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      Stabilising sleep for patients admitted at acute crisis to a psychiatric hospital (OWLS): an assessor-blind pilot randomised controlled trial

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          Abstract

          Background

          When patients are admitted onto psychiatric wards, sleep problems are highly prevalent. We carried out the first trial testing a psychological sleep treatment at acute admission (Oxford Ward sLeep Solution, OWLS).

          Methods

          This assessor-blind parallel-group pilot trial randomised patients to receive sleep treatment at acute crisis [STAC, plus standard care (SC)], or SC alone (1 : 1). STAC included cognitive–behavioural therapy (CBT) for insomnia, sleep monitoring and light/dark exposure for circadian entrainment, delivered over 2 weeks. Assessments took place at 0, 2, 4 and 12 weeks. Feasibility outcomes assessed recruitment, retention of participants and uptake of the therapy. Primary efficacy outcomes were the Insomnia Severity Index and Warwick–Edinburgh Mental Wellbeing Scale at week 2. Analyses were intention-to-treat, estimating treatment effect with 95% confidence intervals.

          Results

          Between October 2015 and July 2016, 40 participants were recruited (from 43 assessed eligible). All participants offered STAC completed treatment (mean sessions received = 8.6, s.d. = 1.5). All participants completed the primary end point. Compared with SC, STAC led to large effect size (ES) reductions in insomnia at week 2 (adjusted mean difference −4.6, 95% CI −7.7 to −1.4, ES −0.9), a small improvement in psychological wellbeing (adjusted mean difference 3.7, 95% CI −2.8 to 10.1, ES 0.3) and patients were discharged 8.5 days earlier. One patient in the STAC group had an adverse event, unrelated to participation.

          Conclusions

          In this challenging environment for research, the trial was feasible. Therapy uptake was high. STAC may be a highly effective treatment for sleep disturbance on wards with potential wider benefits on wellbeing and admission length.

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          Most cited references21

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          The positive and negative syndrome scale (PANSS) for schizophrenia.

          The variable results of positive-negative research with schizophrenics underscore the importance of well-characterized, standardized measurement techniques. We report on the development and initial standardization of the Positive and Negative Syndrome Scale (PANSS) for typological and dimensional assessment. Based on two established psychiatric rating systems, the 30-item PANSS was conceived as an operationalized, drug-sensitive instrument that provides balanced representation of positive and negative symptoms and gauges their relationship to one another and to global psychopathology. It thus constitutes four scales measuring positive and negative syndromes, their differential, and general severity of illness. Study of 101 schizophrenics found the four scales to be normally distributed and supported their reliability and stability. Positive and negative scores were inversely correlated once their common association with general psychopathology was extracted, suggesting that they represent mutually exclusive constructs. Review of five studies involving the PANSS provided evidence of its criterion-related validity with antecedent, genealogical, and concurrent measures, its predictive validity, its drug sensitivity, and its utility for both typological and dimensional assessment.
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            A rating scale for mania: reliability, validity and sensitivity.

            An eleven item clinician-administered Mania Rating Scale (MRS) is introduced, and its reliability, validity and sensitivity are examined. There was a high correlation between the scores of two independent clinicians on both the total score (0.93) and the individual item scores (0.66 to 0.92). The MRS score correlated highly with an independent global rating, and with scores of two other mania rating scales administered concurrently. The score also correlated with the number of days of subsequent stay in hospital. It was able to differentiate statistically patients before and after two weeks of treatment and to distinguish levels of severity based on the global rating.
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              The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis

              Summary Background Sleep difficulties might be a contributory causal factor in the occurrence of mental health problems. If this is true, improving sleep should benefit psychological health. We aimed to determine whether treating insomnia leads to a reduction in paranoia and hallucinations. Methods We did this single-blind, randomised controlled trial (OASIS) at 26 UK universities. University students with insomnia were randomly assigned (1:1) with simple randomisation to receive digital cognitive behavioural therapy (CBT) for insomnia or usual care, and the research team were masked to the treatment. Online assessments took place at weeks 0, 3, 10 (end of therapy), and 22. The primary outcome measures were for insomnia, paranoia, and hallucinatory experiences. We did intention-to-treat analyses. The trial is registered with the ISRCTN registry, number ISRCTN61272251. Findings Between March 5, 2015, and Feb 17, 2016, we randomly assigned 3755 participants to receive digital CBT for insomnia (n=1891) or usual practice (n=1864). Compared with usual practice, the sleep intervention at 10 weeks reduced insomnia (adjusted difference 4·78, 95% CI 4·29 to 5·26, Cohen's d=1·11; p<0·0001), paranoia (−2·22, −2·98 to −1·45, Cohen's d=0·19; p<0·0001), and hallucinations (−1·58, −1·98 to −1·18, Cohen's d=0·24; p<0·0001). Insomnia was a mediator of change in paranoia and hallucinations. No adverse events were reported. Interpretation To our knowledge, this is the largest randomised controlled trial of a psychological intervention for a mental health problem. It provides strong evidence that insomnia is a causal factor in the occurrence of psychotic experiences and other mental health problems. Whether the results generalise beyond a student population requires testing. The treatment of disrupted sleep might require a higher priority in mental health provision. Funding Wellcome Trust.
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                Author and article information

                Journal
                Psychol Med
                Psychol Med
                PSM
                Psychological Medicine
                Cambridge University Press (Cambridge, UK )
                0033-2917
                1469-8978
                July 2018
                07 November 2017
                : 48
                : 10
                : 1694-1704
                Affiliations
                [1 ]Sleep & Circadian Neuroscience Institute (SCNi), Department of Psychiatry, Warneford Hospital, University of Oxford , Oxford, OX3 7JX, UK
                [2 ]Oxford Health NHS Foundation Trust, Warneford Hospital , Oxford, OX3 7JX, UK
                [3 ]Department of Psychiatry, Warneford Hospital, University of Oxford , Oxford, OX3 7JX, UK
                [4 ]Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford , Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
                [5 ]Berkshire Healthcare NHS Foundation Trust, Prospect Park Hospital , Honey End Lane, Tilehurst, Reading, Berkshire, RG30 4EJ, UK
                [6 ]Sleep & Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences, OMPI, Sir William Dunn School of Pathology, University of Oxford , South Parks Road, Oxford, OX1 3RE, UK
                [7 ]Centre for Chronobiology, Psychiatric Hospital, University of Basel , Wilhelm Klein Strasse 27, CH-4012 Basel, Switzerland
                [8 ]Oxford Health NHS Foundation Trust, Warneford Hospital , Oxford, OX3 7JX, UK
                Author notes
                Author for correspondence: Bryony Sheaves, Email: bryony.sheaves@ 123456psych.ox.ac.uk
                Article
                S0033291717003191 00319
                10.1017/S0033291717003191
                6088775
                29108526
                01ce35ff-bdda-42bb-b1e7-77c1f473c81d
                © Cambridge University Press 2017

                This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 17 May 2017
                : 28 September 2017
                : 02 October 2017
                Page count
                Figures: 1, Tables: 5, References: 39, Pages: 11
                Categories
                Original Articles

                Clinical Psychology & Psychiatry
                bipolar disorder,inpatient,insomnia,psychiatric ward,psychosis,schizophrenia,sleep

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