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Cited by 78Sleep and related disordersSchizophrenia research and treatmentPsychological Treatments and Assessments

Treating sleep problems in young people at ultra-high risk of psychosis: a feasibility case series

Open access
Bradley, Jonathan, Freeman, Daniel, Chadwick, Eleanor, Harvey, Allison G., Mullins, Bradley, Johns, Louise, Sheaves, Bryony, Lennox, Belinda +2 more·2018·Behavioural and Cognitive Psychotherapy
DOI 10.1017/s1352465817000601PMC PMC5906720
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Abstract

Background: Our view is that sleep disturbance may be a contributory causal factor in the development and maintenance of psychotic experiences. A recent series of randomized controlled intervention studies has shown that cognitive-behavioural approaches can improve sleep in people with psychotic experiences. However, the effects of psychological intervention for improving sleep have not been evaluated in young people at ultra-high risk of psychosis. Improving sleep might prevent later transition to a mental health disorder. Aims: To assess the feasibility and acceptability of an intervention targeting sleep disturbance in young people at ultra-high risk of psychosis. Method: Patients were sought from NHS mental health services. Twelve young people at ultra-high risk of psychosis with sleep problems were offered an eight-session adapted CBT intervention for sleep problems. The core treatment techniques were stimulus control, circadian realignment, and regulating day-time activity. Participants were assessed before and after treatment and at a one month follow-up. Results: All eligible patients referred to the study agreed to take part. Eleven patients completed the intervention, and one patient withdrew after two sessions. Of those who completed treatment, the attendance rate was 89% and an average of 7.6 sessions (SD = 0.5) were attended. There were large effect size improvements in sleep. Post-treatment, six patients fell below the recommended cut-off for clinical insomnia. There were also improvements in negative affect and psychotic experiences. Conclusion: This uncontrolled feasibility study indicates that treating sleep problems in young people at ultra-high of psychosis is feasible, acceptable, and may be associated with clinical benefits.

AI snapshot

Written from the paper’s full text.

TL;DR

This uncontrolled feasibility case series tested an eight-session adapted CBT intervention for sleep problems in 12 young people at ultra-high risk of psychosis. It found the intervention feasible and acceptable, with large improvements in sleep and smaller improvements in negative affect and psychotic experiences, but no causal conclusions are possible.

Key findings

  • All 12 eligible referred participants consented; 11 completed the intervention, and 1 withdrew after two sessions. Among completers, attendance was 89%, with an average of 7.6 sessions attended (SD = 0.5; range 7–8).
  • There were large effect-size improvements in sleep: ISI d = 6.8, SLEEP-50 insomnia d = 1.7, PSQI d = 2.9, SLEEP-50 circadian rhythm disruption d = 1.2, and SLEEP-50 impact d = 2.9. Post-treatment, 6 of 11 participants fell below the recommended cut-off for clinical insomnia on the ISI.
  • Secondary improvements included depression d = 0.5, stress d = 0.8, anxiety d = 0.2, wellbeing d = 0.7, occupational/social functioning d = 0.7, paranoia d = 0.6, and hallucinations d = 0.3.
  • No participants transitioned to psychosis at post-therapy or one-month follow-up, and there were no hospital admissions, formal complaints, or serious adverse events.

Methods

  • A–B feasibility case series with 12 participants aged 14–24 recruited from child and adolescent mental health services or early intervention in psychosis services in Oxford Health NHS Foundation Trust; inclusion required current sleep problems and meeting ultra-high-risk criteria on the CAARMS.
  • Participants were offered an eight-session manualized SleepWell CBT intervention targeting insomnia and circadian rhythm disruption, with adaptations for adolescents; assessments occurred at baseline, post-therapy, and one-month follow-up.
  • Primary outcomes were descriptive feasibility/acceptability data on recruitment, uptake, and data completion; clinical outcomes used paired t-tests to estimate change scores and confidence intervals, with effect sizes calculated from baseline SDs and p-values not reported.

Limitations

  • The paper states it was an uncontrolled feasibility study, so post-treatment gains cannot be attributed with certainty to the intervention.
  • The paper states follow-up assessments were not blind to whether sleep treatment had been provided, creating potential bias, and that a longer follow-up is needed.
  • The paper states sleep diary completion was much lower than other measures, with only six participants providing baseline and post-therapy data, insufficient for analysis; actigraphy could not be reliably analysed without diary data. The small sample size is also evident from the text.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1017/s1352465817000601

Cites

46 of 46 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 29 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Eleven patients completed the intervention.

    “Eleven patients completed the intervention”
    • Also stated in: § Completion rate of assessments · plain
      “The 11 participants who completed therapy attended all assessments.”
    Quote in the paperSubstantial claim
  • Findingown data

    All eligible patients referred to the study agreed to take part.

    “All eligible patients referred to the study agreed to take part.”
    • Also stated in: § Recruitment rate · plain
      “After screening, all 12 participants who were invited to take part in the study consented to participate.”
    Quote in the paperNot a substantial claim
  • Findingown data

    No participants transitioned to psychosis at either post-therapy or follow-up.

    “No participants transitioned to psychosis (as measured by the CAARMS) at either post-therapy or follow-up.”
    Quote in the paperSubstantial claim
  • Findingown data

    There was evidence of improvements in levels of hallucinations (d = 0.3).

    “and hallucinations (d = 0.3).”
    Quote in the paperNot a substantial claim
  • Findingown data

    One patient withdrew after two sessions.

    “and one patient withdrew after two sessions.”
    • Also stated in: § Participants · plain
      “One participant completed the baseline but discontinued therapy after two sessions without giving a reason.”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 22
  • May combine two claims. 12
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Most participants were either living with family or in student accommodation.

    “The sleep environment was influenced by the developmental life stage of participants: most participants were either living with family or in student accommodation.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingnone given

    The intervention is deliverable in a manualized format.

    “The intervention also has the advantage of being deliverable in a manualized format.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Another challenge for students was that their entire living space might be confined to one room.

    “Another challenge for students was that their entire living space (eating, sleeping, working and relaxing) might be confined to one room.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Nineteen patients were screened by a clinical psychologist.

    “Nineteen patients were screened by a clinical psychologist (J.B.).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Three of the referred individuals were uncontactable and seven declined to be screened.

    “Three of these individuals were uncontactable and seven declined to be screened (one reported no sleep problems, one reported no subthreshold psychotic experiences, and five gave no specific reason).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    There were no hospital admissions, formal complaints regarding the therapy, or serious adverse events reported.

    “There were no hospital admissions, formal complaints regarding the therapy, or serious adverse events reported.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The data completion rate was very high: there was only one questionnaire for which one participant did not provide analysable data.

    “The data completion rate was very high: there was only one questionnaire for which one participant did not provide analysable data.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    There were large effect size improvements in sleep from baseline to post-therapy and follow-up.

    “there were large effect size improvements in sleep and small to large effect size improvements in psychological wellbeing and psychotic experiences.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Five patients were excluded due to current or recent experiences of psychosis and two were excluded due to falling below threshold for ultra-high risk of psychosis or sleep problems.

    “Five were excluded due to current or recent experiences of psychosis and two were excluded due to falling below threshold either for ultra-high risk of psychosis (n = 1) or sleep problems (n = 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Recruitment rates, treatment uptake and data completion were all high.

    “Recruitment rates, treatment uptake and data completion were all high, which demonstrates the feasibility and acceptability of the intervention.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Twenty-nine patients were referred to the study.

    “Twenty-nine patients were referred to the study.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The average session length was 61 minutes.

    “and the average session length was 61 minutes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Sleep dysfunction in adolescence is associated with a number of mental health problems.

    “associated with a number of mental health problems (Morrison et al., 1992)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Morrison et al., 1992

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Sleep dysfunction in adolescence has a wide-ranging impact on wellbeing, from work and social function to suicidal thoughts and self-harm behaviour.

    “and a wide-ranging impact on wellbeing, from work and social function (Gradisar et al., 2011) to suicidal thoughts and self-harm behaviour (Wong et al., 2011).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Gradisar et al., 2011

      Not checked in the free run.

    • cites Wong et al., 2011

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    No study has yet sought to treat sleep problems in adolescents at ultra-high risk of psychosis.

    “and no study has yet sought to treat sleep problems in adolescents at ultra-high risk of psychosis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    A shift in circadian rhythms following puberty interacts with social and behavioural changes in adolescence to delay the sleep phase.

    “A shift in circadian rhythms following puberty interacts with social and behavioural changes in adolescence (such as reduced parental oversight and increased use of social media) to delay the sleep phase.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisereasoning

    The inability to delay the sleep-offset time due to school or work results in a reduced sleep window and can precipitate sleep problems.

    “The inability to delay the sleep-offset time due to school or work, for example, results in a reduced sleep window and can precipitate sleep problems.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Sleep disturbance may be a contributory causal factor in the development and maintenance of psychotic experiences.

    “Our view is that sleep disturbance may be a contributory causal factor in the development and maintenance of psychotic experiences.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Freeman et al., 2009

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Sleep dysfunction is a widespread problem in adolescence.

    “Thus sleep dysfunction is a widespread problem in adolescence (Johnson et al., 2006; Ohayon, 2002)”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Johnson et al., 2006

      Not checked in the free run.

    • cites Ohayon, 2002

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    CBT is the first-line treatment of choice for improving sleep.

    “We have demonstrated the benefit of cognitive behavioural therapy (CBT), the first-line treatment of choice for improving sleep (NICE, 2015), across a number of points of the continuum of psychotic experiences.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites NICE, 2015

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Sleep disturbance predicts the occurrence and persistence of psychotic-like experiences in adolescents and young people at ultra-high risk of psychosis, as well as specific psychotic experiences including paranoia and hallucinations.

    “Sleep disturbance predicts the occurrence and persistence of psychotic-like experiences in adolescents (Lee et al., 2012) and young people who are assessed as at ultra-high risk of psychosis (Lunsford-Avery et al., 2015) as well as specific psychotic experiences, including paranoia (Freeman et al., 2009, 2012a) and hallucinations (Reeve et al., 2015; Sheaves et al., 2016).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Lee et al., 2012

      Not checked in the free run.

    • cites Lunsford-Avery et al., 2015

      Not checked in the free run.

    • cites Freeman et al., 2009, 2012a

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Premisereasoning

    Improving sleep might prevent later transition to a mental health disorder.

    “Improving sleep might prevent later transition to a mental health disorder.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    There may be a particular risk for the onset of sleep problems due to a combination of biological, social and environmental changes which occur during adolescence.

    “Secondly, there may be a particular risk for the onset of sleep problems due to a combination of biological, social and environmental changes which occur during this period (Carskadon, 2011; Harvey, 2016).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Carskadon, 2011

      Not checked in the free run.

    • cites Harvey, 2016

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Psychotic experiences exist on continua of severity and distress.

    “Psychotic experiences exist on continua of severity and distress (van Os et al., 2009).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites van Os et al., 2009

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Cognitive-behavioural approaches can improve sleep in people with psychotic experiences.

    “A recent series of randomized controlled intervention studies has shown that cognitive-behavioural approaches can improve sleep in people with psychotic experiences.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Freeman et al., 2015

      Not checked in the free run.

    • cites Freeman et al., 2017

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    Follow-up assessors were not blind to whether sleep treatment had been provided, which is a potential source of bias.

    “Whilst all follow-up assessments were rated by independent research assistants, they were not blind to whether sleep treatment had been provided, which is a cause of potential bias.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    All follow-up assessments were rated by independent research assistants.

    “Whilst all follow-up assessments were rated by independent research assistants, they were not blind to whether sleep treatment had been provided, which is a cause of potential bias.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The intervention is feasible and acceptable for young people at ultra-high risk of psychosis.

    “Recruitment rates, treatment uptake and data completion were all high, which demonstrates the feasibility and acceptability of the intervention.”
    • Also stated in: § Clinical learning · hedged
      “This study indicates that treating sleep problems in young people at ultra-high risk of psychosis is feasible, acceptable, and may be associated with benefits to sleep and psychological wellbeing.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Recent guidelines in the UK stipulate the provision of services for young people at ultra-high risk of psychosis.

    “Recent guidelines in the UK stipulate the provision of services for young people at ultra-high risk of psychosis (NICE, 2013; NHS England, 2015).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites NICE, 2013

      Not checked in the free run.

    • cites NHS England, 2015

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Treating sleep problems in young people at ultra-high risk of psychosis is feasible, acceptable, and may be associated with benefits to sleep and psychological wellbeing.

    “This study indicates that treating sleep problems in young people at ultra-high risk of psychosis is feasible, acceptable, and may be associated with benefits to sleep and psychological wellbeing.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Sleep disturbance is an identified causal mechanism in the development of psychotic experiences.
    • Rests on an assumption: Sleep problems are common in young people at ultra-high risk of psychosis.
    • Rests on an assumption: Patients want treatment for sleep problems.
    • Rests on an assumption: Treatments can be successfully adapted across the spectrum of psychotic experiences.

  • May combine two claims.

    Premisecitation

    A series of intervention studies demonstrate the benefit of targeting sleep directly and the secondary benefits to psychological wellbeing and other mental health outcomes.

    “The findings fit within a series of intervention studies that demonstrate the benefit of targeting sleep directly and the secondary benefits to psychological wellbeing and other mental health outcomes (Freeman et al., 2015, 2017).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Freeman et al., 2015, 2017

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The intervention has the potential to be delivered by other mental health practitioners, allowing it to be more widely adopted by services.

    “This means it has the potential to be delivered by other mental health practitioners, allowing it to be more widely adopted by services.”
    Quote in the paperSubstantial claim
32 of 32

  • The paper relies on this without support.

    Sleep loss is linked to psychotic experiences.

    “Formal sleep restriction was not included as part of the intervention due to the link between sleep loss and psychotic experiences.”

  • The paper relies on this without support.

    The measures used are appropriate for use in this age range.

    “Consideration was given to the appropriateness of all measures for use in this age range.”

  • The paper relies on this without support.

    Sleep disturbance is an identified causal mechanism in the development of psychotic experiences.

    “this study employed a brief intervention targeted at an identified causal mechanism in the development of psychotic experiences: sleep disturbance.”

  • The paper relies on this without support.

    Sleep problems are common in young people at ultra-high risk of psychosis.

    “These findings fit with the previous research literature: that sleep problems are common, that patients want treatment, and treatments can be successfully adapted across the spectrum of psychotic experiences.”

  • The paper relies on this without support.

    Patients want treatment for sleep problems.

    “These findings fit with the previous research literature: that sleep problems are common, that patients want treatment, and treatments can be successfully adapted across the spectrum of psychotic experiences.”

  • The paper relies on this without support.

    Treatments can be successfully adapted across the spectrum of psychotic experiences.

    “These findings fit with the previous research literature: that sleep problems are common, that patients want treatment, and treatments can be successfully adapted across the spectrum of psychotic experiences.”

  • The paper relies on this without support.

    Sleep disturbance carries less stigma than other mental health difficulties.

    “Sleep disturbance also carries less stigma than other mental health difficulties.”

  • The paper relies on this without support.

    This is the first study evaluating a CBT intervention for sleep problems in young people at ultra-high risk of psychosis.

    “To our knowledge, this is the first study evaluating a CBT intervention for sleep problems in young people at ultra-high risk of psychosis.”
8 of 8

Claims other papers make about this one

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Cites

Flagged first, then by citations

1 of the 47 references couldn’t be matched to a known paper.

Research works printed but not linked: 1

  1. Espie, 2006, Overcoming Insomnia and Sleep Problems

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Related

Authors
Bradley, J., Freeman, D., Chadwick, E., Harvey, A. G., Mullins, B., Johns, L., Sheaves, B., Lennox, B., Broome, M., & Waite, F.
Affiliations
  • Oxford Health NHS Foundation Trust (GB)
  • University of Oxford (GB)
  • University of California, Berkeley (US)
Corresponding author
Bradley, Jonathan
ORCID
Venue
Behavioural and Cognitive Psychotherapy
Publisher
Cambridge University Press (CUP)
Published
2017-10-30
Volume
46
Issue
3
Pages
276-291
ISSN
  • 1352-4658 (ISSN-L)
  • 1469-1833
DOI
10.1017/s1352465817000601
PMC
PMC5906720
OpenAlex
W2765901532
Semantic Scholar
f18592f1e10eeadba07bd1f7a6c8bf55d34e4f0e
Cited by
78
References
47
Citations by year
2026: 4 · 2025: 9 · 2024: 9 · 2023: 10 · 2022: 10 · 2021: 11 · 2020: 12 · 2019: 7 · 2018: 4 · 2017: 1 · 2014: 1
FWCI
8.55
Type
journal article
Language
en
Open access
Licence
Locations
  • Behavioural and Cognitive Psychotherapy (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • eScholarship (California Digital Library) (submittedVersion, cc-by)
  • University of Birmingham Research Portal (University of Birmingham) (submittedVersion, cc-by)
Funders
  • Wellcome Trust (098461, 098461/Z/12/Z, 098461/Z/12, 098461/Z)
  • National Institute for Health and Care Research (RP-2014-05-003)
  • Medical Research Council (MC_PC_13073, MR/J012939/1)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
  • Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
  • Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
Keywords
sleep disorders, youth, cognitive behavioral therapy for insomnia, stimulus control, negative affect, psychotic experiences, feasibility and acceptability
MeSH terms
Adolescent, Feasibility Studies, Female, Humans, Sleep Initiation and Maintenance Disorders, Male, Psychotic Disorders, Sleep Wake Disorders, Cognitive Behavioral Therapy, Treatment Outcome, Young Adult

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