In schizophrenia, sleep disturbance persisting while on adequate antipsychotic treatment can pose a clinical challenge.Insomnia is such situations requires a comprehensive evaluation, to rule out causes/contributing factors. Residual insomnia is usually treated by substituting or adding sedating drugs.Both has its disadvantages ( relapse while substituting , additional side effects when adding). What do evidence suggest?
Baandrup Poul Jennum, Henrik Lublin and Birte Glenthoj discuss the above challenge and treatment options in this discussion paper. Systematic search by authors identified five RCTs investigating pharmacological treatment options.Switching to risperidone or paliperidone or addition of melatonin ( 3 studies) were the strategies thus identified. Though risperidone is a good choice as suggested by the search results, lack of comparison with SGAs is a limitation.Melatonin improved certain sleep characteristics.
Authors highlight that methodological limitations of these studies prevent us from drawing conclusions. Z drugs are widely used in such clinical situations though not been studied in this group. Residual insomnia is a chronic problem and Z drugs are not recommended for prolonged use.Benzodiazepines could contribute to cognitive decline. Medications with antihistamine properties like low-dose doxepin and trazodone are another strategy that is less studied. They do help with insomnia and they may not have tolerance/abuse/weight gain issues. Low dose quetiapine is used to treat residual insomnia , though there is no evidence base.Authors indicate that even low doses are associated with metabolic adverse effects.
In the accompanying editorial comments, C. Andrade and P. N. Suresh Kumar do not consider melatonin, benzodiazepines, Z drugs, antihistaminics, antidepressants , anxiolytics or behavioural interventions as practical solutions.They strongly suggest augmenting with a sedating antipsychotic like quetiapine IR. In their opinion, augmentation can increase the antipsychotic efficacy of the primary drug.
Thorough analysis of the cause of insomnia is important. Sleep hygiene is a useful strategy often neglected. Augmenting with a second antipsychotic is a common and useful clinical practice, safety of which needs to be studied.
Summary of the article:
Treatment options for residual insomnia in schizophrenia. Baandrup L, Jennum P, Lublin H, Glenthoj B.Acta Psychiatr Scand. 2013 Jan;127(1):81-2.