Treatment of sleep dysfunction and psychiatric disorders

Opinion statement

Patients with neurologic disorders commonly experience sleep dysfunction and psychiatric disorders. The most common sleep dysfunction is insomnia, which is a primary symptom in 30% to 90% of psychiatric disorders. Insomnia and fatigue are prominent symptoms of anxiety disorders and major depression, including patients who are treated but have residual symptoms. Anxiety and depressive disorders account for 40% to 50% of all cases of chronic insomnia. It is also recognized that primary insomnia and other primary sleep disorders produce symptoms that are similar to those reported by patients with psychiatric disorders. A clinician must judge whether sleep deprivation causes mood disturbance or whether depressive or anxiety disorder represents the primary reason for sleep dysfunction. When insomnia is comorbid with mild to moderate depression, therapy should begin with bedtime dosing of sedating antidepressants such as mirtazapine, nefazodone, or tricyclic antidepressants, which are preferred because of their sedative effects, although side effects may limit their usefulness. Intervention for chronic insomnia is similar in nonpsychiatric and psychiatric patients. Behavioral therapies, particularly cognitive behavioral therapy, and lifestyle changes show significant long-term efficacy as treatments for chronic insomnia. Sedative hypnotic agents are the most studied agents to treat insomnia, particularly those that are active through the benzodiazepine receptor-GABA complex, such as benzodiazepines, eszopiclone, zaleplon, and zolpidem. The new melatonin-receptor agonist ramelteon has not yet been studied in psychiatric patients. Prescription of adjunctive trazodone 50 to 150 mg is a common clinical practice to treat comorbid insomnia during antidepressant therapy, but published data are surprisingly limited when considered against the frequent usage of trazodone. Although there has been insufficient research on the use of atypical antipsychotic agents in severe insomnia, psychiatrists use quetiapine, olanzapine, or other agents to lessen agitation that disrupts sleep onset or maintenance. When insomnia or hypersomnia continues even as mood, anxiety, or thought disorders improve with standard therapy, the physician should consider the potential presence of underlying sleep disorders.

This is a preview of subscription content, access via your institution.

References and Recommended Reading

  1. 1.

    Bassetti CL: Sleep and stroke. Semin Neurol 2005, 25:19–32. Review of sleep in common neurologic disorder.

    PubMed  Article  Google Scholar 

  2. 2.

    Spalletta G, Ripa A, Caltagirone C: Symptom profile of DSM-IV major and minor depressive disorders in first-ever stroke patients. Am J Geriatr Psychiatry 2005, 13:108–115.

    PubMed  Article  Google Scholar 

  3. 3.

    American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, edn 4, text revision. Washington, DC: American Psychiatric Association; 2000.

  4. 4.

    Ohayon MM, Roth T: Place of chronic insomnia in the course of depressive and anxiety disorders. J Psychiatr Res 2003, 37:9–15. A very large and extensive study.

    PubMed  Article  Google Scholar 

  5. 5.

    Perlis ML, Smith LJ, Lyness JM, et al.: Insomnia as a risk factor for onset of depression in the elderly. Behav Sleep Med 2006, 4:104–113.

    PubMed  Article  Google Scholar 

  6. 6.

    Breslau N, Roth T, Rosenthal L, Andreski P: Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry 1996, 39:411–418.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Ford DE, Kamerow DB: Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA 1989, 262:1479–1484.

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Chang PP, Ford DE, Mead LA, et al.: Insomnia in young men and subsequent depression. The Johns Hopkins Precursors Study. Am J Epidemiol 1997, 146:105–114. This study followed medical students from Johns Hopkins University for more than 30 years.

    PubMed  CAS  Google Scholar 

  9. 9.

    Bernert RA, Joiner TE Jr, Cukrowicz KC, et al.: Suicidality and sleep disturbances. Sleep 2005, 28:1135–1141.

    PubMed  Google Scholar 

  10. 10.

    National Institutes of Health: National Institutes of Health State of the Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults, June 13–15, 2005. Sleep 2005, 28:1049–1057. Expert panel review of insomnia evaluation and treatment.

    Google Scholar 

  11. 11.

    Benca RM: Mood disorders. In Principles and Practices of Sleep Medicine, edn 4. Edited by Kryger M, Roth T, Dement W. Philadelphia: Elsevier; 2005:1311–1326.

    Google Scholar 

  12. 12.

    Lawrence RW: Effect of mirtazapine versus fluoxetine on “sleep quality.” J Clin Psychiatry 2004, 65:1149–1150.

    PubMed  Google Scholar 

  13. 13.

    Nierenberg AA, Keefe BR, Leslie VC, et al.: Residual symptoms in depressed patients who respond acutely to fluoxetine. J Clin Psychiatry 1999, 60:221–225.

    PubMed  CAS  Article  Google Scholar 

  14. 14.

    Nowell PD, Buysse DJ: Treatment of insomnia in patients with mood disorders. Depress Anxiety 2001, 14:7–18. Review from psychiatric perspective.

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Jindal RD, Thase ME: Treatment of insomnia associated with clinical depression. Sleep Med Rev 2004, 8:19–30.

    PubMed  Article  Google Scholar 

  16. 16.

    Smith MT, Perlis ML: Who is a candidate for cognitivebehavioral therapy for insomnia? Health Psychol 2006, 25:15–19. Discussion of treatment selection for CBT, a key issue to successful therapy.

    PubMed  Article  Google Scholar 

  17. 17.

    Becker PM: Pharmacologic and nonpharmacologic treatments of insomnia. Neurol Clin 2005, 23:1149–1163. Comprehensive review of current evidence-based clinical practices.

    PubMed  Article  Google Scholar 

  18. 18.

    Rush AJ, Trivedi MH, Wisniewski SR, et al.: Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. N Engl J Med 2006, 354:1231–1242.

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Bootzin R: Stimulus control treatment for insomnia. In Proceedings of the 80th Annual Convention of the American Psychological Association. Washington, DC: American Psychological Association; 1972:395–396.

    Google Scholar 

  20. 20.

    Spielman AJ, Saskin P, Thorpy MJ: Treatment of chronic insomnia by restriction of time in bed. Sleep 1987, 10:45–56.

    PubMed  CAS  Google Scholar 

  21. 21.

    Hauri PJ: Sleep hygiene, relaxation therapy, and cognitive interventions. In Case Studies in Insomnia. Edited by Hauri PJ. New York: Plenum Publishing; 1991:65–84.

    Google Scholar 

  22. 22.

    Espie CA: Insomnia: conceptual issues in the development, persistence, and treatment of sleep disorder in adults. Annu Rev Psychol 2002, 53:215–243.

    PubMed  Article  Google Scholar 

  23. 23.

    Lichstein KL, Morin CM: Treatment of Late-Life Insomnia. Thousand Oaks, CA: Sage Publications; 2000.

    Google Scholar 

  24. 24.

    Morin CM, Hauri PJ, Espie CA, et al.: Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep 1999, 22:1134–1156. Evidence to support nonpharmacologic treatments of chronic insomnia.

    PubMed  CAS  Google Scholar 

  25. 25.

    Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW: Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med 2004, 164:1888–1896. One of the few studies in clinic patients that compared treatments, although there were high dropout rates.

    PubMed  Article  Google Scholar 

  26. 26.

    Rybarczyk B, Stepanski E, Fogg L, et al.: A placebo-controlled test of cognitive-behavioral therapy for comorbid insomnia in older adults. J Consult Clin Psychol 2005, 73:1164–1174.

    PubMed  Article  Google Scholar 

  27. 27.

    Vallieres A, Morin CM, Guay B: Sequential combinations of drug and cognitive behavioral therapy for chronic insomnia: an exploratory study. Behav Res Ther 2005, 43:1611–1630.

    PubMed  Article  Google Scholar 

  28. 28.

    Silber MH: Clinical practice. Chronic insomnia. N Engl J Med 2005, 353:803–810.

    PubMed  Article  CAS  Google Scholar 

  29. 29.

    Borbely AA, Youmbi-Balderer G: Effect of diphenhydramine on subjective sleep parameters and on motor activity during bedtime. Int J Clin Pharmacol Ther Toxicol 1988, 26:392–396.

    PubMed  CAS  Google Scholar 

  30. 30.

    Mendelson WB: A review of the evidence for the efficacy and safety of trazodone in insomnia. J Clin Psychiatry 2005, 66:469–476. A critique of the fastest growing sedative that is prescribed in primary care.

    PubMed  CAS  Article  Google Scholar 

  31. 31.

    Becker PM: Trazodone as a hypnotic in major depression. Sleep Med 2004, 5:7–8.

    PubMed  Article  Google Scholar 

  32. 32.

    Ringdahl EN, Pereira SL, Delzell JE Jr: Treatment of primary insomnia. J Am Board Fam Pract 2004, 17:212–219.

    PubMed  Article  Google Scholar 

  33. 33.

    Mendelson WB, Roth T, Cassella J, et al.: The treatment of chronic insomnia: drug indications, chronic use and abuse liability. Summary of a 2001 New Clinical Drug Evaluation Unit meeting symposium. Sleep Med Rev 2004, 8:7–17.

    PubMed  Article  Google Scholar 

  34. 34.

    Sateia MJ, Nowell PD: Insomnia. Lancet 2004, 364:1959–1973.

    PubMed  Article  Google Scholar 

  35. 35.

    Krystal AD, Walsh JK, Laska E, et al.: Sustained efficacy of eszopiclone over 6 months of nightly treatment: results of a randomized, double-blind, placebo-controlled study in adults with chronic insomnia. Sleep 2003, 26:793–799.

    PubMed  Google Scholar 

  36. 36.

    Barbera J, Shaprio C: Benefit-risk assessment of zaleplon in the treatment of insomnia. Drug Saf 2005, 28:301–318.

    PubMed  Article  CAS  Google Scholar 

  37. 37.

    Perlis ML, McCall WV, Krystal AD, Walsh JK: Long-term, non-nightly administration of zolpidem in the treatment of patients with primary insomnia. J Clin Psychiatry 2004, 65:1128–1137.

    PubMed  CAS  Google Scholar 

  38. 38.

    Smith MT, Perlis ML, Park A, et al.: Comparative metaanalysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002, 159:5–11.

    PubMed  Article  Google Scholar 

  39. 39.

    Morin CM, Belanger L, Bastien C, Vallieres A: Long-term outcome after discontinuation of benzodiazepines for insomnia: a survival analysis of relapse. Behav Res Ther 2005, 43:1–14.

    PubMed  Article  Google Scholar 

Download references

Author information



Rights and permissions

Reprints and Permissions

About this article

Cite this article

Becker, P.M. Treatment of sleep dysfunction and psychiatric disorders. Curr Treat Options Neurol 8, 367–375 (2006).

Download citation


  • Anxiety Disorder
  • Cognitive Behavioral Therapy
  • Zolpidem
  • Mirtazapine
  • Trazodone