Sleep Complaints in the Psychiatric Hospital: A Qualitative Study of Nurses and Psychiatrists’ Approaches to Sleep Management in a Swiss Psychiatric Hospital

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is an important contribution to insomnia care in inpatient psychiatry, a highly relavant health topic. The manuscript has the potential to contribute to improving  insomnia care in inpatient psychiatry.

I have only minor comments that might help to improve the manuscript:

Introduction
-    Please correct that insomnia disorder is defined as a predominant complaint of dissatisfaction with …, and not as “Insomnia disorder defines as difficulties falling asleep, staying asleep,…”. This difference is very important since the current definition is based on the patient report and not on objective measurements. It is particularly important since sleep-wake regulatory systems are (often) largely intact in patients with insomnia disorder, and there is no evidence for substantial objective sleep loss, at least not on a level that is diagnostically useful.
-    The same applies to daytime function. Also here the disorder is defined by a complaint of daytime dysfunction, which is very often not corroborated in any objective assessments
-    Seems unnecessary to use abbreviations for “psychiatric hospital (PH) regarding their approach to patients’ sleep complaints (SC)”; the use in the Methods section, for instance (“working in a Swiss PH”) does not promote the understanding of the text
Methods
-    Please specify the hospital (name etc)
-    3.2. “Participants identified two things influencing…”, better “Participants identified two factors influencing…”
Discussion
-    Please note that there are prevalence data of other sleep disorders in inpatient psychiatry, https://pubmed.ncbi.nlm.nih.gov/29876601/ and https://pubmed.ncbi.nlm.nih.gov/35370821/
-    Please do not use abbreviations, which are difficult to read, for instance “The main finding of this study is that SC in the PH encompass three different types 313 of problems: acute IS that arise from the hospital environment, acute IS secondary to the 314 underlying psychiatric pathology, and chronic IS. This represents an important finding, 315 as the management of SC could be different for each category.”
-    I suggest a paragraph after the Limitations that identify pathways to improvement, such as adapting training programs (medical studies, programs for nurses), psychologists should be mentioned at one point in the manuscript, adapting postgradual training, please see recommendations of the European CBT-I academy, you might mention CBT-I courses in Europe (such as Oxford, English, Freiburg and Basel, German, Geneva, French), implementing adaptations of CBT-I, such as SLEEPexpert or others (see Allison Harvey’s TransC, B Sheeves Oxford program), you might think about other opportunities, such as outreach activities to inform the public and adapt patient’s expectations over time, resource and finance allocation, politics…?
-    I think the Conclusion does not really reflect the main findings, which is that there is no evidence based approach, insufficient adaptation of CBT-I to inpatient setting; “heterogenous” appears unspecific and too weak as a Conclusion for highly interesting findings; along these lines, I also think the conclusion in the Abstract could be more specific, lack of evidence based strategies, lack of adaptation of CBT-I for this setting, overmedication, future work needed …, implementing adapted programs is needed.

Author Response

Dear Reviewers,

We kindly thank you for your insight and comments, and we have done the following modifications to the first text :

Reviewer 2

• Slightly changed the definition of insomnia disorder in the introduction to specify that it is a subjective insatisfaction with sleep and with daytime functioning
• Avoid the abbreviations for psychiatric hospital, sleep complaints and insomnia symptoms to make the text easier to read
• Specified the name of the hospital
• Replaced “participants identified two things influencing” by “participants identified two factors influencing”, as well as enhanced the English language in general to make it more academic.
• Added restless legs syndrome (and the reference you provided) as other sleep complaints that are prevalent among psychiatric inpatients
• Added a paragraph after limitations about the pathways to improvement, including adapting training programmes (for medical students, nursing students and psychology students) as well as the courses already existing
• Slightly changed the conclusions to better reflect that the approaches were non evidence-based, lacking CBT-I adaptations for the inpatient setting and leading to overmedication (both in the “Conclusion” section and in the abstract

 

Sincerely,

Maria Dalmau i Ribas

Reviewer 2 Report

Comments and Suggestions for Authors

This study is a qualitative study conducted in a Swiss psychiatric hospital, examining how nurses and psychiatrists respond to sleep complaints from inpatients. The authors categorise insomnia in the inpatient psychiatric setting into three types: 'hospital environment', 'acute insomnia secondary to the underlying psychiatric pathology', and 'chronic insomnia', presenting a useful framework for understanding clinical decision-making.

This theme is of significant importance in the context of psychiatric treatment research, being crucial in the initial treatment of mental disorders and potentially influencing treatment outcomes. However, it is a theme that is relatively overlooked within the broader field of general insomnia treatment, and this study helps fill this gap. Although the sample size is small (10 participants out of 100 invited), the participants exhibited a certain degree of diversity, and the amount of information appears sufficient for a qualitative study.

As psychiatric inpatient care systems vary considerably between countries and regions, it would be beneficial to supplement the study with general characteristics of inpatients at the hospital in question, to aid readers in assessing generalizability. For instance, presenting basic information such as primary diagnoses, typical length of stay, and whether the ward primarily targets acute or chronic patients would be desirable.

While approximate staffing numbers are provided, as this is a qualitative study, more specific information on the clinical structure would be useful for understanding the background to on-site decision-making and responses. Adding details on night shift staffing (numbers of nurses, doctors, and other staff) would particularly enhance reader comprehension.

Author Response

Dear Reviewers,

We kindly thank you for your insight and comments, and we have done the following modifications to the first text :

Reviewer 1

• Added a paragraph in “Methods” about characteristics of patients (primary diagnoses, typical length of stay, ward targeting acute patients only) and staffing numbers (both during the day and during the night)

 

Sincerely,

Maria Dalmau i Ribas