A mixed methods expert opinion study on the optimal content and format for an occupational therapy intervention to improve sleep in schizophrenia spectrum disorders

Abstract

Introduction People with schizophrenia spectrum disorder diagnoses commonly have poor sleep, which predicts various negative outcomes. The problems are diverse, including substantial circadian dysregulation, sleep-wake timing issues, hypersomnia (excessive sleep), and more classic insomnia. Methods This paper reports on a mixed methods expert opinion study based on the principles of Delphi methodology. The study examines and explores opinion on the optimal contents and format for an occupational therapy intervention to improve poor sleep in this population. Views of clinical and academic topic experts (n = 56), were elicited, examined and explored in three rounds, views from previous rounds being presented back to participants in subsequent rounds. Participants with relevant personal experience (n = 26) then rated and commented on suggestions, with a focus on acceptability. Descriptive statistics and graphs of ratings were triangulated with qualitative content analysis of free-text. Results Participants emphasised the central importance of intervention personalisation, although the manner and extent of personalisation suggested varied. Many components and domains were acknowledged as important, with the challenge being how to keep such an intervention simple, brief, and feasible for end-users, for sustainable implementation. The strongest consensus was to address evening routine, daytime activity, and environmental interventions. Relaxation, mindfulness, thermoregulation, sensory factors, and cognitive or psychological approaches were rated as less important. There was disagreement on whether to include time in bed restriction, and how to address napping, as well as how far to address medication timing. Clinicians and researchers advocated some version of stimulus control, but participants with personal experience reported low levels of acceptability for this, describing entirely negative experiences using ‘the 15-minute rule’ (part of stimulus control). Conclusion These results are informative for clinicians treating sleep problems in people with schizophrenia and related conditions, as well as for decision makers considering the potential contribution of the profession of occupational therapy toward sleep treatment.

Light–Dark and Activity Rhythm Therapy (L-DART) to Improve Sleep in People with Schizophrenia Spectrum Disorders: A Single-Group Mixed Methods Study of Feasibility, Acceptability and Adherence

“…This compares positively to rates of adherence in sleep-related intervention studies (65.5%) and rates of intervention dropout (14-40%), summarised in the meta-analysis of CBTi intervention in other groups [37]. This contradicts views expressed by some staff that patients with psychosis would not be motivated to improve their sleep [42,43] and better agrees with the views of people with schizophrenia, who said they would be highly motivated to improve their sleep [36].…”

“…Regarding sleeping location, it will be considered whether the behaviour change techniques used in relation to this could be optimised, as for comfort and behavioural association reasons, it is probably usually important. Restricting time in bed and alterations to sleep schedules were better adhered to than expected in development work (which suggested this would be a very difficult element for participants) [36], whilst alterations to daytime activity were somewhat less adhered to. This might reflect that sleep pressure and timing were explained in the video-based educational content, more so than the impact of daytime activity on sleep, which was instead only explained verbally; additional content could be included in a future iteration.…”

“…Although intervention development work highlighted avoiding naps as a key area, no participants reported frequent napping, and those who occasionally napped reported this was easy to stop. During intervention development there was significant resistance and bad experiences described regarding this [36], however the rationale was well accepted by participants, mostly adhered to, and described as helpful by many.…”

“…The high level of co-morbidity of sleep problems, and particularly increased circadian dysregulation in this group, was the rationale for the development of a personalisable behavioural intervention that can accommodate co-morbid sleep issues: Light-Dark and Activity Rhythm Therapy (L-DART). L-DART was based on the findings of an expert opinion study with clinical and research topic experts (in sleep, circadian rhythm, occupational therapy, mental health, and psychosis) and service users and carers with relevant personal experience [36]. L-DART includes elements of Cognitive Behavioural Therapy for Insomnia (CBTi), such as time in bed restriction to manipulate sleep pressure (sleep compression), 'stimulus control' instructions to increase association of bed with sleep, and sleep hygiene advice [37,38].…”

Effects of cognitive training and behavior modification on aggressive behavior and sleep quality in schizophrenia

“…The exact nature of the connection between SCZ and sleep remains elusive, and the findings from scientific investigations show discrepancies, potentially resulting from variations in sample characteristics, confounding variables, and disparities in research approaches. Additionally, the medication administered to individuals with the condition might influence the outcomes of sleep-related analyses ( 19 , 20 ).…”