Trajectories of insomnia following bereavement.

BACKGROUND: Insomnia symptoms are common following bereavement and may exacerbate severe and protracted grief reactions, such as prolonged grief disorder (PGD). However, typical trajectories of insomnia symptoms and risk factors for having a more chronic insomnia trajectory following bereavement are yet unknown. METHOD: In the current investigation, 220 recently bereaved (≤6 months post-loss) participants, completed questionnaires assessing sociodemographic and loss-related characteristics, rumination, experiential avoidance and symptoms of (prolonged) grief and depression, on three time-points (6 months apart). We applied growth mixture models to investigate the typical trajectories of insomnia symptoms following bereavement. RESULTS: Three insomnia trajectory classes emerged, characterized by a resilient (47 %), recovering (43 %), and a chronic trajectory (10 %). Baseline depression symptoms best predicted the type of insomnia trajectory. At one-year follow-up, 9 %, 27 %, and 60 % of participants met the criteria for probable PGD within the resilient, recovering and chronic trajectory, respectively. A parallel process model showed that temporal changes in insomnia symptoms were strongly related to changes in prolonged grief symptoms. CONCLUSION: The results suggest, that targeting insomnia symptoms in the treatment of PGD, particularly with comorbid depression, may be a viable option.

Sleep disorders in a naturalistic cohort of Dutch psychiatric outpatients: prevalence rates and associations with psychopathology symptom severity and well-being.

Sleep problems are very common in individuals with a mental disorder. Given the abundant evidence indicating the negative impact of disturbed sleep on mental health outcome, insight into the prevalence of all types of sleep disorders in specific mental disorders and neurodevelopmental conditions is of practical importance. Therefore, we estimated the prevalence of six types of sleep disorders with the Holland Sleep Disorders Questionnaire in an overall mental health sample (n = 1082) and separately for different mental and neurodevelopmental conditions. Furthermore, associations between specific sleep disorders, psychopathology and well-being were studied. The impact of the total number of sleep disorders on these associations was examined. Overall, 46.2% of all participants scored above the cut-off for having a sleep disorder. Specifically, 26.8% scored on insomnia, 12.1% on sleep breathing disorders, 9.7% on hypersomnia, 13.7% on circadian rhythm sleep-wake disorders, 11.2% on parasomnia, and 17.9% on sleep-related movement disorders. Most sleep disorders were associated with greater severity of psychopathology and lower well-being. These associations got stronger with an increasing number of sleep disorders. Our study revealed higher suspected prevalence of most sleep disorders in a mental disorder sample compared to the general population. Moreover, the presence of sleep disorder(s) was strongly associated with symptom severity and reduced well-being. These findings extend the notion that early detection and treatment of sleep disorders in mental health populations is essential for psychiatric outcome.

Cross-Lagged Analyses of Prolonged Grief and Depression Symptoms With Insomnia Symptoms.

Prolonged grief disorder, characterized by severe, persistent and disabling grief, has recently been added to the DSM-5-TR and ICD-11. Treatment for prolonged grief symptoms shows limited effectiveness. It has been suggested that prolonged grief symptoms exacerbate insomnia symptoms, whereas insomnia symptoms, in turn, may fuel prolonged grief symptoms. To help clarify if treating sleep disturbances may be a viable treatment option for prolonged grief disorder, we examined the proposed reciprocal relationship between symptoms of prolonged grief and insomnia. On three time points across 6-month intervals, 343 bereaved adults (88% female) completed questionnaires to assess prolonged grief, depression, and insomnia symptoms. We applied random intercept cross-lagged panel models (RICLPMs) to assess reciprocal within-person effects between prolonged grief and insomnia symptoms and, as a secondary aim, between depression and insomnia symptoms. Changes in insomnia symptoms predicted changes in prolonged grief symptoms but not vice versa. Additionally, changes in depression and insomnia symptoms showed a reciprocal relationship. Our results suggest that targeting insomnia symptoms after bereavement is a viable option for improving current treatments for prolonged grief disorder.

The influence of sexual activity on sleep: A diary study.

Aiming to promote overall health and well-being through sleep, the present studies examine to what extent sexual activity serves as a behavioural mechanism to improve sleep. The relation between sexual activity, i.e., partnered sex and masturbation with or without orgasm, and subjective sleep latency and sleep quality is examined by means of a cross-sectional and a longitudinal (diary) study. Two hundred fifty-six male and female participants, mainly students, completed a pre-test set of questionnaires and, thereafter, a diary during 14 consecutive days. The cross-sectional study was analysed using analysis of covariance and demonstrated that both men and women perceive partnered sex and masturbation with orgasm to improve sleep latency and sleep quality, while sexual activity without orgasm is perceived to exert negative effects on these sleep parameters, most strongly by men. Accounting for the repeated measurements being nested within participants, the diary data were analysed using multilevel linear modelling (MLM). Separate models for subjective sleep latency and sleep quality were constructed, which included 2076 cases at level 1, nested within 159 participants at level 2. The analyses revealed that only partnered sex with orgasm was associated with a significantly reduced sleep latency (b = -0.08, p < 0.002) and increased sleep quality (b = 0.19, p < 0.046). Sexual activity without orgasm and masturbation with and without orgasm were not associated with changes in sleep. Further, no gender differences emerged. The present studies confirm and significantly substantiate findings indicating that sexual activity and intimacy may improve sleep and overall well-being in both men and women and serve as a directive for future research.

Schema therapy for violent PD offenders: a randomized clinical trial.

BACKGROUND: Violent criminal offenders with personality disorders (PD's) can cause immense harm, but are often deemed untreatable. This study aimed to conduct a randomized clinical trial to test the effectiveness of long-term psychotherapy for rehabilitating offenders with PDs. METHODS: We compared schema therapy (ST), an evidence-based psychotherapy for PDs, to treatment-as-usual (TAU) at eight high-security forensic hospitals in the Netherlands. Patients in both conditions received multiple treatment modalities and differed only in the individual, study-specific therapy they received. One-hundred-three male offenders with antisocial, narcissistic, borderline, or paranoid PDs, or Cluster B PD-not-otherwise-specified, were assigned to 3 years of ST or TAU and assessed every 6 months. Primary outcomes were rehabilitation, involving gradual reintegration into the community, and PD symptoms. RESULTS: Patients in both conditions showed moderate to large improvements in outcomes. ST was superior to TAU on both primary outcomes - rehabilitation (i.e. attaining supervised and unsupervised leave) and PD symptoms - and six of nine secondary outcomes, with small to moderate advantages over TAU. ST patients moved more rapidly through rehabilitation (supervised leave, treatment*time: F(5308) = 9.40, p < 0.001; unsupervised leave, treatment*time: F(5472) = 3.45, p = 0.004), and showed faster improvements on PD scales (treatment*time: t(1387) = -2.85, p = 0.005). CONCLUSIONS: These findings contradict pessimistic views on the treatability of violent offenders with PDs, and support the effectiveness of long-term psychotherapy for rehabilitating these patients, facilitating their re-entry into the community.

Shift work is associated with extensively disordered sleep, especially when working nights.

Background: Shift work is generally associated with working and sleeping out of phase with the endogenous, circadian sleep-wake cycle. This exerts detrimental effects on sleep health. The present study aimed at evaluating the presence of short and long sleep as well as sleep disorders within a broad range of shift work schedules and elucidating the role of sociodemographic factors therein. Methods: A large dataset containing information on sleep was collected through advertisement in a Belgium newspaper (De Standaard). Adult, working individuals were selected (n = 37,662) and categorized based on their work schedule (regular day, early morning, evening, night, and rotating shift). In this cross-sectional study, prevalence rates of short sleep (≤6 h), long sleep (≥9 h) and sleep disorders (screened with Holland Sleep Disorders Questionnaire), and associations between these sleep variables and sociodemographics (age, sex, education, living companion(s)) were analyzed using binominal logistic regression analyses. Results: In the total sample all sociodemographic factors affected prevalences of short, long and disordered sleep, consistent with previous studies. Compared to day workers, shift workers more frequently reported short sleep, most prominently night workers (26 vs. 50%) (p < 0.001). Furthermore, all sleep disorders as well as sleep disorder comorbidity were more common in shift workers, again most pronounced in night workers (all p < 0.05). In night shift workers the level of education had the strongest associations with disturbed sleep with a two-fold higher prevalence of short and disordered sleep in low relative to academic educated groups (all p < 0.02). Conclusion: Shift work is related not only to curtailed sleep and shift work disorder, but also to a plethora of sleep disorders, including insomnia, sleep-related breathing disorders and sleep-related movement disorders. Our findings imply that education on coping strategies may be especially important for young and/or lower educated shift workers.

Effectivity of (Personalized) Cognitive Behavioral Therapy for Insomnia in Mental Health Populations and the Elderly: An Overview.

Insomnia is very prevalent in psychiatry and is considered a transdiagnostic symptom of mental disorders. Yet, it is not only a consequence of a mental condition but may also exert detrimental effects on psychiatric symptom severity and therapeutic response; thus, adequate insomnia treatment is particularly important in psychiatric populations. The first choice of intervention is cognitive behavioral therapy for insomnia (CBT-I) as it is rather effective, also in the long run without side effects. It is offered in various forms, ranging from in-person therapy to internet-delivered applications. CBT-I protocols are typically developed for individuals with insomnia disorder without co-occurring conditions. For an optimal therapeutic outcome of CBT-I in individuals with comorbid mental disorders, adaptations of the protocol to tailor the treatment might be beneficial. Based on a literature search using major search engines (Embase; Medline; APA Psych Info; and Cochrane Reviews), this paper provides an overview of the effectiveness of the different CBT-I applications in individuals with diverse comorbid mental conditions and older adults and describes the functionality of CBT-I protocols that have been personalized to specific psychiatric populations, such as depression, substance abuse, and schizophrenia spectrum disorder. Finally, we discuss urgent needs for insomnia therapy targeted to improve both sleep and psychopathologies.

Disturbed Sleep in PTSD: Thinking Beyond Nightmares.

Sleep disturbances frequently co-occur with posttraumatic stress disorder (PTSD). Insomnia and nightmares are viewed as core symptoms of PTSD. Yet, relations between disturbed sleep and PTSD are far more complex: PTSD is linked to a broad range of sleep disorders and disturbed sleep markedly affects PTSD-outcome. This article provides a concise overview of the literature on prevalent comorbid sleep disorders, their reciprocal relation with PTSD and possible underlying neurophysiological mechanisms. Furthermore, diagnostic procedures, standard interventions-particularly first choice non-pharmacological therapies-and practical problems that often arise in the assessment and treatment of sleep disturbances in PTSD are described. Finally, we will present some perspectives on future multidisciplinary clinical and experimental research to develop new, more effective sleep therapies to improve both sleep and PTSD.

The association of sleep quality and aggression: A systematic review and meta-analysis of observational studies.

Poor sleep quality is closely related to aggression, but despite the promise of new therapeutic possibilities, a systematic synthesis of observational research on the association between sleep quality and aggression is lacking. This systematic review and meta-analysis examined the association between sleep quality and aggression, using the academic databases PubMed and PsycINFO. Subjective and objective measures of sleep quality were included, as well as multiple measures of aggression, assessing aggressive and externalizing behavior, anger, hostility and irritability. Ninety-two observational articles, containing 96 studies, encompassing a total of 58.154 children, adolescents and adults were sourced out of 7161 references identified. Methodological quality was moderate or strong in 76% of studies. Data for meta-analysis was available from 74 studies. Poorer sleep quality was associated with higher aggression in 80.8% of studies. Pooled results showed a correlation of 0.28 (95%CI 0.25-0.31; I2 = 90.1%) and odds ratio of 3.61 (95%CI 1.13-11.51; I2 = 88.3%). Effect estimates and heterogeneity varied according to population type and measurement instruments, but not according to article quality or age group. Our findings confirm that poor sleep quality is consistently associated with higher aggression. As most evidence is cross-sectional, more prospective and high-quality experimental evidence is required to elucidate cause-effect and optimize prevention and treatment of aggression.

Insomnia disorder and its reciprocal relation with psychopathology.

Sleep is crucial for daytime functioning. In populations with psychiatric conditions, many people suffer from insomnia symptoms or an insomnia disorder. Emerging evidence suggests a bidirectional relationship between insomnia and various psychopathologies, implying that insomnia not only may be a consequence of mental disorders but also may contribute to new development, symptom severity, and reoccurrence of diverse mental disorders. Research on potential mechanisms underlying the insomnia psychopathology association is important, both from the preventive and treatment perspective. Most hypotheses concern the influence of insomnia on emotion regulation and on shared pathophysiological pathways, ranging from gut microbiome composition to genetic and specific neurotransmitter system aberrations.

Sleep disturbances in bereavement: A systematic review.

Severe, persistent and disabling grief occurs among a sizable minority experiencing bereavement, with diagnostic manuals newly including complicated grief (CG) disorders. Sleep disturbances/disorders have been established as worsening affective and stress-related conditions. However, the role of sleep difficulties in bereavement and CG has not received similar scientific attention. We therefore conducted a systematic review with narrative syntheses on this topic to clarify the role of sleep in bereavement (PROSPERO: CRD42018093145). We searched PubMed, Web of Science and PsychInfo for peer-reviewed English-language articles including (at least one) bereaved sample and sleep disturbance measure. We identified 85 articles on 12.294 participants. We answered seven pre-defined research questions demonstrating: high prevalence of sleep disturbances in bereavement; positive associations of grief intensity with sleep difficulties; preliminary indications of risk factors of post-loss sleep disturbance; higher prevalence of sleep disturbances in CG, enhanced by psychiatric comorbidity (i.e., depression); and initial evidence of causal relationships between (complicated) grief and sleep. Grief therapy partly improves sleep difficulties, yet no intervention studies have specifically targeted sleep problems in bereaved persons. Causal relationships between sleep and grief require further examination in intensive longitudinal investigations, including randomized trials, thereby clarifying whether treating sleep problems enhances CG treatment effects.

The clinical relevance of early identification and treatment of sleep disorders in mental health care: protocol of a randomized control trial.

BACKGROUND: Sleep disorders are a risk factor for developing a variety of mental disorders, have a negative impact on their remission rates and increase the risk of relapse. Early identification and treatment of sleep disorders is therefore of paramount importance. Unfortunately, in mental health care sleep disorders are often poorly recognized and specific treatment frequently occurs late or not at all. This protocol-paper presents a randomized controlled trial investigating the clinical relevance of early detection and treatment of sleep disorders in mental health care. The two aims of this project are 1) to determine the prevalence of sleep disorders in different mental disorders, and 2) to investigate the contribution of early identification and adequate treatment of sleep disorders in individuals with mental disorders to their sleep, mental disorder symptoms, general functioning, and quality of life. METHODS: Patients newly referred to a Dutch mental health institute for psychiatric treatment will be screened for sleep disorders with the self-assessment Holland Sleep Disorders Questionnaire (HSDQ). Patients scoring above the cut-off criteria will be invited for additional diagnostic evaluation and, treatment of the respective sleep disorder. Participants will be randomly assigned to two groups: Immediate sleep diagnostics and intervention (TAU+SI-T0), or delayed start of sleep intervention (TAU+SI-T1; 6 months after inclusion). The effect of sleep treatment as add-on to treatment as usual (TAU) will be tested with regard to sleep disorder symptoms, general functioning, and quality of life (in collaboration with a psychiatric sleep centre). DISCUSSION: This trial will examine the prevalence of different sleep disorders in a broad range of mental disorders, providing information on the co-occurrence of specific sleep and mental disorders. Further, this study is the first to investigate the impact of early treatment of sleep disorders on the outcome of many mental disorders. Moreover, standard sleep interventions will be tailored to specific mental disorders, to increase their efficacy. The results of this trial may contribute considerably to the improvement of mental health care. TRIAL REGISTRATION: This clinical trial has been retrospectively registered in the Netherlands Trial Register (NL8389; https://www.trialregister.nl/trial/8389) on February 2th, 2020.

Patient-rated impulsivity and aggression compared with clinician-rated risk in a forensic psychiatric sample: Predicting inpatient incidents.

BACKGROUND: Measures of impulsivity and aggression help to indicate risk of future violence or rule-breaking. Both clinician-rated risk assessment and self-report measures have been used but hardly ever compared in their ability to predict inpatient incidents. AIMS: To compare the self-report on the Barratt Impulsiveness Scale (BIS-11) and Buss-Perry Aggression Questionnaire (BPAQ) with the clinician-rated HKT-30, a Dutch adaptation of the Historical Clinical Risk Management-20, for their capacity to predict inpatient incidents. METHODS: All men newly admitted to a forensic psychiatric hospital were invited to participate in this study unless in intensive care. Tests of correlation were run between the BIS-11 and BPAQ scale scores and the HKT-30. Each was then tested separately for capacity to predict the number of aggressive and nonaggressive incidents while resident. Finally, scores of all rating scales were entered together into a negative binomial regression to compare their relative strengths in predicting later incidents. RESULTS: Patient and staff baseline impulsivity and aggression ratings correlated moderately well. All measures performed well in univariate analyses of relationship between baseline measures and later incidents. In final models, which included both patient and staff baseline ratings, the HKT-30 generally outperformed the self-report measures in the prediction of aggressive and nonaggressive incidents in both the first year and total length of stay. IMPLICATIONS FOR CLINICAL PRACTICE: Our findings suggest that some reliance may be placed on patient ratings of their own propensity for impulsive and/or violent acts, but, when used, they should remain combined with clinician-rated risk assessment for the time being. Future research should explore their utility in dialogue about treatment, and also the relative strength of staff response to each.

Low doses of mirtazapine or quetiapine for transient insomnia: A randomised, double-blind, cross-over, placebo-controlled trial.

Low doses of the antidepressant mirtazapine or the neuroleptic quetiapine are often prescribed off-label for insomnia. However, studies on the effects on sleep and hangover effects the following day are scarce. In this randomised, double-blind, cross-over, placebo-controlled trial, the influence of 7.5 mg mirtazapine and 50 mg quetiapine on both normal sleep and sleep disturbed by acoustic stress (traffic noise) as a model for transient insomnia was assessed. Additionally, hangover effects on next-day alertness and cognitive functioning were examined. A total of 19 healthy men without sleep complaints completed three treatment sessions, each session consisting of three consecutive nights in one of the mirtazapine, quetiapine or placebo conditions. Sleep was assessed using polysomnography and the Leeds Sleep Evaluation Questionnaire. Daytime sleepiness and cognitive functioning were assessed using the Leeds Sleep Evaluation Questionnaire, Karolinska Sleepiness Scale, Digit Symbol Substitution Task, Psychomotor Vigilance Task and an addition task. Under acoustic stress, both mirtazapine and quetiapine increased total sleep time by half an hour and reduced the number of awakenings by 35-40% compared to placebo. While quetiapine specifically increased the duration of non-rapid eye movement sleep, stage N2, mirtazapine mainly increased deep sleep stage N3. Subjects reported that both mirtazapine and quetiapine eased getting to sleep and improved sleep quality. Both drugs caused daytime sleepiness and lessened sustained attention. These findings support the use of low doses of mirtazapine and quetiapine for the treatment of insomnia. Further prospective studies on the long-term effects regarding effectiveness and adverse effects are needed.

Sleep restriction in rats leads to changes in operant behaviour indicative of reduced prefrontal cortex function.

Sleep deprivation has profound effects on cognitive performance, and some of these effects may be mediated by impaired prefrontal cortex function. In search of an animal model to investigate this relationship we studied the influence of restricted sleep on operant conditioning in rats, particularly the performance in a differential reinforcement of low rate responding (DRL) task, which is highly dependent upon an intact prefrontal cortex. Animals were trained to withhold a lever press until an imposed delay of 30 s after the last press had passed in order to achieve a food reward. Once the animals had mastered the task, they were sleep-restricted for 7 days with 20 h of sleep deprivation per day. At the end of each daily sleep deprivation session, performance on the DRL task was assessed. The results show that sleep-restricted animals were less able to time their responses correctly, started pressing the lever more randomly and showed signs of behavioural disinhibition, the latter possibly reflecting enhanced impulsivity. Our data support the hypothesis that a sleep debt has disruptive consequences for the functioning of the prefrontal cortex. This model offers possibilities for future studies investigating the underlying biochemical and molecular mechanisms of this relationship.

Deep sleep after social stress: NREM sleep slow-wave activity is enhanced in both winners and losers of a conflict.

Sleep is considered to be a recovery process of prior wakefulness. Not only duration of the waking period affects sleep architecture and sleep EEG, the quality of wakefulness is also highly important. Studies in rats have shown that social defeat stress, in which experimental animals are attacked and defeated by a dominant conspecific, is followed by an acute increase in NREM sleep EEG slow wave activity (SWA). However, it is not known whether this effect is specific for the stress of social defeat or a result of the conflict per se. In the present experiment, we examined how sleep is affected in both the winners and losers of a social conflict. Sleep-wake patterns and sleep EEG were recorded in male wild-type Groningen rats that were subjected to 1h of social conflict in the middle of the light phase. All animals were confronted with a conspecific of similar aggression level and the conflict took place in a neutral arena where both individuals had an equal chance to either win or lose the conflict. NREM sleep SWA was significantly increased after the social conflict compared to baseline values and a gentle stimulation control condition. REM sleep was significantly suppressed in the first hours after the conflict. Winners and losers did not differ significantly in NREM sleep time, NREM sleep SWA and REM sleep time immediately after the conflict. Losers tended to have slightly more NREM sleep later in the recovery period. This study shows that in rats a social conflict with an unpredictable outcome has quantitatively and qualitatively largely similar acute effects on subsequent sleep in winners and losers.

Specific risk factors of arsonists in a forensic psychiatric hospital.

Arsonists are often treated in forensic settings. However, high recidivism rates indicate that treatment is not yet optimal for these offenders. The aim of this case series study is to identify arsonist specific dynamic risk factors that can be targeted during treatment. For this study, we used patient files of and interviews with all patients that were currently housed at a forensic psychiatric hospital in the Netherlands (14 arsonists, 59 non-arsonists). To delineate differences in risk factors between arsonists and non-arsonists, scores on the risk assessment instrument the Historical Clinical Future-30 (HKT-30; completed for 11 arsonists and 35 non-arsonists), an instrument similar to the Historical Clinical Risk Management-20 (HCR-20), were compared. The groups did not differ on demographic factors and psychopathology. Concerning dynamic risk factors, arsonists had significantly poorer social and relational skills and were more hostile. Although this study needs replication, these findings suggest that the treatment of people involved in firesetting should particularly target these risk factors.

The relation between poor sleep, impulsivity and aggression in forensic psychiatric patients.

Psychiatric disorders are often associated with disturbed sleep. Poor sleep can attenuate emotional control, including the regulation of aggression, and thus, may increase the risk of impulsive, aggressive acts. This cross-sectional study aimed to investigate the potential contribution of sleep problems to subjective and objective aggressiveness and impulsivity in a forensic psychiatric population. Questionnaires on sleep quality (Pittsburgh Sleep Quality Index), chronic severe insomnia (Sleep Diagnosis List), aggressiveness (Aggression Questionnaire) and impulsivity (Barratt Impulsiveness Scale-11) were completed by 96 forensic psychiatric inpatients, admitted to two forensic facilities in the Netherlands. To obtain more objective measurements of aggression and impulsivity, observational scores on a professional instrument to assess the risk of future aggression (Historical Clinical Future-30) and reported aggressive incidents were collected from files. Results showed that a worse sleep quality and higher insomnia scores were significantly associated with self-reported aggression and impulsivity, clinician-rated hostility and involvement in aggressive incidents within the facility. Whether a participant was professionally judged as impulsive could not be predicted by sleep quality or the insomnia score. To a large extent the results of this study support the hypothesis that poor sleep is related to impulsive, aggressive behavior in forensic psychiatric patients. It is worthwhile to examine the protective effect of treatment of sleep difficulties on aggressive reactivity in (forensic) psychiatric populations.

Sleep disturbances in a clinical forensic psychiatric population.

OBJECTIVE: Poor sleep is known to cause detrimental effects on the course of diverse psychiatric disorders and is a putative risk factor for hostility and aggression. Thus, sleep may be crucial in forensic psychiatric practice. However, little is known about the prevalence of sleep disturbances in these complex psychiatric patients. METHODS: In this study we investigated the presence of sleep disorders and subjective sleep quality using the Sleep Diagnosis List (SDL), the Pittsburgh Sleep Quality Index (PSQI), interviews addressing the causes of sleep complaints, and file information on sleep medications in 110 patients admitted to a forensic psychiatric hospital. RESULTS: Almost 30% of the participants suffered from one or more sleep disorders, especially insomnia. An even larger proportion of the participants (49.1%) experienced poor sleep quality. Interestingly, patients with an antisocial personality disorder or traits were particularly dissatisfied with their sleep. The most common causes of sleep problems were suboptimal sleep hygiene, stress or ruminating, negative sleep conditioning, and side effects of psychotropic medication. Of the poor sleepers, 40.7% received a hypnotic drug. CONCLUSION: Despite intensive clinical treatment, sleep problems are experienced by a large number of forensic psychiatric patients. It would be worthwhile to examine the effects of pharmacological and non-pharmacological sleep interventions on both psychiatric symptoms and reactive aggressive behavior in forensic patients.