newly diagnosed with schizophrenia (n = 54), young non-psychotic siblings of schizophrenia patients (n = 56) and a sample of healthy controls matched to the patients and siblings (n = 61) were evaluated on Horne and Ostberg Morningness-Eveningness Questionnaire, Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index. Severity of symptoms and functioning are assessed using the Positive and Negative Syndrome Scale and the Global Assessment of Functioning Scale, respectively. Age, gender, occupation and marital status were regarded as covariates, and differences between the three groups were evaluated using analysis of covariance.

Early course schizophrenia patients and non-psychotic siblings of schizophrenia patients showed significantly reduced sleep quality relative to healthy controls (P < .001). Schizophrenia patients had significantly higher daytime sleepiness compared to controls (P < .001). Chronotypes in schizophrenia patients and unaffected siblings did not significantly differ from those of the healthy controls.

Like chronic medicated schizophrenia patients, early course schizophrenia patients and young non-psychotic siblings of individuals with schizophrenia have sleep disturbances. These findings indicate that sleep markers can distinguish unaffected siblings of schizophrenia from healthy controls and serve as an endophenotype for schizophrenia.

Sleep disturbances are commonly observed in schizophrenia, including in chronic, early-course, and first-episode patients. This has generated considerable interest, both in clinical and research endeavors, in characterizing the relationship between disturbed sleep and schizophrenia. Sleep features can be objectively assessed with EEG recordings. Traditionally, EEG studies have focused on sleep architecture, which includes non-REM and REM sleep stages. More recently, numerous studies have investigated alterations in sleep-specific rhythms, including EEG oscillations, such as sleep spindles and slow waves, in individuals with schizophrenia compared with control subjects. In this article, the author reviews state-of-the-art evidence of disturbed sleep in schizophrenia, starting from the relationship between sleep disturbances and clinical symptoms. First, the author presents studies demonstrating abnormalities in sleep architecture and sleep-oscillatory rhythms in schizophrenia and related psychotic disorders, with an emphasis on recent work demonstrating sleep spindles and slow-wave deficits in early-course and first-episode schizophrenia. Next, the author shows how these sleep abnormalities relate to the cognitive impairments in patients diagnosed with schizophrenia and point to dysfunctions in underlying thalamocortical circuits, Ca+ channel activity, and GABA-glutamate neurotransmission. Finally, the author discusses some of the next steps needed to further establish the role of altered sleep in schizophrenia, including the need to investigate sleep abnormalities across the psychotic spectrum and to establish their relationship with circadian disturbances, which in turn will contribute to the development of novel sleep-informed treatment interventions.

The experience of childhood trauma is linked to more severe symptoms and poorer functioning in severe mental disorders; however, the mechanisms behind this are poorly understood. We investigate the relationship between childhood trauma and sleep disturbances in severe mental disorders including the role of sleep disturbances in mediating the relationship between childhood trauma and the severity of clinical symptoms and poorer functioning.

In total, 766 participants with schizophrenia-spectrum (n = 418) or bipolar disorders (n = 348) were assessed with the Childhood Trauma Questionnaire. Sleep disturbances were assessed through the sleep items in the self-reported Inventory of Depressive Symptoms. Clinical symptoms and functioning were assessed with The Positive and Negative Syndrome Scale and the Global Assessment of Functioning Scale. Mediation analyses using ordinary least squares regression were conducted to test if sleep disturbances mediated the relationship between childhood trauma and the severity of clinical symptoms and poorer functioning.

Symptoms of insomnia, but not hypersomnia or delayed sleep phase, were significantly more frequent in participants with childhood trauma experiences compared to those without. Physical abuse, emotional abuse, and emotional neglect were significantly associated with insomnia symptoms. Insomnia symptoms partly mediate the relationship between childhood trauma and the severity of positive and depressive/anxiety symptoms, in addition to poorer functioning.

We found frequent co-occurrence of childhood trauma history and current insomnia in severe mental disorders. Insomnia partly mediated the relationship between childhood trauma and the severity of clinical symptoms and functional impairment.

Previous studies have found that sleep problems are associated with psychotic experiences (PEs) across clinical designs, but many confounding factors from uncertain variables have been unclear in observational designs. The aim of the present study was to detect the genetic correlations and causal relationship between sleep-related traits and PEs using the largest current genome-wide association study (GWAS) summary statistics.

GWAS results were obtained for positive PEs (N = 116,787-117,794) and sleep-related traits [insomnia complaints (N = 386,533), morningness (N = 345,552), sleep duration (N = 384,317), ease of getting up in the morning (N = 385,949), daytime napping (N = 386,577), daytime sleepiness (N = 386,548), and snoring (N = 359,916)]. Linkage disequilibrium score regression (LDSC) was used to investigate genetic correlations. Mendelian randomization (MR) was conducted on trait pairs with significant genetic associations.

We found that auditory hallucinations were significantly genetically correlated with insomnia complaints (rg = -0.27, p = 1.1 × 10^-3), sleep duration (rg = 0.21, p = 9.7 × 10^-3), and ease of getting up (rg = 0.31, p = 2 × 10^-4). Visual hallucinations and insomnia complaints were highly genetically correlated (rg = 0.36, p = 6.4 × 10^-5). Mendelian randomization indicated a unidirectional causal relationship between sleep duration with auditory hallucinations (β = -0.93, p = 7.9 × 10^-4 for sleep duration as the exposure). We used large GWAS summary statistics across the LDSC and MR programs to determine that sleep duration as exposure to increase the risk of auditory hallucinations.

Taken together, these findings suggest that treatment of sleep problems should be considered as a higher priority for future mental health services.

Sleep disruption is pervasive in people with schizophrenia, but few studies have explored their sleep experiences. This study aims to identify factors relevant to sleep problems and explore coping methods used by community-dwelling people with schizophrenia.

Eighteen participants with schizophrenia were recruited from three mental health centers in Taiwan. They completed a semi-structured interview and the Pittsburgh Sleep Quality Index (PSQI) assessment. The Person-Environment-Occupation model offered a framework to assess factors related to sleep. Thematic analysis was used for the qualitative data analysis.

Factors related to sleep were classified under person, environment, and occupation domains. The person domain included three subthemes: psychiatric symptoms, unpleasant emotions, and frustration about sleep. The environment domain included three subthemes: sensory intrusions from the environment, quality of bedding, and roommates. The occupation domain included sleep interruption and sleep preparation. There were notable discrepancies in sleep quality between the participants' narratives and their PSQI global scores. Regarding coping methods for poor sleep, sleep medication was the primary strategy while some participants also used other strategies, such as modifying the environment, adjusting routines, or engaging in activities that improve sleep quality.

Psychiatric symptoms and nightmares were identified as unique sleep disruptions in people with schizophrenia, and poor economic status was also found to impact their sleep. The sleep quality of people with schizophrenia tends to be poor, as identified by the PSQI, even though they may have positive perceptions of their sleep quality. Our participants appeared to prefer to take hypnotics to address their sleep problems, which may be due to limited knowledge about alternatives. Mental health professionals are encouraged to receive training in the application of non-pharmacological approaches to support their clients' issues related to sleep.

Individuals with schizophrenia spectrum disorders (SSD) experience frequent sleep disturbances in addition to enduring cognitive impairments. The purpose of the present review was to systematically summarise our current understanding of the association between sleep disturbances and cognition in SSD. Through this, it was aimed to identify features of disturbed sleep that are reliably associated with cognitive deficits in SSD and identify the gaps within the current literature that require future investigation. Eighteen relevant studies were identified following a two-stage screening process. Following a structured narrative synthesis of key study components, no clear and consistent pattern emerged. Considerable methodological variability was present amongst the reviewed studies. Although some broad consistencies were identified, such as associations between sleep spindle density and sleep-dependent memory consolidation, the overall pattern of results lacked a cohesive composition due to the diverse list of sleep parameters and cognitive domains investigated, as well as a lack of replication. Additional research is needed before more definitive remarks can be made regarding the influence of sleep disturbances on cognitive function in SSD.

Poor sleep and poor mental health go hand in hand and, together, can have an adverse impact on physical health. Given the already disproportionate physical health inequities experienced by people with a mental health condition worldwide, the need to consider and optimise sleep has been highlighted as a means of improving both physical and mental health status. Sleep recommendations recently developed by the United States' National Sleep Foundation incorporate a range of sleep parameters and enable the identification of 'suboptimal' sleep. Among community-dwelling persons with and without a 12-month mental health condition in Australia, this study reports: [1] the prevalence of 'suboptimal' sleep and [2] rates of sleep assessment by a health care clinician/service and receipt of and desire for sleep treatment.

A descriptive study (N = 1265) was undertaken using self-report data derived from a cross-sectional telephone survey of Australian adults, undertaken in 2017.

Fifteen per cent (n = 184) of participants identified as having a mental health condition in the past 12 months. Across most (7 of 8) sleep parameters, the prevalence of suboptimal sleep was higher among people with a mental health condition, compared to those without (all p < 0.05). The highest prevalence of suboptimal sleep for both groups was seen on measures of sleep duration (36-39% and 17-20% for people with and without a mental health condition, respectively). In terms of sleep assessment and treatment, people with a mental health condition were significantly more likely to: desire treatment (37% versus 16%), have been assessed (38% versus 12%) and have received treatment (30% versus 7%).

The prevalence of suboptimal sleep among persons with a mental health condition in Australia is significantly higher than those without such a condition, and rates of assessment and treatment are low for both groups, but higher for people with a mental health condition. Population health interventions, including those delivered as part of routine health care, addressing suboptimal sleep are needed.

Sleep disturbances in patients with psychotic disorders are common and associated with poor clinical outcomes, but research on negative symptoms is limited. This study aimed to examine the association between subjective sleep disturbances and negative symptoms in 525 patients with non-affective psychotic disorders, 569 unaffected siblings and 265 healthy controls (HC) from the Genetic Risk and Outcome of Psychosis (GROUP) study. Several aspects of subjective sleep disturbances were assessed: sleep satisfaction, sleep onset insomnia, midnocturnal insomnia, early morning insomnia, and hypersomnia. Regression analyses revealed significant negative associations between sleep satisfaction and negative symptoms in all three groups. In addition, significant associations with sleep onset insomnia and hypersomnia were found in patients and with early morning insomnia and hypersomnia in siblings. Exploratory mediation analyses showed that depressive symptoms partly mediated all associations on the subclinical level in siblings and healthy controls, whereas only the association with sleep onset insomnia was mediated in patients. The results of this study implicate specific sleep disturbances and depressive symptoms as potential targets in prevention or intervention strategies focussed on negative symptoms in individuals suffering from, or at risk of non-affective psychotic disorders.

This study aimed to examine the mediating role of sleep quality in the association of problematic internet use (PIU) and problematic gaming with psychological distress among college students in China.

Data of 1040 full-time students from multiple colleges in China were examined. Respondents were asked about their internet use and gaming behaviors, sleep quality, psychological distress, and sociodemographic characteristics. The mediating role of sleep quality in the PIU- and problematic gaming-psychological distress link was examined respectively.

PIU was associated with decreased sleep quality (r = .32, p < .001) and increased psychological distress (r = .46, p < .001). Problematic gaming was also associated with decreased sleep quality (r = .22, p < .001) and increased psychological distress (r = .46, p < .001). Sleep quality accounted for 23.5% of the indirect effect of PIU on psychological distress, and 17.9% of the indirect effect of problematic gaming on psychological distress.

Sleep quality had a meaningful mediating effect on the PIU-psychological distress link, but only exerted a small mediating effect on the problematic gaming-psychological distress link. In addition to promoting healthy internet usage, strategies aimed at mitigating the negative effect of excessive internet use on psychological health might benefit from those aimed at improving sleep quality.

Suicide is a leading cause of death for young adults, and college-enrolled students are at markedly high risk for suicide. Psychotic-like experiences (PLEs) and sleep difficulties are prevalent among college students and have been linked to increased suicidal ideation (SI). This cross-sectional study examined the relation between PLEs and SI, moderated by sleep quality, in a sample of 442 students at a university counseling center. The Behavioral Health Measure-43 (BHM-43) was used to evaluate mental health symptoms, including sleep quality and SI. The PRIME Screen-Revised was used to measure PLEs. Regression results indicated that higher PRIME scores statistically predicted greater SI. There was a significant interaction between PRIME and sleep quality in predicting SI. Among individuals with greater sleep difficulties, PLEs were positively, significantly associated with SI. The PRIME was not a significant predictor of SI at lower levels of sleep difficulties (i.e. better sleep quality). This interaction effect remained significant when controlling for age and the BHM-43 depression and bipolar subscales. Findings suggest that sleep difficulties may be linked to increased SI for individuals with PLEs, and better sleep may be protective. Further research is needed to explore treatment targeting PLEs and/or sleep to mitigate suicide risk among university students.

Clinical experience indicates that excessive sleepiness and hypersomnia may be a common issue for patients with psychosis. Excessive sleepiness is typically ascribed to the sedating effects of antipsychotic medications but there may be other potential contributors such as sleep disorders and depression. Furthermore, the impact of excessive sleepiness itself on patients' symptoms and general wellbeing is yet to be examined. The current study reports an exploratory cross-sectional between-groups comparison of patients with early psychosis fulfilling criteria assessed in a diagnostic interview for problematic excessive sleepiness (n = 14), compared with those not reporting excessive sleepiness (n = 46). There were no differences between the groups in diagnosis, medication type, or antipsychotic medication dosage. There were no significant group differences in sleep duration. Significantly lower activity levels were found in the excessive sleepiness group. Insomnia and nightmares were common in those reporting excessive sleepiness. No significant differences were found in psychiatric symptoms, although data did indicate more severe cognitive disorganisation and grandiosity, but less severe paranoia and hallucinations, in the excessive sleepiness group. Wide confidence intervals and small sample size mean that care should be taken interpreting these results. Overall, this study indicates that excessive sleepiness may not be solely related to medication but also to low levels of activity and other sleep disorders. This is a novel finding that, if replicated, could indicate routes of intervention for this clinical issue. Future research should aim to disentangle directions of effect amongst sleepiness, mood, activity, and psychotic symptoms and investigate possible interventions for excessive sleepiness in psychosis.

Sleep disturbances are prevalent in people with psychosis and are related to several negative outcomes. Recent research indicates that sleep disturbances contribute to the development of psychosis and is therefore an important treatment target. Despite this, a study found that sleep problems in people with psychosis were mostly assessed informally and treated with non-recommended interventions. However, it is uncertain whether these findings reflect local practise or rather status quo for how sleep disturbances in the context of psychosis are approached across different treatment sites. We aimed to replicate this study and investigate how sleep disturbances in people with psychosis are viewed, assessed and treated by clinicians across several mental health services, and the clinicians' perceived barriers to sleep treatment.

A total of 204 clinicians completed an e-mail survey about sleep problems and psychosis.

The main findings were highly consistent with previous research; the clinicians found sleep problems in patients with psychosis to be highly prevalent and with negative consequences. However, structured assessments and the use of recommended treatment interventions were rare. This apparent paradox may at least partly be explained by the clinicians' perceived barriers to sleep treatment, including their declared lack of knowledge about sleep assessment and sleep treatment, and beliefs that sleep treatment is (too) demanding in this population.

Many patients with psychosis across several treatment sites receive less than optimal sleep treatment. Increasing clinicians' knowledge about adequate sleep treatment and its feasibility for patients with psychotic disorders is therefore imperative.

Sleep disturbance is a common clinical issue for patients with psychosis. It has been identified as a putative causal factor in the onset and persistence of psychotic experiences (paranoia and hallucinations). Hence sleep disruption may be a potential treatment target to prevent the onset of psychosis and reduce persistent psychotic experiences. The aim of this review is to describe developments in understanding the nature, causal role, and treatment of sleep disruption in psychosis.

A systematic literature search was conducted to identify studies, published in the last five years, investigating subjective sleep disruption and psychotic experiences.

Fifty-eight papers were identified: 37 clinical and 21 non-clinical studies. The studies were correlational (n = 38; 20 clinical, 18 non-clinical), treatment (n = 7; 1 non-clinical), qualitative accounts (n = 6 clinical), prevalence estimates (n = 5 clinical), and experimental tests (n = 2 non-clinical). Insomnia (50%) and nightmare disorder (48%) are the most prevalent sleep problems found in patients. Sleep disruption predicts the onset and persistence of psychotic experiences such as paranoia and hallucinations, with negative affect identified as a partial mediator of this relationship. Patients recognise the detrimental effects of disrupted sleep and are keen for treatment. All psychological intervention studies reported large effect size improvements in sleep and there may be modest resultant improvements in psychotic experiences.

Sleep disruption is a treatable clinical problem in patients with psychosis. It is important to treat in its own right but may also lessen psychotic experiences. Research is required on how this knowledge can be implemented in clinical services.

People with psychosis benefit enormously from Cognitive Behavioural Therapy for Insomnia (CBTI), although some variability exists in treatment outcomes. While recent efforts have focused on profiling sleep at treatment initiation, an alternative methodological approach involves using treatment response as a starting point to better understand what constitutes an effective treatment. This study used Grade of Membership analysis (GoM) to estimate the occurrence of unique treatment outcomes and associated patient characteristics. Outcome measures included changes in sleep (self-reported latency, efficiency, duration, quality), functional outcomes (daytime dysfunction, negative mood, need for sleep medication) and treatment goal, collected in 50 individuals with a psychotic disorder and insomnia who underwent CBT-I treatment. Three distinct profiles were identified: (1) Strong responders, who met their treatment goals and showed broad improvements in both sleep and functional domains; (2) Partial responders, who showed sleep improvements (particularly in total sleep time), without noticeable gains in function, and who were predominantly female; and (3) Non-responders who showed little treatment response and failed to meet their treatment goals. This group was also more likely to have greater psychopathology (high levels of negative mood and psychotic symptoms, and antipsychotic medication dosage). These findings suggest that (i) CBT-I can serve to improve sleep and daytime function (although sleep can improve independently from function), (ii) client-elicited treatment goals are a key predictor of CBT-I response, (iii) other important variables associated with treatment response include sleep profile, clinical acuity, and sex.

Signs of mental ill health that cut across psychiatric diagnostic categories at high rates are typically viewed as non-specific occurrences, downgraded in importance and disregarded. However, problems not associated with particular diagnoses should be expected if there is shared causation across mental health conditions. If dynamic networks of interacting symptoms are the reality of mental health presentations, then particularly disruptive and highly connected problems should be especially common. The non-specific occurrence might be highly consequential. One non-specific occurrence that is often overlooked is patients' chronic difficulty in getting good sleep. In this Review, we consider whether disrupted sleep might be a contributory causal factor in the occurrence of major types of mental health disorders. It is argued that insomnia and other mental health conditions not only share common causes but also show a bidirectional relationship, with typically the strongest pathway being disrupted sleep as a causal factor in the occurrence of other psychiatric problems. Treating insomnia lessens other mental health problems. Intervening on sleep at an early stage might be a preventive strategy for the onset of clinical disorders. Our recommendations are that insomnia is assessed routinely in the occurrence of mental health disorders; that sleep disturbance is treated in services as a problem in its own right, yet also recognised as a pathway to reduce other mental health difficulties; and that access to evidence-based treatment for sleep difficulties is expanded in mental health services.

Sleep has been shown to impact on both physical and mental health, and sleep problems present a considerable burden for individuals and society. There appears to be a complex bidirectional relationship between sleep disturbance and psychiatric symptoms, each potentially influencing the other. In particular, sleep disorders have been associated with more severe symptoms and are predictive of relapse in those with psychotic disorders. This article discusses the relationship between psychosis and insomnia, sleep apnoea, nightmares, circadian rhythm abnormalities and the impact of medications on these relationships. We also discuss the clinical implications of the relationship between sleep disturbance and psychotic disorders along with potential targets for intervention.

The majority of people with serious mental illness experience insomnia, and insomnia is one of the most frequent reasons for mental health referrals in the Veterans Health Administration. Insomnia also represents a critical obstacle to mental health recovery. Little is known about how military veterans with mental health problems conceptualize their sleep and sleep problems; such information may uncover new avenues for research and treatment. Therefore, the purpose of this study was to explore how veterans with serious mental illness and insomnia experience and understand their sleep, towards the aim of identifying these new avenues. Participants included 20 veterans with insomnia and serious mental illness (i.e. schizophrenia spectrum, bipolar or major depressive disorders, with serious functional impairments). Data were collected via an inductive phenomenological approach using semi-structured interviews. We identified five themes: Sleep to Recharge; Sleep as a Fight; Sleep as Safety or Escape; Sleep as Dangerous; and Military Influence. Participants' relationship with sleep was complex; many associated it with intrusive and troubling hallucinations, paranoia and military experiences, yet at the same time desired sleep for its potential to liberate them from distress. Military mindsets both helped and hindered sleep. These results extend existing models of insomnia development and maintenance, and illuminate phenomena previously unidentified in this underserved veteran population. Clinical and theoretical implications are discussed, as well as new research directions for enhancing therapeutic efficacy.

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.

The Pittsburgh Sleep Quality Index (PSQI) is a measure of self-reported sleep quality and sleep disturbance. Though the PSQI is widely used, it is unclear if it adequately assesses self-reported sleep disturbance in people with schizophrenia spectrum disorders. We used mixed methods to examine the relationship between scores on the PSQI and qualitative self-report during in-depth interview in a group of participants diagnosed with schizophrenia spectrum disorders (N = 15). Although the PSQI appears to accurately capture issues related to sleep initiation, average duration, and interruption by physical complaints, it did not adequately assess other salient issues including irregularity in sleep duration and timing, shallow unrefreshing sleep, prolonged sleep inertia, hypersomnia, and sleep interrupted by mental or psychological complaints. In interview by contrast these types of problems were readily reported and described as important by participants. Our findings suggest that using the PSQI summary score as a measurement of general sleep disturbance in this population may be misleading, as this failed to capture some of the types of sleep problems that are particularly common in this group.

Insomnia has been shown to contribute to the development of psychotic experiences, predominantly via increasing negative affect. However, the role of insomnia in the persistence of psychotic experiences is yet to be investigated in a clinical population. Furthermore, other plausible influences, such as psychotic experiences contributing to insomnia, remain to be evaluated. This study tests the role of insomnia as a predictor of persistence of psychotic experiences versus other potential causal routes. Twenty-nine patients aged 18-30 with non-affective psychosis completed three assessments over three months of their insomnia, negative affect, and psychotic experiences. Mixed effect models allowed comparisons between hypothesis-based models (comprising insomnia as predictor, negative affect as mediator, and psychotic experiences as outcome) and oppositional models, where relationships were reversed. The results supported the hypothesised mediation model above models where negative affect was primary. Insomnia was also found to be a stronger predictor of later hallucinations than vice versa, although a bidirectional relationship was indicated between insomnia and paranoia. In conclusion, insomnia predicts persistence of psychotic experiences over time to the same or greater extent than psychotic experiences contribute to insomnia. This supports insomnia as a potential intervention target in psychosis.

This study investigated sleep subtypes in schizophrenia, and their response to Cognitive Behavioural Therapy for Insomnia (CBT-I) treatment. Sleep profiling was conducted using latent class analysis on baseline Pittsburgh Sleep Quality Index data (N = 74 outpatients with schizophrenia who were poor sleepers, 52% male, mean age = 41.4 years). Of these, 40 took part in CBT-I treatment. Analyses revealed three sleep subtypes based on total sleep time (TST), sleep efficiency (SE), and sleep onset latency (SOL) parameters: Cluster 1 ('classic severe insomnia', 44.6%), Cluster 2 ('insomnia with normal sleep duration', 37.8%), and Cluster 3 ('insomnia with hypersomnia', 17.6%). Gains analysis of pre- and post-treatment data from CBT-I participants revealed improvements in sleep and psychopathology in all three clusters, although there were some group differences in the areas and magnitude of improvement. Cluster 1 showed the greatest benefits with longer TST and improved SE. Cluster 2 showed a comparatively blunted treatment response although TST moved closer to recommended sleep guidelines. Cluster 3 showed significant reductions in TST. Altogether, this is the first demonstration of different sleep profiles in schizophrenia and their influence on treatment response to CBT-I. It also supports the notion that therapies should be tailored to the person and their insomnia presentation.

Nightmares occur more frequently in patients with schizophrenia than they do in the general population. Nightmares are profoundly distressing and may exacerbate daytime psychotic symptoms and undermine day-to-day function. Clinicians do not often ask about nightmares in the context of psychotic illness and patients may underreport them or, if nightmares are reported, they may be disregarded; it may be assumed that they will disappear with antipsychotic medication and that they do not, therefore, require separate intervention. This is a missed opportunity because Image Rehearsal Therapy, among other psychological and pharmacological interventions, has proven effective for nightmares in non-schizophrenia populations and should be considered at an early stage of psychotic illness as an important adjunct to standard treatment. There is active ongoing research in this field, which will undoubtedly benefit patients with schizophrenia in the future.

Undertaking research studies in the field of mental health is essential in mental health nursing. Qualitative research methodologies enable human experiences to become visible and recognize the importance of lived experiences. This paper argues that involving people with schizophrenia in research is critical to promote their health and well-being. The quality of qualitative research needs scrutinizing according to methodological issues such as trustworthiness and ethical standards that are a fundamental part of qualitative research and nursing curricula. The aim of this study was to critically review recent qualitative studies involving people with severe and persistent mental illness such as schizophrenia and other psychotic conditions, regarding descriptions of ethical and methodological issues in data collection and analysis. A search for relevant papers was conducted in three electronic databases, in December 2016. Fifteen qualitative interview studies were included and reviewed regarding methodological issues related to ethics, and data collection and analysis. The results revealed insufficient descriptions of methodology regarding ethical considerations and issues related to recruitment and sampling in qualitative interview studies with individuals with severe mental illness, putting trustworthiness at risk despite detailed descriptions of data analysis. Knowledge from the perspective of individuals with their own experience of mental illness is essential. Issues regarding sampling and trustworthiness in qualitative studies involving people with severe mental illness are vital to counteract the stigmatization of mental illness.

Sleep problems are pervasive in people with schizophrenia, but there are no clinical guidelines for their treatment. The Better Sleep Trial (BEST) concluded that suitably adapted cognitive-behavioural therapy (CBT) is likely to be highly effective, although its cost-effectiveness is unknown.

To assess the potential cost-effectiveness of CBT for sleep disorders in patients with schizophrenia.

An economic evaluation of the BEST study with a 6-month time horizon was used to establish the cost-effectiveness of CBT plus usual care in terms of costs per quality-adjusted life year (QALY) gained. Uncertainty was displayed on cost-effectiveness planes and acceptability curves. Value of information analysis was performed to estimate the benefits of obtaining further evidence.

On average, the treatment led to a 0.035 QALY gain (95% CI -0.016 to 0.084), and £1524 (95% CI -10 529 to 4736) and £1227 (95% CI -10 395 to 5361) lower costs from National Health Service and societal perspectives, respectively. The estimated value of collecting more information about the effects of the CBT on costs and QALYs was approximately £87 million.

CBT for insomnia in people with schizophrenia is effective and potentially cost-effective. A larger trial is needed to provide clear evidence about its cost-effectiveness.

Patients with schizophrenia have multiple complex health needs, as well as very high rates of depression, suicidal ideation and poor physical health. The results of this study showed that treating pervasive sleep problems in this patient group with cognitive-behavioural therapy (CBT) is very likely to improve patient quality of life in the short term. Clinicians most commonly use hypnotic medication to treat sleeping disorders. This study indicates that CBT may be an effective and cost-effective intervention in this patient group. This alternative would also be aligned with patient preferences for psychological and behavioural-type therapy.

None.

Our view is that insomnia may be a causal factor in the occurrence of psychotic experiences such as paranoia and hallucinations. However, the causal relationship is not established. The aim of the study was to investigate the causal role of insomnia in psychotic experiences via a sleep restriction manipulation. The study was a within-subjects crossover design that included a planned mediation analysis. Sixty-eight nonclinical volunteers underwent a sleep loss condition (restricted to 4 h sleep for 3 nights) and a control condition (standard sleep) in randomized order in 2 consecutive weeks, with a weekend washout period. Psychotic experiences (paranoia, hallucinations, grandiosity, and cognitive disorganization) and candidate mediating variables (negative affect and related processes, working memory, decision making, and perceptual processing) were assessed before and after each condition. Actigraphy verified an average sleep duration of 5 h 15 min in the sleep loss condition, vs 6 h 58 min in the control condition. After the sleep loss condition, relative to the control condition, participants reported significant increases in paranoia, hallucinations, and cognitive disorganization, with no significant changes in grandiosity. The sleep loss condition was also associated with significant increases in negative affect, negative self and other cognitions, worry, and working memory impairment. Mediation analyses indicated that changes in psychotic experiences were mediated by changes in negative affect and related processes, but not memory impairment. The overall conclusion is that insomnia has a causal role in the occurrence of certain psychotic experiences, and that a key route is via negative affect.

We view sleep disruption as a contributory causal factor in the development of psychotic experiences. Clinical trials indicate that psychological interventions targeting insomnia result in improvements in both sleep and psychotic experiences. The aim of this study was to gain the perspective of young people at ultra-high risk of psychosis on their sleep problems and associated psychological treatment. Interviews were conducted with 11 patients, aged 15-22 years, at ultra-high risk of psychosis who had received a psychological sleep intervention. Responses were analyzed using thematic analysis. Disrupted sleep timing and a lack of routine were the characteristic hallmarks of participants' sleep problems. Sleep disturbance, psychological wellbeing, and functioning had a reciprocal relationship. There were negative expectations prior to therapy, however meaningful improvements occurred in sleep, mood, and functioning. The active implementation of therapy techniques was highlighted as important. These findings indicate that the treatment of sleep problems is highly valued and has a meaningful impact on wellbeing in young people at ultra-high risk of psychosis.

Sleep problems are very common in people with schizophrenia spectrum disorders, and impact negatively on functioning and wellbeing. Research regarding interventions to improve sleep in this population has been lacking. Little is known regarding these patient's perspectives on sleep problems and their treatment, providing very little foundation on which to develop acceptable and patient-centred treatments.

This study aims to explore perspectives and priorities of participants with schizophrenia spectrum disorders regarding sleep and sleep disturbance, and their perspectives on existing treatments. An Interpretive Phenomenological Analysis (IPA) study was conducted; data were gathered through in depth interviews with 15 people with schizophrenia spectrum disorders and varying degrees of self-reported sleep disturbance, each case was analysed individually before cross-case comparisons were made.

Sleep maintenance and sleep quality were universally valued. Changes to sleep were interpreted as part of a perceived loss of normality relating to diagnosis. Participants differed in the extent of any hopes that sleep would improve. Sleep disturbances were linked to a reduced ability or opportunity to participate in valued activities, and were entangled with self-image due to a wish to be perceived as alert and in control. During difficult times, sleep could be seen as an escape. Concerns were expressed regarding the negative effects of using hypnotics or anti-psychotics to aid sleep, although typically antipsychotics were deemed more acceptable than hypnotics. Concerns regarding barriers to adherence and effectiveness of self-help approaches were common. Non-pharmacological interventions were noted to require a personalised whole-lifestyle approach.

This is the first study to explore sleep perspectives in participants with established schizophrenia spectrum disorders, recruited from a population receiving usual care. Findings re-enforce the importance of considering sleep within recovery focused practice. In developing and adapting interventions routine-based approaches should be considered. Approaches should attempt to make gradual changes more easily perceptible, should support motivation for behaviour change, and should consider the impact of regular psychotropic medications.

Schizophrenia is a major psychiatric disorder that has a massive, long-lasting negative impact on the patients as well as society. While positive symptoms (i.e., delusions and hallucinations), negative symptoms (i.e., anhedonia, social withdrawal), and cognitive impairments are traditionally considered the most prominent features of this disorder, the role of sleep and sleep disturbances has gained increasing prominence in clinical practice. Indeed, the vast majority of patients with schizophrenia report sleep abnormalities, which tend to precede illness onset and can predict an acute exacerbation of psychotic symptoms. Furthermore, schizophrenia patients often have a comorbid sleep disorder, including insomnia, obstructive sleep apnea, restless leg syndrome, or periodic limb movement disorder. Despite accumulating data, the links between sleep disorders and schizophrenia have not been thoroughly examined, in part because they are difficult to disentangle, as numerous factors contribute to their comorbidity, including medication status. Additionally, sleep disorders are often not the primary focus of clinicians treating this population, despite studies suggesting that comorbid sleep disorders carry their own unique risks, including worsening of psychotic symptoms and poorer quality of life. There is also limited information about effective management strategies for schizophrenia patients affected by significant sleep disturbances and/or sleep disorders. To begin addressing these issues, the present review will systematically examine the literature on sleep disorders and schizophrenia, focusing on studies related to 1) links between distinct sleep disorders and schizophrenia; 2) risks unique to patients with a comorbid sleep disorder; and 3) and management challenges and strategies.

Sleep problems are common in people with serious mental illness, and impact negatively on functioning and wellbeing. To understand the development of sleep problems, their maintenance, and their treatment, an in depth understanding of patient perspectives is crucial. A systematic literature review was conducted using Medline, AMED, PsychInfo, Embase and CINAHL. Qualitative and quantitative studies were included if they explored or measured patient perspectives on sleep, sleep problems or sleep treatments in people with serious mental illness. Of the 2,067 hits, only 22 met review inclusion criteria, and high quality evidence was sparse. The limited findings suggested sleep was seen as highly interlinked with mental health. Evaluations of treatments varied, however perceived efficacy and personalisation of treatments were valued. Some evidence suggested patient priorities and conceptualisations regarding sleep may diverge from those of validated screening tools developed in general population and sleep medicine samples. More rigorous research is needed to support adaptation and development of interventions and outcome measures for use in specialist mental health settings. Qualitative studies exploring the experience of sleep disturbance in particular diagnostic groups and contexts are urgently required, as are patient perspectives on sleep interventions.

Insomnia is common in people experiencing psychosis. It has been identified as a contributory cause of paranoia, but any causal relationship with hallucinations has yet to be established. We tested the hypotheses that insomnia i) has a cross-sectional association with hallucinations ii) predicts new inceptions of hallucinations and iii) that these associations remain after controlling for depression, anxiety, and paranoia. Data from the second (2000, N=8580) and third (2007, N=7403) British Psychiatric Morbidity Surveys were used to assess cross-sectional associations between insomnia and hallucinations. The 2000 dataset included an 18 month follow up of a subsample (N=2406) used to test whether insomnia predicted new inceptions of hallucinations. Insomnia was associated with hallucinations in both cross-sectional datasets. Mild sleep problems were associated with 2-3 times greater odds of reporting hallucinations, whilst chronic insomnia was associated with four times greater odds. Insomnia was also associated with increased odds of hallucinations occurring de novo over the next 18 months. These associations remained significant, although with smaller odds ratios, after controlling for depression, anxiety and paranoia. This is the first longitudinal evidence that insomnia is associated with the development of hallucinatory experiences. Effective treatment of insomnia may lessen the occurrence of hallucinations.

Aims and method: To assess clinicians' views about their understanding and treatment of sleep problems in people with non-affective psychosis. An online survey was emailed to adult mental health teams in two NHS trusts. Results: One hundred and eleven clinicians completed the survey. All clinicians reported disrupted sleep in their patients, and endorsed the view that sleep and psychotic experiences each exacerbate the other. However, most clinicians (n = 92, 82%) assessed sleep problems informally, rather than using standard assessment measures. There was infrequent use of the recommended cognitive-behavioural treatments for sleep problems such as persistent insomnia, with the approaches typically used being sleep hygiene and medications instead. Clinical implications: Clinicians recognise the importance of sleep in psychosis, but the use of formal assessments and recommended treatments is limited. Barriers to treatment implementation identified by the clinicians related to services (e.g. lack of time), patients (e.g. their lifestyle) and environmental features of inpatient settings.

Sleep disturbance is increasingly recognized as a major problem for patients with schizophrenia but it is rarely the direct focus of treatment. The main recommended treatment for insomnia is cognitive behavioural therapy, which we have been evaluating for patients with current delusions and hallucinations in the context of non-affective psychosis.

In this article we describe the lessons we have learned about clinical presentations of sleep problems in schizophrenia and the adaptations to intervention that we recommend for patients with current delusions and hallucinations.

Twelve factors that may particularly contribute to sleep problems in schizophrenia are identified. These include delusions and hallucinations interfering with sleep, attempts to use sleep as an escape from voices, circadian rhythm disruption, insufficient daytime activity, and fear of the bed, based upon past adverse experiences. Specific adaptations for psychological treatment related to each factor are described.

Our experience is that patients want help to improve their sleep; sleep problems in schizophrenia should be treated with evidence-based interventions, and that the interventions may have the added benefit of lessening the psychotic experiences. A treatment technique hierarchy is proposed for ease of translation to clinical practice.