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Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

Original Article 

Relation between quality and quantity of sleep and 

psychological distress among hospitalized patients 
 Aatir H. Rajput1, Nimra Aslam2, Farheen Yousaf 3 & Muhammad Muneeb4 

Liaquat University Hospital1 & 4 

LUMHS Research Forum 1, 2, 3 & 4 

Sir Cowasjee Jehangir Institute of Psychiatry, Hyderabad 1 & 4 

Liaquat University of Medical & Health Sciences, Jamshoro 1, 2, 3 & 4 

Corresponding email: aatirh.rajput@gmail.com 
  

Abstract 

Background Sleep is a fundamental component of good health, however its promotion in acute hospital settings 

does not appear to be a priority. Causes of sleep disruption are varied and include environmental and bio-cognitive 

factors, including pain, bright light, noise, anxiety and stress. The environmental and bio-cognitive consequences of 

sleep deprivation on the health and recovery of hospital inpatients are various. Inadequate sleep can lead to both 

psychological and physiological consequences. Objective This observational study was aimed at determining the 

pattern, quantity and quality of sleep and the prevalence, causes and effect of sleep deprivation / disturbance among 

patients hospitalized at the elective wards of a tertiary care hospital. Methods This observational study was 

conducted from August 2015 to January 2016, upon a sample of 50 patients admitted to Liaquat University Hospital 

(who had spent at least 4 weeks at the hospital). The sample of patients (chosen via simple random sampling), were 

interviewed consecutively every morning for 4 days and their mean response was evaluated to account for 

irregularities in experience. Data was collected using interview based structured questionnaire which included the 42 

point DAS scale approved by Australian Center for Posttraumatic Mental Health. The data was analyzed in SPSS v. 

17.0 and MS Excel 2013. Results During the stay at the hospital, DAS score of depression, anxiety and stress all 

rose. The most reported bothersome elements that disturbed sleep included, pain (30%), Noise (6%), and feeling of 

unease, irritation and panic (6%). Majority of the sample comprised of female (56%) respondents coming from rural 

areas (74%) with a low socioeconomic background (86%). The quantity of sleep dwindled between (but not more 

than) 5 to 6 hours. The quality too (self-rated by the respondents did not rise above a value of 6.5. Conclusion 

The conclusion is in line with our hypothesis. With the hustle and bustle happening at all hours in a hospital, patients 

have trouble getting adequate sleep, which has an evident the quality and quantity of sleep during their stay. Owing 

to the belief that sleep-deprived patients are less likely to be fully active participants in their care. It is recommended 

that steps should be taken to deal with this problem on a priority basis.  

 

Keywords 

Sleep, depression, anxiety, stress, psychological distress. 

 

Introduction 

Sleep is a fundamental component of good health, 

however its promotion in acute hospital settings does 

not appear to be a priority. Causes of sleep disruption 

are varied and include environmental and bio-

cognitive factors, including pain, bright light, noise, 

anxiety and stress. The environmental and bio-

cognitive consequences of sleep deprivation on the 

health and recovery of hospital inpatients are various. 

Inadequate sleep can lead to both psychological and 

physiological consequences. 

 

Hospitalized patients, particularly those who are 

critically ill, are known to have severe sleep 

fragmentation and disturbed sleep. The sleep typical 

of an ill patient is characterized by a predominance of 

wakefulness and light sleep (sleep stages I and II), 

and a relative lack of rapid eye movement (REM) and 

deep sleep (delta sleep, formerly referred to as non-

REM sleep stages III/IV) (Cooper AB. et al, 2000; 

Aurell J. et al, 1985; Freedman NS. et al, 2001; 

Gabor J. et al, 2003). Sleep deprivation is known to 

lead to several clinical, physiologic and 

psychological manifestations such as depression, 

anxiety and stress. Dement and Vaughan studied the 

effects of prolonged wakefulness, and observed that 

healthy volunteers who were sleep deprived would 

become confused, ill-tempered, and extremely 

sleepy; however, they never became either psychotic 

or hyperactively delirious (Dement WC. et al, 1999). 

The longest observed case of sleep deprivation 

involved an 18-year-old who stayed awake for 264 

hours. At times during his long-term sleep 

deprivation, he would become angry that he was not 

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Aatir H. Rajput 22 

  

Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

being allowed to fall asleep. He was not, however, 

reported to experience symptomatology consistent 

with hyperactive delirium or hallucinations (Gulevich 

G. et al, 1966). However, if ill patients are subjected 

to wakefulness of even disturbed sleep for a fraction 

of the above listed experience, they are more prone to 

develop psychological distress. This observational 

study was aimed at determining the pattern, quantity 

and quality of sleep and the prevalence, causes and 

effect of sleep deprivation / disturbance among 

patients hospitalized at the elective wards of a tertiary 

care hospital. 

 

Methodology 

This observational study was conducted from August 

2015 to January 2016, upon a sample of 50 patients 

admitted to Liaquat University Hospital (who had 

spent at least 4 weeks at the hospital). The sample of 

patients (chosen via simple random sampling), were 

interviewed consecutively every morning for 4 days 

and their mean response was evaluated to account for 

irregularities in experience. Data was collected using 

interview based structured questionnaire which 

included the 42 point DAS scale approved by 

Australian Center for Posttraumatic Mental Health. 

The data was analyzed in SPSS v. 17.0 and MS Excel 

2013. 

 

Results 

During the stay at the hospital, DAS score of 

depression, anxiety and stress all rose.

  

 
Figure 1: The mean stress levels rose continuously. Starting from 2.4 and reaching up to 7.74.  

(i.e. a 3-fold rise) 

The increase in levels of stress was less marked, however the fact that it started from a higher baseline projected it 

well above anxiety.  

 
Figure 2: The levels rose from a mean value of 5.9 to 8.83. 

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Aatir H. Rajput 23 

  

Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

Figure 3: Depression reached the highest levels reported by either of the three factors gauged by the DAS 

scale. It started from 6.1 and went up till 9.76. 
The most reported bothersome elements that disturbed sleep included, pain (30%), Noise (6%), and feeling of 

unease, irritation and panic (6%).  

Figure 4: Interestingly, majority of the patients either refrained from reporting any bothersome elements or 

were affected to such a less extent by the elements that they did not recognize them as bothersome. 

Majority of the sample comprised of female (56%) respondents coming from rural areas (74%) with a low 

socioeconomic background (86%). The quantity of sleep dwindled between (but not more than) 5 to 6 hours.  

 

 

 

 

 

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Aatir H. Rajput 24 

  

Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

 
Figure 5: The WHO recommended sleep mark of 8 hours per 24 hours was from what the patients expected 

to get. Even the best of the patients did not rise above 6 hours while the still less fortunate ones struggled to 

get 5 hours at best. 

The quality too (self-rated by the respondents did not rise above a value of 6.5. 

 

Figure 6: The quality standards too were below the recommended levels and poor even to below average standards. 

 

Discussion 

Although previous investigators evaluating sleep 

patterns in hospitalized patients have demonstrated 

altered sleep architecture and sleep deprivation 

(Richards K. et al, 1988; Broughton R. et al, 1978; 

Aurell J. et al, 1985; Hilton B. et al, 1996), little is 

actually known about the effects that this casts on the 

psychological wellbeing of the patients. Most of our 

current knowledge is based on studies evaluating 

only nocturnal sleep, rather than over 24-h periods 

(Richards K. et al, 1988; Broughton R. et al, 1978). 

Two studies have monitored polysomnography 

continuously for ⩾ 24 h, albeit in only a total of 19 

patients (Aurell J. et al, 1985; Hilton B. et al, 1996). 

Hilton B. et al, 1996, demonstrated a mean total sleep 

time per 24-h period of 5.5 ± 3.4 h (range 0.1–13.3) 

in 10 patients with respiratory insufficiency. Aurell 

and Elmquist (1985) found the mean total sleep time 

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Aatir H. Rajput 25 

  

Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

per 24-h, to be 4.6 ± 1.6 h (range 0–7) in 9 

postoperative patients. In addition to the reduction in 

total sleep time, these studies demonstrated altered 

sleep architecture with a predominance of stage 1 and 

2 sleep, decreased or absent stage 3, stage 4, and 

rapid eye movement (REM) sleep, shortened REM 

periods, and sleep fragmentation. Sleep distribution 

was also abnormal, as up to 50% of the total sleep 

time occurred during the day. 

 

The etiologies of these sleep disturbances in the 

hospital are presumed to be multifactorial, although 

little is actually known about the mechanisms 

responsible for sleep–wake cycle disturbances in the 

hospital. Environmental stimuli are proposed to be 

the most disruptive factors to achieving sleep in the 

hospital (Aaron J. et al, 1996; Bentley S. et al, 1977; 

Meyer T. et al, 1994; Topf M, 1992; Topf M. et al, 

1993; Cropp A. et al, 1994; Woods N. et al, 1974). 

The environmental stimulus most often cited in the 

literature to disturb sleep is noise (Bentley S. et al, 

1977; Meyer T. et al, 1994). Several studies have 

shown that noise levels in the hospital are 

substantially higher than the Environmental 

Protection Agency (EPA) recommendations for 

maximum hospital room noise levels, both at night 

and during the day (Bentley S. et al, 1977; Meyer T. 

et al, 1994; Woods N. et al, 1974, Gowan N, 1979; 

Falk S. et al, 1973) 

 

Polysomnographic studies evaluating the effect of 

nocturnal ICU noise on sleep in normal individuals in 

a sleep laboratory demonstrated decreased total sleep 

time, total REM time, and sleep efficiency, and 

increased REM latency and arousal index (number of 

arousals per hour of sleep). However, nocturnal 

polysomnographic studies of ICU patients have only 

indirectly linked noise to sleep disruption by 

attempting to correlate environmental noise levels 

with arousals from nocturnal sleep. These studies had 

small sample sizes and were not designed to 

determine the specific etiologies of the sleep 

disruption. 

 

Literature has demonstrated that although hospital 

patients subjectively experienced significantly poorer 

sleep quality in the hospital than at home, Hospital 

noise was not perceived as the most disruptive 

environmental stimulus (Freedman N. et al, 1973). 

Hospital patients perceived frequent interruptions 

from vital signs and diagnostic testing to be as 

disruptive to achieving quality sleep as noise, 

although statistically no single environmental factor 

was perceived as significantly more disruptive than 

any other (Freedman N. et al, 1973). Our data 

however, shows pain to be a factor too, despite its 

absence from existing literature. This may be due to 

poorer care placed at relieving pain of the patients by 

the hospital. 

 

Conclusion 

The conclusion is in line with our hypothesis. With 

the hustle and bustle happening at all hours in a 

hospital, patients have trouble getting adequate sleep, 

which has an evident the quality and quantity of sleep 

during their stay. Owing to the belief that sleep-

deprived patients are less likely to be fully active 

participants in their care. It is recommended that 

steps should be taken to deal with this problem on a 

priority basis. 

 

Conflict of interest 

All the authors disclosed that there is no conflict of 

interest associated in the preparation of this article. 

 

Acknowledgements 

We would like to acknowledge the intellectual 

assistance and technical support provided by 

LUMHS Research Forum 

 

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Aatir H. Rajput 26 

  

Annals of Psychophysiology                                                                                                        Volume 3, October 2016                  
©Advance Educational Institute & Research Centre                                                                    www.aeirc-edu.com 

ISSN 2412 - 3188 
 

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