Knitting up the ravelled sleeve of care: sleep and psychosis
Authors: Max Birchwood
Journal: The Lancet Psychiatry (2015)

Sleep problems are pervasive in people with schizophrenia. There is a strong documented link between insomnia and psychosis symptoms, and longitudinal studies1Freeman D Brugha T Meltzer H Jenkins R Stahl D Bebbington P Persecutory ideation and insomnia: findings from the second British National Survey of Psychiatric Morbidity.J Psychiatr Res. 2010; 44: 1021-1026Summary Full Text Full Text PDF PubMed Scopus (73) Google Scholar suggest that insomnia predicts new episodes of paranoia. We cannot assume that standard interventions for insomnia will be successful in psychosis and no trial of such interventions in psychosis has been done. On this basis, Daniel Freeman and colleagues' study2Freedman D Waite F Startup H Effectiveness of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial.Lancet Psych. 2015; (published online Sept 10.)http://dx.doi.org/10.1016/S2215-0366(15)00314-4Google Scholar in The Lancet Psychiatry is well founded. This pilot feasibility trial assesses the benefit of cognitive behavioural therapy (CBT) in the context of insomnia in individuals with a schizophrenia spectrum diagnosis and persistent delusions or hallucinations. Participants were successfully recruited, adhered to treatment, and were followed up to a high level. The CBT intervention was well received by participants, leading to reductions in the primary outcome measure of levels of insomnia 12 weeks after treatment (adjusted mean difference 6·1, 95% CI 3·0–9·2, effect size d=1·9). Despite reductions in insomnia in the large effect size range, there was only a weak indication that the intervention would lead to improvements in psychosis symptoms, including paranoia. This trial comes at a time when conventional CBT for psychosis, although recommended by NICE, has come under scrutiny,3Jauhar S McKenna PJ Radua J Fung E Salvador R Laws KR Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias.Br J Psychiatry. 2014; 204: 20-29Crossref PubMed Scopus (332) Google Scholar and for good reason: the effect sizes of this first wave of CBT for psychosis are small to moderate in terms of effect on psychosis itself. This outcome was evident nearly 10 years ago; we argued that CBT should concentrate mainly on the affective dimension of psychosis (which is after all where CBT cut its teeth) and on well theorised mechanisms.4Birchwood M Trower P The future of cognitive-behavioural therapy for psychosis: not a quasi-neuroleptic.Br J Psychiatry. 2006; 188: 107-108Crossref PubMed Scopus (142) Google Scholar The affective dimension in psychosis is increasingly understood, as is its link with psychosis onset and persistence.5van Rossum I Dominguez MD Lieb R Wittchen HU van Os J Affective dysregulation and reality distortion: a 10-year prospective study of their association and clinical relevance.Schizophr Bull. 2011; 37: 561-571Crossref PubMed Scopus (123) Google Scholar CBT for psychosis has become a very complex intervention and, because the population under study is heterogeneous, it risks losing impact because the effect on individual mechanisms and outcomes is diluted. Freeman and colleagues' study is an excellent example of the new wave of CBT interventions in psychosis focusing on the affective dimension and theoretically driven treatment targets, and for which trials are parsimonious and focused on hypothesised mechanisms. The emphasis on feasibility, acceptability, and effect sizes in the present study, rather than on p values, is apposite. Notable is the very high rate of completion of the CBT intervention (96%) and the high acceptability, similar to that achieved in equally focused interventions for post-traumatic stress disorder and command hallucinations in psychosis.6Birchwood M Michail M Meaden A et al.Cognitive behaviour therapy to prevent harmful compliance with command hallucinations (COMMAND): a randomised controlled trial.Lancet Psychiatry. 2014; 1 (2014): 23-33Summary Full Text Full Text PDF Scopus (105) Google Scholar, 7van den Berg DPG de Bont PA van der Vleugel BM et al.Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: a randomized clinical trial.JAMA Psychiatry. 2015; 72: 259-267Crossref PubMed Scopus (224) Google Scholar The Schizophrenia Commission emphasised the need for new interventions, particularly those with high acceptability, which current, predominantly drug-based, treatments tend not to have.8The Schizophrenia CommissionThe abandoned illness.www.rethink.org/media/514093/TSC_main_report_14_nov.pdfDate: November, 2012Google Scholar This sleep intervention satisfies this requirement. However, one of the downsides of focusing on single, but nevertheless important, symptoms is that they are rarely present alone. In this case, sleep difficulty usually accompanies depression and anxiety. The question is raised as to what extent insomnia is embedded in depression; indeed, many patients in the present study were receiving SSRIs and most were severely depressed. This issue is important from a theoretical perspective, because depression and emotional dysregulation have generally been implicated in the ontogeny of psychosis; moreover, depression and suicidal thinking are, over time, virtually ubiquitous in patients with psychosis.9Upthegrove R Birchwood M Ross K Brunett K McCollum R Jones L The evolution of depression and suicidality in first episode psychosis.Acta Psychiatr Scand. 2010; 122: 211-218Crossref PubMed Scopus (147) Google Scholar The definitive trial should examine depression as a mediator of any effect on paranoia. Although the effect of CBT on insomnia was in the large range, the effect on hallucinations and delusions was small at best. Importantly, the effect on quality of life and overall fatigue was in the medium range, underscoring the notion that CBT might be most effective when focusing on distress and quality of life. Many individuals with persecutory thinking feel under threat and mitigate this in various different ways,10Freeman D Garety PA Kuipers E Fowler D Bebbington PE Dunn G Acting on persecutory delusions: the importance of safety seeking.Behav Res Ther. 2007; 45: 89-99Crossref PubMed Scopus (145) Google Scholar and threat monitoring and hypervigilance can lead to (or perhaps in some cases are the same as) insomnia. Although direct intervention in insomnia will still be a valid therapeutic approach, for some patients, it might increase the perceived threat. In this regard, there might be important subgroups in the case of any effect of the intervention on psychosis, and the possibility of distinct responder and non-responder subgroups could be examined in the next trial. Finally, the large variation in effect sizes by the method and dimension of sleep assessed in the present study was intriguing, with the Insomnia Severity Index having the largest effect size and actigraphy (total sleep time) the weakest. What was the cause of this variation and what do the secondary sleep outcomes measure that the primary one does not? Consideration of these questions will no doubt be useful in planning of the next trial. In conclusion, Freeman and colleagues' new-wave, high-quality, feasibility trial fully deserves a definitive randomised controlled trial and, like all good science, raises as many questions as it answers. I am supported by the National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care West Midlands. Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trialOur findings show that CBT for insomnia might be highly effective for improving sleep in patients with persistent delusions or hallucinations. A larger, suitably powered phase 3 study is now needed to provide a precise estimate of the effects of CBT for sleep problems, both on sleep and psychotic experiences. Full-Text PDF Open Access