The treatment of sleep disorders in schizophrenic patients is preferred to the application of antipsychotic drugs to improve psychotic symptoms and sleep disorders, which can be combined with benzodiazepines if necessary. The excessive sedative effects of antipsychotics and benzodiazepines may continue into the next day, so it is necessary to give due consideration to whether the patient is experiencing pharmacogenic negative symptoms, pharmacogenic cognitive dysfunction, and secondary sleep disorders due to biological clock disturbances.
I. Pharmacological treatment of schizophrenia-related sleep disorders
1. Typical antipsychotic drugs
A relatively consistent finding is that typical antipsychotic drugs have the effect of shortening sleep latency, increasing total sleep time, improving sleep efficiency and improving sleep maintenance difficulties in schizophrenia patients. Most studies have concluded that typical antipsychotics can increase REM sleep latency in schizophrenia patients, but cannot improve slow-wave sleep.
2.Atypical antipsychotic drugs
(1) Clozapine
Clozapine can shorten sleep latency and increase sleep duration. Most studies have concluded that clozapine can increase the duration of stage 2 sleep and significantly improve the symptoms of persistent difficulty in sleep in schizophrenia patients, but it has no improvement on slow-wave sleep.
(2) Olanzapine
Salin-Pascual et al. concluded that olanzapine increased total sleep time and improved persistent sleep difficulties, while decreasing stage 1 sleep and increasing stage 2 sleep, and increasing slow-wave sleep from 35 to 98 minutes.
(3) Risperidone
A study by Eisho Yamashita et al. concluded that the group of patients treated with risperidone had significantly more slow-wave sleep than the haloperidol group. The results of a study on paliperidone, the active ingredient of risperidone metabolite, showed that paliperidone had the effect of shortening sleep latency, increasing total sleep time, reducing stage 1 sleep and increasing stage 2 sleep, and improving difficulty in sleep persistence.
(4) Quetiapine
Eisho Yamashita et al. concluded that quetiapine, olanzapine and risperidone were all more effective than typical antipsychotic drugs in improving sleep disorders in schizophrenic patients, while the results of a survey of patients’ complaints about their conscious sleep status showed no significant differences among the three drugs.
3.Benzodiazepines
Although antipsychotic medication should be considered first in the treatment of schizophrenia sleep disorders, short-term combined benzodiazepine treatment is a better choice for patients in the acute phase if necessary. Studies on benzodiazepine addiction have shown that the risk of drug dependence can be high with continuous use for more than three months. Therefore, it is recommended that the dose of benzodiazepines be gradually reduced until discontinued within 1 month after the patient’s sleep has improved, if possible. Clonazepam should be preferred for the treatment of restless legs syndrome in schizophrenic patients, and long-term use can be considered when it seriously affects sleep and life.
4, melatonin receptor agonist class hypnotic drugs
Remelaton is a melatonin receptor agonist, the drug is characterized by a rapid onset of action and a short half-life, so it is effective only for sleep-initiated insomnia and can shorten the sleep latency. It has no abuse potential, no withdrawal symptoms, and no rebound insomnia. It can be safely used in schizophrenic patients with combined mild to moderate obstructive sleep apnea syndrome and chronic obstructive pulmonary disease, and is better tolerated than other classes of hypnotics in patients with concomitant somatic disorders. Adverse effects of the drug should be noted, including elevated prolactin levels in adult women, decreased testosterone levels in adult men, and should be used with caution in patients with moderate or greater liver disease. Several studies have concluded that Remelaton has the effect of shortening the sleep latency of schizophrenia patients and is effective for difficulty falling asleep.
II. Non-pharmacological treatment of schizophrenia-related sleep disorders
The application of the “biological, psychological and social” medical model to establish a “person-centered” systematic approach to rehabilitation and prevention is an effective way to rehabilitate and prevent schizophrenia-related sleep disorders.
1.Biological factors
(1) Remove the cause of the disease.
Try to remove the disease factors that cause sleep disorders, actively treat schizophrenia, and insist on taking antipsychotic drugs for maintenance treatment to prevent relapse. Actively treat related somatic diseases and improve health status.
(2) Regulation of sleep rhythm.
Through the implementation of regular work and rest schedule, guide patients to develop good sleep hygiene habits and gradually correct the sleep-wake rhythm to make it conform to the usual circadian rhythm, so as to obtain satisfactory sleep quality.
2.Psychological aspect
Cognitive behavioral therapy is mainly used to eliminate the psychological triggers of insomnia and rebuild a regular and quality sleep pattern. Behavioral therapy techniques should be used to alleviate or eliminate concerns about mental illness and relieve mental stress. The main methods are.
(1) Stimulus control therapy.
① Go to bed only when you are sleepy
②The bedroom is only used for sleep
(3) When you cannot fall asleep for a short period of time (15-20 minutes), go to another room to read or do quieter activities, and go to bed when you are sleepy
④Wake up at a fixed time regardless of the length of sleep
⑤ Avoid daytime naps, etc.
(2) Sleep restriction therapy.
①Reduce the time spent in bed to the estimated total sleep time (at least 5 hours)
②Increase the time spent in bed by 15 minutes per week when the estimated sleep efficiency (ratio of sleep time to bed time) is at least 90%.
(3) Relaxation therapy.
① Somatic relaxation: progressive muscle relaxation, biofeedback.
(2) Mental relaxation: imagery training, meditation, hypnosis.
(4) Cognitive therapy: educate patients to change misconceptions and attitudes about sleep. Misconceptions such as: needing at least 8 hours of sleep per night to be considered healthy, etc.
(5) Sleep hygiene education: teach patients various measures to deal with insomnia on their own.
①Living a regular life.
② Avoid strenuous activities that cause excitement 4 hours before bedtime, advocate drinking a glass of hot milk before bedtime, and avoid eating food or medicine that affects sleep.
③Appropriately increase the amount of daytime activities, reduce daytime sleep, and receive more light in the morning.
④ Correct understanding and reasonable use of sedative-hypnotic drugs to avoid abuse, etc.
3.Social aspects
(1) Create a good family harmony and social support environment for schizophrenia patients as much as possible, and assist many parties to form a treatment alliance. This will help the patient’s mental recovery and has a curative significance.
(2) Create an optimal sleep environment and avoid adverse stimuli. Adjust the temperature, humidity and light of the room, maintain air circulation, keep the surrounding environment quiet to avoid noise disturbance, and choose comfortable bedding, etc.