Sleep and mental disorders

Leslie M Swanson PhD (Dr. Swanson of the University of Michigan has no relevant financial relationships to disclose.)
Antonio Culebras MD, editor. (

Dr. Culebras of SUNY Upstate Medical University at Syracuse received an honorarium from Jazz Pharmaceuticals for a speaking engagement.

Originally released September 9, 1993; last updated October 15, 2014; expires October 15, 2017
Notice: This article has expired and is therefore not available for CME credit.


The author reviews sleep problems and disorders associated with psychiatric disorders, including affective, anxiety, and psychotic disorders. Sleep disturbances are common in individuals who are experiencing psychiatric illness and are included in the diagnostic criteria of many of the affective and anxiety disorders. Sleep symptoms hinder response to treatment and frequently persist after treatment of psychiatric conditions, increasing the risk of relapse. Thus, clinical attention to sleep disturbances during acute and maintenance treatment of psychiatric conditions is important. The author discusses general treatments for the management of sleep disturbances experienced in the context of psychiatric illness, including cognitive behavioral therapy for insomnia and its effects on insomnia comorbid with psychiatric conditions.

Key points


• Sleep disturbances are exceedingly common in patients with psychiatric conditions.


• The presence of sleep disturbance, such as insomnia, can complicate clinical course for patients with psychiatric illness.


• Effective treatment of sleep disturbance comorbid with psychiatric illness can be accomplished using both pharmacological and nonpharmacological strategies.


• Sleep disturbance often persists after successful treatment of depression.


• Treatment of insomnia comorbid with depression can enhance treatment response to antidepressant medication.

Historical note and terminology

Sleep complaints have long been recognized as common in psychiatric disorders, but scientific study of the relationship between sleep and psychiatric disorders began with the introduction of polysomnography as a research and subsequent clinical tool in the 1960s.

During the 1960s nocturnal dreaming was thought to be restricted to REM sleep, which had only recently been differentiated from other stages of sleep (Dement and Kleitman 1957). Due to the centrality of dreams in psychoanalytic theory, psychotic hallucinations were thought to be caused by dreams somehow entering the waking state. Gross intrusion of REM sleep into the daytime hours was not observed in schizophrenics, however. Nor was their nocturnal REM sleep much different from normals (Rechtschaffen et al 1964; Gulevich et al 1967).

In the late 1960s it was discovered that intrusion of REM sleep into waking life in the form of hypnagogic hallucinations, sleep paralysis, and cataplexy occurs with narcolepsy.

Kupfer first observed that a short latency from initial sleep onset to REM sleep onset (REM latency) could be demonstrated in major, or endogenous, depression (Kupfer 1972). This finding is not unique to depression but occurs also in schizophrenia (Tandon et al 1992), panic disorder (Uhde et al 1984), and perhaps other psychiatric illnesses. Sitaram and colleagues first suggested that centrally acting cholinergic agonists could induce short REM latency (Sitaram et al 1977). An abnormal cholinergic mechanism may, therefore, be common to several severe mental illnesses. Much current work focuses on the role of central monoaminergic dysfunction in the pathogenesis of psychiatric disorders and the associated sleep disturbance.

The classification of psychiatric disorders and current diagnostic criteria are contained in the fourth edition text revision of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2000). The International Classification of Sleep Disorders: Diagnostic and Coding Manual, 2nd ed. (ICSD-2) (American Academy of Sleep Medicine 2005) places sleep complaints in psychiatric disorders under the category of “Other Psychiatric and Behavioral Disorders Frequently Encountered in The Differential Diagnosis of Sleep Disorders,” with the subcategories of mood disorders; anxiety disorders; somatoform disorders; disorders usually first diagnosed in infancy, childhood, or adolescence; and personality disorders.

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