Schizophrenia is a major psychiatric disorder that has a massive, long-lasting negative impact on the patients as well as society, the vast majority of patients with schizophrenia report insomnia, which tend to precede illness onset and can predict an acute exacerbation of psychotic symptoms. The aim of this study is to evaluate the effect of sleep hygiene guidelines on insomnia among patients with schizophrenia. A quasi-experimental design (pretest - posttest) was used to achieve this aim. The study was conducted at The Psychiatric and Addiction Treatment Hospital in Meet-Khalaf at Menoufia Governorate, Egypt. A Purposive sample of 65 patients with schizophrenia from inpatient unit of the above mentioned setting was recruited for this study and randomly divided into two equal groups study and control group. Three tools for data collection were used: Tool (I): Structure interview schedule to assess socio demographic data, Tool (II): Insomnia Severity Index (ISI) to assess the subject's level of insomnia, Tool (III): Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality. The study illustrated that there was a statistically significant improvement in quality of sleep among patients with schizophrenia in study group compared to control group. Conclusions: the sleep hygiene guidelines were effective in improvement of sleep quality among patients with schizophrenia in study group. Recommendation: Sleep hygiene guidelines should be routinely applied to all patients with psychiatric illness to improve their quality of sleep and relive insomnia.
Adequate sleep is a fundamental to health which effects on many aspects of individual's life as emotional, cognitive, and psychomotor abilities and also influence person physically and psychologically 1. Sleep help in strengthening the memory, enhance immune system, and help in prevention of many diseases as diabetes, hypertension, heart disease stroke, and mental disorders additionally improve quality of life 2, 3.
Although most of psychiatric patients know sleep is vital, many do not prioritize sleep and so they reported symptoms of sleep depravity 4. There was growing experimental evidence that the relationship between psychiatric disorders and sleep was complex and included bi-directional causation and is considered as a separate entity, which can co-occur with psychiatric disorders. The highest prevalence of insomnia is observed in psychiatric patients as comorbidity in conditions such as posttraumatic stress disorder, mania, and depression 5, 6, 7. It is essential symptom in 30% to 90% of psychiatric disorders and it is seen in clinical practices and characterized by difficulty falling, remaining sleeping, wake up in a mid-night and trouble going back to sleep 8, 9, 10, 11.
Although sleep disturbance is not included in the diagnostic criteria for schizophrenia, it is consistently reported in those patients. That is unlike some psychiatric disorders such as major depression, generalized anxiety disorder, post-traumatic stress and bipolar disorder, sleep is not a core character of schizophrenia. However, sleep disturbances are common in schizophrenic patients and not studied 12, 13. Severe disturbance of sleep has been noticed to occur before the development of acute psychotic episode in schizophrenia and linked to worsening of psychosis symptoms and poorer quality of life, so schizophrenia and insomnia frequently co-occur 6, 13, 12, 14.
Majority of patients with schizophrenia believed that pharmacotherapy could not an acceptable intervention, due to undesirable side effects and drugs interactions, they also reported that constant adherence on one type or dose of medication that is negatively affected their sleep. Cognitive and behavioral interventions had been perceived positively but patients were doubtful of their efficacy. So, active engagement in the intervention process was viewed positively, because it could provide a sense of autonomy 13.
The psychiatric nurse should provide sleep hygiene guidelines. By increasing sleep hygiene education, patients with schizophrenia could improve their sleep. Sleep hygiene: is a set of guidelines about sleep practices and environmental considerations that can either aid the quality and quantity of sleep 15, 16. Guideline: refers to a set of instructions to be followed by patients with schizophrenia to improve the knowledge and practices to reach good sleep quality. Sleep hygiene behaviors consisted of making the bedroom environment calmed to sleep, avoiding activities that stimulate anxiety and stress before bed, reducing tobacco consuming, reducing hunger and thirst before going to bed, regularly exercising and a balanced diet 17. So, the researchers aimed at utilizing a non-pharmacological approach to improve the condition of insomnia among patients with schizophrenia.
1.1. Significance of the StudyThe attainment of better sleep leads to an improvement in patients' mental condition such as improvement in concentration and consequently decreasing in length of hospital staying; decreasing health care costs as well as productivity will be improved. 18. Sleep disturbance especially insomnia is commonly seen in clinical practice. It is appeared to be closely tied to schizophrenia 13. Lack of awareness of the seriousness and potential morbidity associated with sleep problems especially in psychiatric patients such as schizophrenia has indicated the need for more research in this field 19. Studies have shown that up to 80% of patients diagnosed with schizophrenia report symptoms of insomnia 20. To the best of our knowledge, little data exists on insomnia in hospitalized psychiatric patient. Few studies have investigated clinical insomnia in psychosis, which clearly cause sleep disturbance and therefore present targets for intervention.
A psychiatric nurse was well positioned to educate patients about healthy sleep habits and to recommend non-pharmacological strategies. This research is based on the benefits that arise from the use of sleep hygiene guidelines. These include the improvement in the sleep quality and decreasing in the severity of insomnia.
Aim of the Study: to evaluate the effect of sleep hygiene guidelines on insomnia among patients with schizophrenia
1- There will be a decrease in severity of insomnia after applying guidelines of sleep hygiene among patients with schizophrenia in study group compared to control group.
2- There will be improving in quality of sleep among patients with schizophrenia in study group compared to control group.
Theoretical and operational definitions of the studied variables
Insomnia is theoretically defined as difficulty falling asleep, staying asleep or nonrestorative sleep and complaint of inadequate or poor-quality sleep; despite adequate opportunity and circumstance to sleep 20. Insomnia in the present study is operationally defined as the total score or levels of insomnia which is measured by Insomnia Severity Index (ISI).
Sleep hygiene is theoretically defined as a variety of different practices and habits that are necessary to have good nighttime sleep quality and full daytime alertness. Sleep hygiene in the present study is operationally defined as the total score of Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality.
A quasi experimental research (pretest - posttest) design was utilized to fulfill the aim of this study.
2.2. SettingThe study was conducted at The Psychiatric and Addiction Treatment Hospital in Meet-Khalaf that affiliated to the Minstery of Health at Menoufia Governorate, Egypt.
2.3. Sample SizeThe sample sizing adopts that the appraised effect size is 5 and the standard deviation of result variable is 10. To accomplish 80% power to detect this difference with a significance level of 0.05 by the equation: n = [(Zα/2 + Zβ) 2 × 2(ó)2]/ (µ1 - µ2)2 it is estimated that 25 subjects per group would be required. By means of a withdrawal/non-evaluable subject rate of 10% a total of 25 subjects per group, so that the total sample size of 65 subjects would be included in the present study.
2.4. SubjectsA purposive sample of 65 schizophrenic patients from inpatient of the above mentioned setting was recruited for this study. The study sample was divided into two groups 35 patients in study group and 30 patients in control. The study group (I) received a structured education guidelines about sleep hygiene in addition to routine hospital care. Control group (II) received only routine hospital care. The researcher deal with the control group first, to prevent result contamination and bias. They were chosen based on the subsequent power analysis and inclusion criteria
Inclusion criteria
Patients were suitable for study participation when they had the subsequent criterion:
a) Medically diagnosed schizophrenia
b) Both sexes
c) Age from 18-60 years
d) Able to cooperate and communicate to participate in the study.
2.5. Tools of Data CollectionBased on the review of the related literature three tools were utilized by the researcher to achieve the aim of the study: as the following:
Tool (I): Structure Interview Schedule:
This questionnaire was developed by the researcher based on pertinent literature to assess socio-demographic characteristics including patient's age, sex, level of education, marital status, working, and smoking.
Tool (II) Insomnia Severity Index
It was developed by Charles M. Morin, 2001 21. It was utilized to assess the subject's level of insomnia. The Insomnia Severity Index has seven questions. The ISI comprises seven items assessing the perceived severity of difficulties initiating sleep, staying asleep, and early morning awakenings, satisfaction with current sleep pattern, interference with daily functioning, noticeability of impairment attributed to the sleep problem, and degree of distress or concern caused by the sleep problem.
Scoring system:
Each item was scored on a range from one to four (one means no problem and four means very severe problem). This results in a field score ranging from 0 to 28, with a higher score representing a bad result on every domain.
The total score is interpreted as: –0-7 indicated No clinically significant insomnia, 8-14 indicated sub threshold insomnia, 14-21 indicated Clinical insomnia (moderate severity( and 22–28 indicated Clinical insomnia (severe).
Tool (III) Pittsburgh Sleep Quality Index (PSQI)
It was developed by Buysse et al., (1989) 22. It is a 19-item questionnaire evaluating sleep quality and disturbances over the past month. The first 4 items are open questions, whereas items 5 to 19 are rated on a 4-point Likert scale. Individual items scores yield 7 components.
Scoring system:
A total score, ranging from 0 to 21, is obtained by adding the 7 component scores. A score > 5 suggests poor sleep quality. The psychometric properties of the PSQI have been documented in multiple studies, including one with a French-Canadian sample. The PSQI was used because it measures a construct (sleep quality) that is related to insomnia but a construct that is broader than insomnia severity.
Validity of the tools: The content validity of the tools were tested by a panel of five experts specialized in psychiatric Nursing.
Reliability of the tools: The reliability of all tools was tested by intra class reliability coefficient. It was 0.9 for tool I and 0.80 and Cronbach’s alpha above 0.80 for tool II and the internal consistency of tool III was 0.87 and test- retest was 0.90.
Administrative approval: Before starting the study, an administrative approval was obtained from directors of psychiatric hospital after explanation of the purpose of the study.
2.6. Ethical ConsiderationPermission to conduct the study was obtained from the hospital authorities of Meet Khalaf psychiatric hospital. Prior to the initial interview, the researchers introduced themselves to patients and their relatives and explained the purpose and nature of the study, and then an informed consent was obtained from participants who accept to participate in the study. The researchers emphasized that participation in the study is entirely voluntary and withdrawal from the study would not affect the care provided; anonymity and confidentiality were assured through coding the data.
2.7. Pilot StudyA pilot study was carried out on 10 % of patients representing the study sample to test the feasibility and clarity of the used tools; modifications were done based on the results. The sample included in the pilot study was excluded from the final study sample.
2.8. Procedure of Data Collection- Data were collect over a period of 4 months from the beginning of December, 2018 to March, 2019. The researcher collected the data during the morning at two days/week from 10 AM to 11.5 PM., the subjects of study group(35) were divided into 4 groups; each of them consisted of 8 to 9 patients (each group took four sessions). Each session lasted for 60-90 minutes, depending on the response of patients. The data in the current study was collected through three phases: assessment phase, implementation phase and evaluation phase.
I. Assessment phase
An extensive literature related to the study was done, including electronic dissertations, available books, articles, doctoral dissertations, research and peer interaction, and ideas from external sources and periodicals. A review of literature to formulate a knowledge base relevant to the study was also done.
- A comfortable, place was chosen for the interviewers. Orientation was done about the purpose of the study and content of the study
- All subjects who were met the inclusion criteria were included in the study; the researcher introduced herself to them, provides verbal explanation of the study and answered all related questions.
- All Patients of both groups were interviewed individually and the researchers initiated data collection by assessing socio-demographic data, then assess the severity of insomnia and assess quality of sleep was performed using previous illustrated tools.
II-Implementation phase:
For study group: Sleep hygiene guidelines divided into 4 sessions. Each session lasted for one hour at least and has a set of specific objectives. This was achieved through several teaching methods as group discussion, lecture, role playing, posters and colored pictures were used as media to the patients about sleep hygiene as avoid (getting into bed when you are hungry or in a very full stomach or thirsty, no naps, no noise, make sure to arrange the room and bed before going to sleep with a dim light at night.
- At the end of each session summary, feedback, further clarification was done for vague items and homework activity for the following session.
Content of the nursing intervention sessions:-
Short description of the sleep hygiene guidelines sessions employed in the study is discussed below.
Session 1: involved developing a trusting relationship with the patients and encouraging them to discuss their opinions, expectations, and specific needs.
Session 2: concerned with knowledge about, definition of adequate sleep and sings of healthy sleep.
Session 3: concerned with definition of insomnia, and its criteria.
Session 4: concerned with Sleep hygiene guidelines
Ÿ Avoid technological sleep thieves (mobile phones, TV). They lead to delayed circadian rhythm
Ÿ Use your bed for sleep only
Ÿ Stick to a bedtime schedule even during weekends.
Ÿ The bedroom should be cool, Avoid noise, bright light when sleeping
Ÿ Sleep when sleepy, no clock watching. If you can’t sleep after 30 minutes in bed get up and do something relaxing, then return to sleep.
Ÿ Make your bedroom is arranged.
Ÿ Manage your thoughts and fear and replace unrealistic worries to more productive thoughts.
Ÿ Relaxation techniques for better sleep
Ÿ Avoid mentally stimulating arguments before going to bed.
Ÿ Taking a shower, meditation, and listening to music.
Ÿ Herbal teas like chamomile and passion flower help the patient to relax
Ÿ Dark chocolate: Contains serotonin which relaxes the mind and body
Ÿ Warm glass of milk (may add honey to make it sweet)
Ÿ Bananas: Contain magnesium and potassium, which serves as a relaxant.
For control group: the patients received routine hospital care only as taking medication according to doctor prescription.
III-Evaluation phase:
The last phase in which the researcher assess the achievement of the aim of the study through reintroducing the research tools (posttest) for both experimental and control groups post intervention to evaluate the effectiveness of sleep hygiene intervention sessions among the experimental group.
2.9. Statistical AnalysisThe data collected were tabulated & analyzed by SPSS (statistical package for the social science software) statistical package version 20 on IBM compatible computer. Two types of statistics were done:
1) Descriptive statistics: were expressed as mean and standard deviation (X+SD) for quantitative data or number and percentage (No & %) for qualitative data.
2) Analytic statistics:
1. Student t- test: is a test of significance used for comparison between two independent groups of normally distributed quantitative variables.
2. Fisher`s Exact Test: It is the test of significance used to study association between two qualitative variables.
3. ANOVA test: is a test of significance used for comparison between more than two independent groups of normally distributed quantitative variables.
Table 1: Showed that, the mean age of studied sample was (39.25 ± 13.81& 39.80 ±9.78) in study & control group respectively. Most of studied sample were male (88.6% in study group& 86.7 in control group). In relation to marital status, less than half were married 40% in study group, while half of them in control group were married 50%. In relation to educational level and Occupation 60% & 80% of studied sample (study and control group) had primary education& were working respectively. More than half of study group were smoker (57.1%) while nearly half of control group were smoker (46.7%).
Figure 1: Revealed that there a was significant decreasing of mean Insomnia Severity Index scores in the study group after intervention than before (19.42±3.1 to be 5.97) and the mean Insomnia Severity Index scores among control group from 18.26 to 14.56 respectively.
Figure 2 illustrated that there was decrease of Pittsburgh Sleep Quality Index (PSQI) scores (from 15.24 to 4.57 & 15.13 to 13.06) among study and control groups pre and post intervention respectively.
Table 2 showed that there was statistical relationship between the baseline global score of PSQI among the studied group and their demographic characteristics regarding to age, Occupation P (0.003, 0.02 &0.03, 0.01) respectively.
Table 3 showed that there was no statically significant relationship between the baseline Insomnia Severity Index scores among the studied group and their demographic characteristics except age there was relation ship P(0.005 S &0.04 S )in study & control group respectively.
Figure 3 showed that there was a positive correlation between Insomnia Severity Index scores and global score of PSQI among the studied group.
Schizophrenia and sleep disturbance as insomnia have negative effect on psychiatric patients' health. Sleep disturbance affect social and cognitive functioning, and consequently are probable to participate in a critical manner to the daily challenges specially patients with schizophrenia.
The majority of studied sample was male. This result was the same line Parekh 23 who reported that schizophrenia affects men and women about equally but may have an earlier onset in male. More than half of study group were smoker while nearly half of control group were smoker. This result was the same line with Buysse, 2013, 24 who studied the risk factors of insomnia, he stated that heavy smoking is considering as risk factor of sleep disorder. This result applied on the current research because the majority of study group had smoked
Regarding to insomnia ; the present study noticed that the majority of studied sample in study and control group had moderate insomnia level according to Insomnia Severity Index (ISI)scores before applying guidelines of sleep hygiene which clarified insomnia as difficulty falling asleep, difficulty staying asleep ,problems waking up too early, impairing the quality of life with sleep problem. This result was on the same line with National Institute of Health, 2016 and Punnoose et al 2012 25, 26 who knows insomnia as alertness, in which people have disorder sleeping. They may have problem falling asleep, or remaining asleep as wanted. It is characteristically followed by daytime sleepiness, decrease level of energy, irritability, and change in mood. It may result in an increased risk trauma, moreover problems in concentration and learning. While post application of sleep hygiene guidelines, the current study revealed that the study group had no insomnia after application of sleep hygiene guidelines, and the mean (ISI) score decreased, this indicate the effectiveness of sleep hygiene guidelines sessions .This result was consistent with the, Qaseem and Ellis, as in 27, 28 who studied management of chronic insomnia disorder, they illustrated that dealing with sleep disorder by changing behaviors of sleep and follow tips of sleep hygiene as decreasing amount of caffeine , nicotine intake, reducing daytime napping, keeping environment quiet and dark lead to promotion of sleep. The researchers explained that problem in sleeping affect individual 'health by decreasing the immune system expose them to disease and impaired quality of life, while post application of sleep hygiene guidelines, the sleep pattern improved when the patients follow instructions, the patients can sleep comfortably.
Regarding to insomnia according to Pittsburgh Sleep Quality Index (PSQI) scores; the mean score was higher in study and control group pre intervention which indicated poor quality of sleep .This result was the line with Chan, et al, 2017 29 who sleep in schizophrenia: a systematic review and meta-analysis of polysomnographic. They stated that sleep efficiency has been found to be lower on average in groups with schizophrenia. While post application of sleep hygiene to study group, the Pittsburgh Sleep Quality Index (PSQI) scores decreased compared to control group. This clarifies the effectiveness of sleep hygiene guidelines sessions which was within the need and interest of the participants. This result was agreement with Jin Ju & Woo 2016 30 who studied the effects of sleep hygiene program on sleep quality in the elderly women; they stated that the experimental group showed lower sleep quality score than the control group, which indicated elevated sleep quality after application of a sleep hygiene education to insomnia.
Regarding to insomnia and quality of sleep correlation. The present study showed that there was a positive correlation between Insomnia Severity Index scores and global score of PSQI among the studied group. This result was the same line with Khalladi et al, 2019 31. who studied the inter-relationship between sleep quality, insomnia and sleep disorders, they reported that more than half of study had poor sleep quality, when these patients had sub threshold insomnia , also the researchers stated that there was positive relation between insomnia and quality of Sleep. The researchers explained that as the score of Insomnia Severity Index increase, as the PSQI increase which indicated the bad sleep quality, also sleep disorder can change quality of sleep.
Regarding to relationship between Insomnia Severity Index scores and their demographic characteristics the current study showed that there was no statically significant relationship between the baseline Insomnia Severity Index scores among the studied group and their demographic characteristics except age there was relationship in study & control group respectively. This result was the same line with Jinsong Tang, et al., 2017 32 who studied "Gender and Regional Differences in Sleep Quality and Insomnia". They found there were no significant gender differences in other two PSQI components and daytime dysfunction. While females had a higher PSQI total score than males.
The sleep hygiene guidelines were effective in improvement of quality of sleep among patient with Schizophrenia in study group.
A psychiatric nurse was well positioned to educate psychiatric patients about healthy sleep habits as recommended non-pharmacological strategies and application of sleep hygiene guidelines routinely for managing insomnia among psychiatric patients.
We are very grateful to Allah and the patients who participated in this study in addition; we would like to thank psychiatric nursing staff in the inpatient section for kind cooperation.
The authors declare no conflict of interest.
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Published with license by Science and Education Publishing, Copyright © 2019 Lamiaa Hassnin Eita, Asmaa Hamed Abd Elhy and Samira E. Aboalizm
This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit
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| [1] | Orzech, K., Salafsky, D, and Haimalton, L. (2011). The state of sleep among college student at a large public university, J American college health, 59(7): 612 619. | ||
| In article | View Article PubMed | ||
| [2] | Tahil, F, Ajaltouni, J, Ghanour, H, Abu-mohammed, A and Kobeissy, f, (2018). Insomnia in hospitalized psychiatric patients. prevalence and associated factors. Neuro psychiatric disease and treatment. 14, 969-975. | ||
| In article | View Article PubMed PubMed | ||
| [3] | Faraklas, I, Holt, B, Txan, S, Lin, H, Sabble, J and cocrran, A. (2013). Impact of nursing – driven sleep hygiene protocol on sleep quality J. burn care to research; 34(2): 249-254. | ||
| In article | View Article PubMed | ||
| [4] | Wang, p. (2016). Editorial sleep dicorders in pregnancy.science Direct Journal of the Chinese Medical Association, 793e4. | ||
| In article | |||
| [5] | Batterham, P.J, Glosier, N, and Chridtenen, H. (2012). The onset of depression and anxiety. prospective cohort study, Aust, N.Z.J. psichatry; 46(11):1089-1098 | ||
| In article | View Article PubMed | ||
| [6] | APA. (2013). Diagnostic and statistical manual OF mental disorders. 5the ed. Washington .American psychotric pub; American psychiatric Association | ||
| In article | |||
| [7] | Krystal, A. (2012). Psychiatric disorders and sleep, Near clin, November; 30(4): 1389-1413. | ||
| In article | View Article PubMed PubMed | ||
| [8] | Stummer, L, Markovic, M, and Maroney, M. (2018) pharmacolgictreatment options for insomnia in patiente with schigophrein, Medicine; 5(88): 1-100. | ||
| In article | View Article PubMed PubMed | ||
| [9] | N Ishinoue, N, Takano, T, kaku, A, Eto, R kato, N ono, Y, and tanaka, K (2012). Effects of sleep hygiene eduction and behavirol therapy on sleep quality of whit –collar workers arandomiged controlled trail ,I ndns . health, 50(2): 123-131. | ||
| In article | View Article PubMed | ||
| [10] | Kira, G, Maddison, R, Hull, M, Blunden, S, and olds, T. (2014). Sleep education improves the sleep duration of adolescent: a randomized controlled pilot study, J clinical sleep medicine; 10(7): 787. 790. | ||
| In article | View Article PubMed PubMed | ||
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