Differential Effects of Morning Versus Afternoon Accelerated High-Frequency Repetitive Transcranial Magnetic Stimulation on Sleep Outcomes in Hospitalised Patients With Schizophrenia: Retrospective Cohort Study

Abstract

Background: This study aimed to investigate the differential effects of accelerated high-frequency repetitive transcranial magnetic stimulation (aHF-rTMS) administered in the morning and afternoon on sleep outcomes in hospitalised patients with schizophrenia.

Methods: This single-centre retrospective cohort study was based on existing inpatient records from the Department of Psychiatry at The Third People’s Hospital of Fuyang between November 2023 and May 2025. Eligible cases were identified from electronic medical records, nursing documentation and aHF-rTMS treatment logs. Patients were divided into a morning aHF-rTMS group and an afternoon aHF-rTMS group according to the predominant treatment-time category documented during hospitalisation. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), and nighttime sleep duration was obtained from nursing records. Psychiatric symptoms and cognitive function were assessed using the Positive and Negative Syndrome Scale (PANSS) and Montreal Cognitive Assessment (MoCA), respectively. The influencing factors of sleep outcomes at discharge were explored by multivariate linear regression analysis, and sensitivity analysis was performed using propensity score matching.

Results: The two groups were comparable in baseline demographics, sleep parameters and psychiatric symptoms. During hospitalisation, both groups showed substantial improvement in sleep quality and psychiatric symptoms compared with those upon admission. The morning aHF-rTMS group had significantly lower total PSQI scores at discharge (p < 0.001) and longer nighttime sleep duration (β = 0.58, p < 0.001) than the afternoon aHF-rTMS group. Sensitivity analysis showed that morning aHF-rTMS remained associated with low total PSQI scores at discharge (β = −1.83, p < 0.001). No statistically significant differences in PANSS total scores and MoCA scores at discharge were found between the two groups (both p > 0.05). The overall incidence of adverse reactions was 44.44%, slightly higher in the morning group than in the afternoon group (54.02% vs. 35.48%, p = 0.012).

Conclusions: The timing of aHF-rTMS treatment may be associated with sleep-related treatment outcomes in hospitalised patients with schizophrenia. Compared with afternoon treatment, morning aHF-rTMS was associated with better subjective sleep quality and longer nighttime sleep duration.