Abstract
Background
Sleep problems are prevalent in schizophrenia spectrum disorders, and include psychophysiological insomnia, and sleep disturbances caused predominantly by circadian dysregulation. Studies using motion sensing wearables (including actigraphy) have shown a diverse range of rest activity patterns, including mis-timed sleep, irregular sleep, or non-24hr (free-running) sleep patterns. Sleep and circadian rhythm disturbances impact negatively on functioning and quality of life, and long term poor sleep is linked to weight gain, and other serious physical health conditions. Many of the factors supposed to cause or maintain poor sleep in this group are modifiable through behavioural and environmental alterations.
Methods
An expert consensus study (Delphi study) was conducted to examine and explore the views of relevant experts, regarding the appropriate contents and format of an occupational therapy intervention to improve sleep in schizophrenia spectrum disorders. Experts were recruited with expertise in: occupational therapy, sleep, insomnia, circadian rhythm, and schizophrenia spectrum disorders. Experts with clinical and/or research expertise were sought, as well as service users and carers. We conducted three rounds of online surveys, individual interviews, and a day of content presentation, comments and voting, and discussion groups with service users and carers. Quantitative data were analysed using descriptive statistics and presented graphically for comparisons. Qualitative data (survey comments and interviews) was analysed using thematic analysis. Analysis and data collection was iterative; with later rounds exploring views raised during earlier rounds. The results informed the development of the intervention now being tested in a single group feasibility study recruiting twenty participants. Using mixed methods, this study will evaluate acceptability, homework adherence and trial related procedures, informing adjustments prior to larger scale testing.
Results
The Delphi study recruited and retained participants well (n=82 of target=85, 66% uptake from professionals approached, 97% completion), suggesting a high level of interest in this topic. Participants reached consensus regarding relevant content within the initial assessment, increasing daytime natural light exposure (when possible), approaches to evening routine, and the approach to activity and occupation. Views varied regarding the relative importance of sleep restriction and building ‘sleep drive’, versus reducing arousal such as through relaxation, mindfulness, or cognitive approaches to anxiety. Often service users’ and carers’ views reflected those of professionals, however on some areas views between these groups differed, such as acceptable levels of intervention burden, and regarding wearables. Overall views highlighted the importance of a tailored intervention, with adjustable and selectable elements. The tailoring of recommendations will be achieved through a thorough assessment, including longitudinal use of light and movement sensing wearables, and a detailed initial interview. Many intervention components are optional based on needs, and the homework recommendations from ‘core’ intervention elements will vary depending upon individual needs, preferences, and baseline problems and situation.
Discussion
The diversity of sleep disturbance presentations within this group poses a unique challenge when developing a brief first-line intervention. Individually tailored recommendations can be derived through the combination of wearable technology and self-report, and a growing body of work informing models of sleep disturbance in this group.