Take-home points

Insomnia is a common symptom in schizophrenia

This is sometimes due to paranoia, agitation, or a circadian rhythm phase shift, as some schizophrenics become nocturnal

Often, atypical antipsychotics possess the pharmacodynamic properties to treat insomnia as they induce somnolence through H1 receptor antagonism and promote deeper sleep through 5-HT2A receptor antagonism. Some antagonize noradrenergic alpha-1 receptors to induce somnolence as well

If this monotherapy approach fails, approved hypnotic agents that act through GABA, melatonin, or histamine systems may be utilized to improve sleep

To treat insomnia, clinicians should be aware of on- and off-label medications that antagonize H1 receptors, alpha-1 receptors, onexis receptors or agonize MT1/MT2 receptors or GABA-A receptors

Finally, a new class of hypnotic agent has been approved, called suvorexant (Belsomra), which antagonizes orexin receptors

• – Agonism of orexin receptors promotes and stabilizes normal wakeful states

• – Therefore, blocking orexin receptor activity may destabilize wakefulness and promote sleep

• – It could have been used as an alternative in this case

Performance in practice: confessions of a psychopharmacologist

What could have been done better here?

• – The patient was doing well on the very first atypical antipsychotic, perhaps this should never have been changed

• – More aggressive anxiolysis through even higher-dosed BZs could have been utilized to overcome the desensitization or tolerance

• – A referral to short-term psychotherapy (perhaps CBT) may have been utilized to treat the somatic anxiety and insomnia

• – Be aware that insomnia may be an independent risk factor indicative of a pending relapse into psychosis

Possible action items for improvement in practice

• – Research the rates of development of TD and metabolic disorder over long- term care in schizophrenia to better determine the risks and benefits of using certain atypical antipsychotics versus high-potency typical antipsychotics as in this case; manipulating his effective atypical may have started the cascade of medication changes

• – Research clinical rationale for utilizing typical antipsychotics in an era dominated by atypical antipsychotic use

• – Research and become more familiar with typical and atypical antipsychotics that possess potential hypnotic pharmacodynamic profiles

Tips and pearls

Primary insomnia is prevalent and common even in non-psychiatric patients

Primary insomnia may be comorbid with both mental and medical disorders

Insomnia may also be secondary to one of these primary disorders

Interestingly, in the DSM-5 there is no longer the need to debate if insomnia is primary or secondary. Insomnia disorder can now be listed as a separate disorder of concern along with other psychiatric conditions being treated, if it is a focus of treatment

Insomnia is often a side effect of prescribing antidepressants and stimulants

Insomnia is often a residual untreated symptom of many psychiatric disorders

Insomnia is a risk factor for acute suicidal behavior, depressive, manic, or psychotic relapse

Routine monitoring and aggressive treatment of insomnia is warranted

Monotherapy using the safest agent first is suggested

Escalating treatment of insomnia, including the use of polypharmacy, may be needed in severe cases

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