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Abstract
Objectives This study aims to investigate the relationship between anxiety levels and poor sleep quality among family caregivers of psychiatric patients, based on the history of sharp object injuries (SOI) inflicted by the patients.
Design A case-control study.
Setting and data The data were collected through face-to-face interviews with family caregivers of patients at the Bitlis Province Community Mental Health Center and Bitlis State Hospital Psychiatry Service between December 2021 and May 2022.
Participants A total of 111 family caregivers participated in the study.
Outcome measures The sleep quality of family caregivers was evaluated using the Pittsburgh Sleep Quality Index, while anxiety levels were assessed using the Beck Anxiety Inventory (BAI).
Results Among family caregivers, 52.3% had poor sleep quality, 24.3% experienced moderate anxiety and 31.5% experienced severe anxiety. An increase of one point on the anxiety scale (measured by BAI) raised the odds of poor sleep by 14%. The anxiety-poor sleep relationship was stronger in SOI-exposed caregivers (r=0.699) than in non-exposed ones (r=0.607). When age was controlled, the relationship strengthened among SOI-exposed individuals (r=0.722) but remained unchanged for non-exposed ones (r=0.608).
Conclusions This study shows that each point increase on the anxiety scale is associated with a 14% increase in the odds of poor sleep among family caregivers of psychiatric patients. The relationship between anxiety level and poor sleep quality was further elevated among individuals exposed to SOI. Providing family caregivers of psychiatric patients, especially those exposed to SOI, with coping strategies and sleep hygiene training can improve their anxiety and sleep quality and assist in managing the care process.
- Wounds and Injuries
- Caregivers
- Sleep Medicine
- Anxiety disorders
Data availability statement
Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study used a case-control design to compare family caregivers exposed to sharp object injuries with those not exposed.
Standardised and validated scales were employed to assess anxiety and sleep quality among participants.
The inability to standardise family caregivers was due to the limited number of psychiatric patients treated at the hospital in the province where the study was conducted.
The study did not evaluate factors such as stress, depression, support systems and family dynamics, which may influence the relationship between anxiety and sleep quality.
The single-region nature of the study limits the geographical representativeness of the results.
Introduction
Violent tendencies may emerge in some psychiatric disorders. Anti-social personality disorders, schizophrenia and post-traumatic stress disorder are among the mental illnesses that can lead to aggression in patients.1 Generally, psychiatric patients are not predisposed to aggression, and their propensity for aggressive behaviour varies from person to person depending on their condition.2 3
Family caregivers who spend time with patients exhibiting aggressive tendencies may be subjected to aggression from these patients. Typically, the patient’s mother and spouse serve as primary caregivers and spend more time with the patient. This situation can lead to a greater psychological impact on them. Psychological effects may include increased conflict and heightened levels of depression.4–8 As a result of being exposed to aggression, these caregivers may experience not only psychological adversities but also physical adversities.2 9 This situation represents a significant care burden for the patient’s primary family caregivers.10–12
The combination of the psychiatric patient’s illness and the increasing caregiving burden can adversely affect both the quality and quantity of family caregivers’ sleep. Additionally, impaired sleep quality can reduce caregivers’ psychological resilience and negatively affect their mental health.13–16 Research has shown that insomnia is correlated with anxiety levels and depression.17–19 Sleep problems and anxiety can trigger each other.20 The effects of this on family caregivers, in relation to psychiatric patient assaults, should be examined. The literature review revealed the need to examine this relationship among family caregivers of psychiatric patients, considering the patient’s aggression status. Accordingly, the aim of this study was to determine the anxiety and sleep quality of family caregivers of psychiatric patients and to investigate the relationship between anxiety levels and poor sleep quality in these caregivers, based on their history of sharp object injuries (SOI).
Research questions
How does the relationship between anxiety and poor sleep quality change among family caregivers exposed to SOI inflicted by psychiatric patients, and what is the extent of this relationship?
Does this relationship also change among family caregivers who are not exposed to SOI inflicted by psychiatric patients?
What is the status of anxiety and poor sleep quality among family caregivers?
Methods
Study design
The study is correlational in nature and was designed as a case-control study.
Scope and sample
In the city centre of Bitlis, located in the Eastern Anatolia region of Turkey, there is a state hospital and a community mental health centre. During the study period, the psychiatric care service and the Community Mental Health Support Unit were located at Bitlis State Hospital. The population of the study consisted of the family caregivers of patients who received care from the psychiatric service of Bitlis State Hospital and the Bitlis Community Mental Health Center between December 2021 and May 2022. Using G*Power 3.1.9.7, the required number of participants was determined according to the ‘Correlation: Normal Model’ test; in the calculation, effect size=0.3, 1—β error probability=0.94 and α=0.05 were set.
Family caregivers of the patients were asked through a closed-ended question whether they had been exposed to SOI by the patient during caregiving. In the study, family caregivers of patients exposed to SOI constituted the case group, while those not exposed to SOI formed the control group. Individuals were included in the study between the specified dates, considering the inclusion and exclusion criteria for both the case and control groups. The duration of each interview with the participants is approximately 5 min.
The study matched family caregivers based on their exposure to SOI inflicted by patients. For each case (caregivers exposed to SOI), one control (caregivers not exposed to SOI) was selected. A total of 114 individuals (57 cases and 57 controls) were included in the study. Due to incomplete data from three individuals and the withdrawal of one participant, 111 family caregivers (55 cases and 56 controls) were evaluated in the study.
Informed consent
Family caregivers of psychiatric patients were visited at both the psychiatry department and the community mental health centre. They were given information about the study’s purpose, scope and data usage, which would be solely for scientific purposes with maintained confidentiality. Participation was voluntary, with the option to withdraw at any time, no payments or fees involved. It was also communicated that the study could be reviewed by ethical committees and official authorities if necessary.
Participants
Family caregivers of psychiatric patients who were 18 years of age or older, had no mental health issues and consented to participate in the study were included. Those who had incomplete or inaccurate completion of survey or scale data, or a history of SOI not related to caregiving, were excluded.
Patient and public involvement
None.
Data sources and measurement
To collect the data, the researchers used a 7-question Personal Information Questionnaire, the Beck Anxiety Inventory (BAI) and the Pittsburgh Sleep Quality Index (PSQI).
The personal information form includes seven questions prepared by the research team on participants’ gender, marital status, occupation, income and SOI status.
The BAI, developed by Beck et al,21 was used to assess anxiety status. The Likert scale consists of 21 items that are scored between 0 and 3 (0=none, 3=intensive). The score ranges from 0 to 63. As the score increases, the level of anxiety increases. BAI scores were categorised into four groups: minimal (0–7), mild (8–15), moderate (16–25) and severe (26–63) anxiety. A validity and reliability study of the Turkish version was conducted by Ulusoy et al.22 The Turkish version of the scale has a Cronbach’s alpha of 0.93. The Turkish version of the scale, which has structural validity and a high internal consistency coefficient, is valid and reliable. The Cronbach’s alpha for the scale in our study was 0.95.
The PSQI developed by Buysse et al23 evaluates the quality of sleep experienced by individuals over the past month. The scale comprises 24 questions, 19 of which are scored. Each item included in the PSQI is calculated in the range of 0–3 points, and a component score of 7 is created. ‘0’ indicates that there is no difficulty in the component, and ‘3’ indicates a serious difficulty. The total score (ranging from 0 to 21) is obtained by summing the component scores. A total score of ‘0’ indicates no difficulty across all components, whereas a score of ‘21’ indicates severe difficulty in all domains. As the score increases, the quality of sleep decreases. Additionally, the PSQI score can be classified, and a total score >5 indicates poor sleep quality. Ağargün et al24 conducted a validity and reliability study of the Turkish version. The Turkish PSQI is valid and reliable. The Cronbach’s alpha value has been determined to be >0.7. The PSQI’s internal consistency was 0.7 in our study. The components and descriptions of the PSQI are presented below (table 1).
The components and descriptions of the PSQI
Statistical methods
In this study, the numerical values of kurtosis and skewness were analysed to determine whether the data were normally distributed. The calculated values range from −1 to +1.25 26 The data distribution was analysed visually using histograms and boxplots. The data have no skewness or kurtosis. It also meets the normal distribution conditions visually. Since the parametric conditions were met, partial correlation and Pearson correlation analysis were used. Partial correlation analysis was used to measure the relationship coefficient between two variables, controlling for third variables such as age. Additionally, logistic regression analysis was used to compare participant variables with PSQI score classifications. Categorical variables were compared using χ2 and slope χ2 tests, with the latter applied to age. Statistical significance was accepted as p < 0.05 (95% CI). Analyses were done using Jamovi (V.2.5).27
Ethical and administrative approval
Ethical approval (E.1276, 21/11–10) was granted by the Bitlis Eren University Ethics Committee, with administrative approval from the Bitlis Provincial Health Directorate. The study adhered to the Declaration of Helsinki principles.
Results
Family caregivers’ sociodemographic characteristics
Between the relevant dates, family caregivers of psychiatric patients were visited at the Psychiatry Department of the hospital and the Community Mental Health Center in the city. A total of 114 individuals (57 cases and 57 controls) were included in the study. Three were excluded due to incomplete data, and one withdrew voluntarily. The mean age of the 111 remaining family caregivers was 37.6 years (range: 18–72), with 55 caregivers having been subjected to SOI by their patients. The comparison of SOI according to the sociodemographic characteristics of the participants is presented in table 2. A statistically significant difference was found only between marital status and SOI exposure (p=0.034).
The sociodemographic characteristics and SOI exposure of patients’ family caregivers
Poor sleep quality was 52.3%, moderate anxiety was 24.3% and severe anxiety was 31.5% among family caregivers. The distributions and χ2 comparisons of age, education, sex, income and marital status for family caregivers of patients from the psychiatric service and Community Mental Health Centre are shown below (table 3).
Distribution of patients’ family caregivers by age, income, occupation, education and sex
Women had more moderate/severe anxiety than men, but this difference was not statistically significant (p>0.05). While there was a significant difference between marital status and anxiety level (minimum-mild; moderate-severe; χ2=14.17, degree of freedom, SD=2, p=0.001), there was no statistically significant difference between marital status and sleep quality (p=0.08). Despite the lack of significant difference between marital status and sleep quality, table 3 shows that sleep quality was worse in widowed, divorced and separated individuals.
Anxiety and poor sleep quality relationship
The logistic regression analysis results showing the relationship between certain variables of the participants and the PSQI are presented in table 4.
The relationship between age, SOI exposure and anxiety levels of family caregivers of psychiatric patients with the PSQI
An increase of one point on the anxiety scale (measured by BAI) raised the odds of poor sleep by 14% (p<0.05). Exposure to SOI among family caregivers increases the odds of poor sleep quality by 25%, but this is not statistically significant (p>0.05). The model’s explanatory power is indicated by an R² value, with a maximum R²Nagelkerke = 0.469 and a minimum R²Cox&Snell=0.351. The Hosmer–Lemeshow test showed that the model provided a good fit (χ² = 8.089, p=0.425). The Variance Inflation Factor ranges from 1.03 to 1.07, indicating acceptable levels of multicollinearity.
The relationship between the anxiety level and sleep quality of the family caregivers of the patients is presented in table 5.
The relationship between anxiety level and poor sleep quality according to SOI exposure
When the effect of age of family caregivers is statistically controlled for, the strength of the relationship changes. When controlling for age among those exposed to SOI, the correlation between anxiety level and poor sleep quality was found to be rpartial=0.722, r2=0.521, p<0.001 (table 5).
Discussion
Anxiety and poor sleep quality relationship
In our study, the relationship between anxiety and poor sleep quality was assessed based on family caregivers’ exposure to SOI by psychiatric patients. The literature contains studies indicating a relationship between anxiety and sleep quality.20 However, examining this relationship among family caregivers of psychiatric patients in the context of SOI exposure is crucial. The aim was to explore the links between violence, anxiety and poor sleep.
The numerical value of the r coefficient indicates the strength of the relationship. Correlations are categorised by Cohen and Michael28 as moderate (r=0.40 to .69), high (r=0.70 to .89) and very high (r=0.90 to 1).29 Among family caregivers exposed to SOI inflicted by patients, the relationship between anxiety and poor sleep quality was stronger compared with those not exposed. When controlling for participants’ age, this relationship was further strengthened. Older adults are more likely to adopt strategies for preventing and reducing negative emotions compared with younger adults.30 Additionally, as age progresses, family caregivers may become more experienced.
Anxiety should not be considered as the only variable associated with poor sleep. Sleep quality is a complex condition, that is, related to many variables. However, it is quite common in sleep disorders.31 Factors such as duration of caregiving, hopelessness, obesity and employment status may also affect the sleep quality of family caregivers.32–34
In our study, it was observed that the relationship between anxiety levels and poor sleep quality increased among family caregivers exposed to SOI. An increase of one unit in anxiety level increases the odds of poor sleep quality among family caregivers by 14%. Sleep quality and anxiety can mutually influence each other, and there is a correlation between these two parameters. Anxiety can increase poor sleep quality, and poor sleep quality can increase the level of anxiety. As anxiety increases, sleep quality decreases.35 36
The frequency of anxiety and poor sleep
The frequency of poor sleep quality and anxiety observed in our study is consistent with other studies and the general population. In a study conducted in the general population, the prevalence of anxiety was reported to be 33.6%.37 In our study, 31.5% of the participants were found to have high levels of anxiety symptoms. The frequency of poor sleep quality in our study was found to be 52.3%. According to the literature review, the prevalence of poor sleep quality has been reported to range between 27.3% and 59.2% in studies.36 38–40 Although our study did not examine the severity of SOI, statements from family caregivers suggest that the exposure was generally at a level that did not endanger bodily integrity. This, combined with social and familial support, may have positively influenced anxiety and sleep quality.
Family caregivers’ sociodemographic characteristics
Our study found no statistically significant differences between sociodemographic characteristics such as age, sex, income, education level, occupational status and sleep quality among the family caregivers of psychiatric patients. There was a significant difference only between marital status and anxiety status. According to a study, marital status is a significant predictor of sleep disturbances.41
The literature presents varied results on this topic. For example, a study found that anxiety disorders and sleep characteristics were strongly correlated among males when analysed by gender.37 On the other hand, a study conducted in China found no significant correlation between sex and sleep quality.39 Additionally, age was found to be a predictor of anxiety.42 In another study, sleep quality was significantly worse in women than in men.38 The fact that our study was conducted among family caregivers of psychiatric patients may have influenced the observed differences in poor sleep and anxiety according to sociodemographic variables.
Due to the limited number of psychiatric patients served by the hospital in the province where the study was conducted, it was not possible to standardise the family caregivers. Additionally, the results of this study can be generalised to the individuals within the scope of the research. Future studies could plan comprehensive multicenter research to overcome this limitation and reach a larger sample of family caregivers of psychiatric patients. Furthermore, this study did not examine factors such as stress levels, depression, support systems or family dynamics that could influence the relationship between anxiety and sleep quality. These gaps may restrict the broader interpretation of the study’s findings.
Conclusion
This study shows that each point increase on the anxiety scale is associated with a 14% increase in the odds of poor sleep among family caregivers of psychiatric patients. The relationship between anxiety levels and poor sleep quality is stronger among family caregivers of psychiatric patients exposed to SOI. When controlling for the age of family caregivers, this relationship remains unchanged among those not exposed to SOI but reaches a higher level among those exposed to SOI.
Providing family caregivers of psychiatric patients, especially those exposed to SOI, with strategies to cope with violence and anxiety, as well as sleep hygiene training, may improve their anxiety and sleep quality. In addition, this approach may help them manage the care process. The same applies to family caregivers who are not exposed to SOI.
Data availability statement
Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Ethical approval. The study was obtained using the document with registration number E.1276 and number 21/11-10 of the Ethical Principles and Committee of Bitlis Eren University. Administrative approval was obtained from the Bitlis Provincial Health Directorate, Public Hospitals Department. In addition, the study was conducted in accordance with the principles of the Declaration of Helsinki. Participants gave informed consent to participate in the study before taking part.
References
Footnotes
Contributors All authors collaborated on the study design and reviewed its phases. CÖ wrote the introduction, literature review, materials and methods, statistical analysis, and discussion sections. AG contributed to the analysis, introduction, materials and methods, and discussion. ŞO contributed to the title, introduction, materials and methods, and discussion. CÖ, AG and ŞO have taken full responsibility for the completed work, had access to the data and controlled the decision to publish. CÖ is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.