Sleep problems during the COVID-19 pandemic by population: a systematic review and meta-analysis

Effects of Online Psychological Crisis Intervention for Frontline Nurses in COVID-19 Pandemic

OBJECTIVE

The psychological problems of frontline nurses in COVID-19 prevention and control are very prominent, and targeted intervention is needed to alleviate them. This study was to assess the impact of online intervention programs on psychological crisis of anxiety, depression levels and physical symptoms among frontline nurses fighting the COVID-19 pandemic.

METHODS

A three-stage online psychological crisis intervention program was established. The General Anxiety 7 (GAD-7) assessment, Patient Health Questionnaire-9 (PHQ-9), and the Self-rating Somatic Symptom Scale (SSS) were used to evaluate the effect of intervention on the day before entering isolation wards (Time 1), the first day after leaving the isolation ward (Time 2), and at the end of the intervention (Time 3).

RESULTS

Sixty-two nurses completed the study, including 59 female (95.2%) and three male nurses (4.8%) with an age range of 23-49 (mean 33.37 ± 6.01). A significant (P < 0.01) difference existed in the scores of GAD-7, PHQ-9, and SSS at different intervention periods. The GAD-7 score was significantly (P < 0.001) lower at the end of quarantine period (time 3) than that before entering the isolation wards (time 1) or after leaving the isolation wards (time 2), the PHQ-9 score was significantly (P = 0.016) lower at the end of quarantine period (time 3) than that after leaving the isolation wards (time 2), and the SSS score was significantly (P < 0.001) lower at the end of quarantine period (time 3) than that before entering the isolation wards (time 1) or after leaving the isolation wards (time 2).

CONCLUSION

The three-stage online intervention program based on the psychological crisis can be effective in reducing negative emotions and somatic symptoms and improving the mental health of frontline nurses in prevention and control of the COVID-19 epidemic. It may provide an empirical basis for psychological crisis intervention of frontline medical staff when facing public health emergencies.

Associations Between Childhood Stressors, COVID-19-Related Anxiety, and Sleep Quality of Adults During the Third Wave of the COVID-19 Pandemic in Israel

PURPOSE

Studies point to a persistent effect of the COVID-19 pandemic on sleep quality and mental health, including anxiety. Exposure to stressors during childhood increases the susceptibility to anxiety in later life. Given the negative effects of anxiety on sleep quality, the present study aimed to examine the associations between various childhood stressors and poor sleep quality of adults during the COVID-19 pandemic, and whether these associations are mediated by COVID-19-related anxiety.

PARTICIPANTS AND METHODS

A total of 586 participants aged 18-40 (mean age 27.53± 6.48 years, 301 females) were recruited to take part in an online survey conducted in Israel between February 7 and 15, 2021, during the third wave of the COVID-19 pandemic. Participants completed questionnaires assessing retrospectively adverse childhood experiences (ACEs), childhood harshness (indexed separately by exposure to morbidity and mortality and low socioeconomic status, SES), and childhood unpredictability. COVID-19-related anxiety was assessed using two items. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI), and insomnia symptoms with the Insomnia Severity Index (ISI). Participants were asked to complete the ISI concerning two time points: (a) retrospectively, before the COVID-19 outbreak, and (b) currently, during the pandemic.

RESULTS

Path analysis indicated that poor sleep quality (PSQI) was directly and indirectly (through COVID-19-related anxiety) predicted by the number of ACEs and childhood morbidity-mortality exposure, directly predicted by childhood low SES, and indirectly predicted by childhood unpredictability. Insomnia symptoms increase (ISI) was indirectly predicted by the number of ACEs, childhood morbidity-mortality exposure, and childhood unpredictability.

CONCLUSION

ACEs as well as harsh and unpredictable childhood environments are predictive of poorer sleep during the COVID-19 pandemic. COVID-19-related anxiety mediates the effects of childhood stressors (other than low SES) on sleep. These findings may have clinical implications relevant to stressful periods in general.

Sleep Quality Among Informal Caregivers During the COVID-19 Pandemic: A Cross-Sectional Study

Sleep is an integral component of health. The impact of the COVID-19 pandemic on sleep quality among informal caregivers, individuals who provide unpaid care or assistance to family members or friends, assisting older adults is not well understood. Therefore, informal caregivers in the United States providing care for individuals aged 50+ were recruited via Amazon's Mechanical Turk, an online platform for enrolling study participants into social and behavioral science research, to complete an online survey. The sample of informal caregivers (n = 835) was 69% male and 55% non-Hispanic. Multivariable linear regression models were constructed to assess the associations between sleep disturbance scores (SDS) and sleep-related impairment scores (SIS) and caregiving-related measures (hours caregiving/week, length of time spent caregiving, and caregiver burden), demographics, and region of the United States. The analysis determined that Black (β = 2.6, 95% CI [-4.3, -0.9]) and Asian informal caregivers (β = -1.8, 95% CI [-3.4, -0.3]) had lower mean SIS than White caregivers, the referent group. In addition, increasing caregiver burden was associated with increased SDS (β = 0.8, 95% CI [0.6, 1.0]) and SIS (β = 1.3, 95% CI [0.7, 1.6]). In conclusion, higher caregiver burden was associated with higher SIS and SDS, suggesting that informal caregivers' sleep should be assessed, and when needed interventions should be offered.

Insomnia and Related Factors During the Delta Wave of the COVID-19 Pandemic in the Kingdom of Bahrain: A Cross-Sectional Study

PURPOSE

This study aims to estimate the prevalence of insomnia and related risk factors during the Delta wave of the COVID-19 pandemic in the Kingdom of Bahrain.

METHODS

An analytical cross-sectional study included 646 individuals from the general population aged 18 years and over, living in the Kingdom of Bahrain during the Delta wave of the pandemic. Data were collected by an anonymous online questionnaire using the snowball-sampling technique between June and August 2021. We used the Insomnia Severity Index (ISI) and the generalized anxiety disorder scale (GAD-7) to measure the level of insomnia and anxiety, respectively.

RESULTS

A total of 646 individuals participated in the study. Most of the participants were females (86%). The mean age was 38.7 ± 12.7 years (age range 18-89) and around half of the participants were 35 years or older. Clinical insomnia was reported by 20% [95% CI, 16.9-20.0] of the participants, and 50.1% [95% CI, 46.2-50.1] had subclinical insomnia according to ISI. The proportion of insomnia was significantly higher among females, healthcare workers, participants with lower educational levels, a lower or decreased monthly income during the pandemic, or participants who reported anxiety symptoms (all P < 0.01). Scales of anxiety and insomnia revealed a high correlation (r² = 0.347, P< 0.01). The logistic regression model confirmed that factors independently associated with insomnia are female gender (OR=1.94, 95% CI, 1.00-3.76, P < 0.050) as well as presence of anxiety (GAD-7 score ≥ 5) [OR=12.98, 95% CI, 5.61-30.00, P < 0.001].

CONCLUSION

The burden of insomnia was significant among the general population in the Kingdom of Bahrain during the Delta wave of the COVID-19 pandemic despite the low severity of this variant. Mental health programs are a high priority during the pandemic and afterward. Detection of insomnia could be used to treat some mental health problems at an early stage.

Socio-Ecological Context of Sleep: Gender Differences and Couples' Relationships as Exemplars

PURPOSE OF REVIEW

We summarized recent findings on insufficient sleep and insomnia, two prominent sleep issues that impact public health. We demonstrate the socio-ecologial impact of sleep health with findings on gender and couples' relationships as exemplars.

RECENT FINDINGS

Robust gender differences in sleep duration and insomnia are due to biological and socio-ecological factors. Gender differences in insufficient sleep vary by country of origin and age whereas gender differences in insomnia reflect minoritized identities (e.g., sexual, gender). Co-sleeping with a partner is associated with longer sleep and more awakenings. Gender differences and couples' sleep were affected by intersecting social and societal influences, which supports a socio-ecological approach to sleep. Recent and seminal contributions to sleep health highlight the importance of observing individual sleep outcomes in a socio-ecological context. Novel methodology, such as global measures of sleep health, can inform efforts to improve sleep and, ultimately, public health.

Poor sleep quality and unhealthy lifestyle during the lockdown: an Italian study

Background

The lockdown measure implemented to face the 2019 Coronavirus Disease (COVID-19) first wave deeply modified the lifestyle of the Italian population. Despite its efficacy in limiting the number of infections, forced home confinement was paralleled by sleep/wake cycle disruptions, psychological distress and maladaptive coping strategies (i.e., unhealthy behaviours, such as tobacco and alcohol consumption). Under these unprecedented stress conditions, we explored a possible association between poor sleep quality and increased likelihood of engaging in an unhealthy lifestyle.

Methods

A cross-sectional study was conducted by disseminating an online survey via social networks and e-mail. We collected information on demographics, COVID-19-related data, sleep quality, chronotype, circadian misalignment, and lifestyle before and during the lockdown (i.e., consumption of cigarettes, alcoholic beverages, coffee, hypnotics, comfort food and fresh food; practice of physical activity). A global healthiness score was computed to assess participants’ modifications in lifestyle since the beginning of the lockdown.

Results

1297 respondents were included in the study: 414 (31.9%) from Northern Italy, 723 (55.8%) from Central Italy, 160 (12.3%) from Southern Italy. The following variables were found to be significant predictors of the adoption of an unhealthy lifestyle since the beginning of the lockdown: poor sleep quality, high BMI and considering the measures adopted by the government to fight the pandemic as excessive. Living in Northern Italy, instead, was associated with healthier habits compared to living in Central Italy.

Conclusions

Poor sleepers may represent the share of the general population who paid the highest price for social isolation. Further investigations are required to explore the role of sleep quality assessment in the identification of individuals vulnerable to unhealthy behaviours under stressful conditions.

Prevalence of Sleep Problems Among Chinese Medical Students: A Systematic Review and Meta-Analysis

BACKGROUND

Sleep is a necessary physiological process, which is closely related to cognitive function, emotion, memory, endocrine balance, and immunity. The prevalence of sleep problems continues to rise in Chinese medical students, which has a potential influence on living and work.

OBJECTIVE

This study aimed to observe the prevalence of sleep problems among medical students in China.

METHOD

The included cross-sectional studies on the prevalence of sleep problems of medical students in China were retrieved from PubMed, Embase, the Cochrane Database of Systematic Reviews, CNKI, and Wanfang database. An 11-item checklist recommended by the Agency for Healthcare Research and Quality was adopted to evaluate the methodological quality of the included studies. Software Stata 12.0, SPSS 26.0, and R were used to analyze the data. Registration: PROSPERO, CRD 42021237303.

RESULT

The prevalence of sleep problems among Chinese medical students was 27.38%. The subgroup analysis showed significant differences in the prevalence of sleep problems among different regions, educational backgrounds, grades, and University types. The region, latitude, and gross domestic product (GDP) were significant heterogeneous sources of sleep problems. The prevalence is positively correlated with latitude and negatively correlated with GDP per capita. Regular screening and appropriate intervention are recommended for these mental health problems.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021237303, identifier: CRD42021237303.

COVID-19 Vaccine Could Trigger the Relapse of Secondary Hypersomnia

The coronavirus disease (COVID-19) has brought significant social and economic disruptions and devastating impacts on public health, and vaccines are being developed to combat the disease. Timely vaccination may prevent complications and morbidity but may also potentially result in unforeseen outcomes in some special clinical populations. We report on a case of hypersomnia relapse after the COVID-19 vaccination, with the aim of informing the development of the guideline on vaccination in specific groups. A 19-year old female presented with persistent daytime sleepiness after receiving the COVID-19 vaccine. She had a known history of hypersomnia secondary to infectious mononucleosis but has fully recovered for 8 months. A series of examinations were performed on this patient. Neurologic and psychiatric examinations were unremarkable. Despite normal nocturnal subjective sleep quality (Pittsburgh Sleep Quality Index score = 5, Insomnia Severity Index score = 7), her Epworth sleepiness scale score (15) suggested an abnormal level of subjective sleepiness. Consistent with the subjective report, the objective assessment by Multiple Sleep Latency Test found mean sleep latency was 1.3 min with no sleep onset rapid-eye-movement (REM) period. We speculate that COVID-19 vaccine may potentially trigger the relapse of hypersomnia. The immune memory could be an explanation for the increased response to vaccine in patients with secondary hypersomnia. Caution should be warranted when administering COVID-19 vaccine in patients with hypersomnia secondary to infections.

Working Mode and Physical Activity as Factors Determining Stress and Sleep Quality during COVID-19 Pandemic Lockdown in Poland

The coronavirus pandemic and related government restrictions have a significant impact on peoples' everyday functioning and working, which influences their physical and mental health. The aim of the study was to examine the associations between stress and sleep quality of people of different working modes: working in the workplace (WP), working remotely (RW), and nonworking (NW) in relation to their physical activity (PA) during COVID-19 pandemic lockdown in Poland. It was an online survey performed during governmental lockdown in April 2020. The data were collected form 1959 adults using International Physical Activity Questionnaire-Short Form (IPAQ-SF), Pittsburgh Sleep Quality Index (PSQI), and Perceived Stress Scale (PSS). The conducted analysis included t-Student test, analysis of variance (ANOVA), and mediation analysis (MANOVA). A moderate level of stress was reported in 57% of participants, and 34% of them reported a high stress level. Poor sleep quality was reported in 64% of participants. Total PA performed daily was, on average, 184.8 ± 170.5 min/day for WP, 120.6 ± 124.4 min/day for RW, and 124.6 ± 114.7 min/day for NW (p < 0.001). There was a relationship observed between the stress and sleep quality vs. PA habit and working mode, with p < 0.05. Being physically active can be beneficial to perceive less stress and sleep disturbances influencing sleep quality, especially in remotely or nonworking people. Planning future pandemic restrictions, the policymakers should be aware of the appropriate guidelines of work planning and PA recommendations for people of different working modes.

Insomnia, Pre-Sleep Arousal, Psychosocial Factors and Changes in Sleep Pattern during the Second Wave Lockdown of the COVID-19 Pandemic in Georgia

Studies performed across the COVID-19 pandemic waves point to the persistent impact of the pandemic on sleep and mental health. We expand these data by examining insomnia, pre-sleep arousal, psychosocial factors, and retrospective changes in sleep pattern during the COVID-19 second wave lockdown period in Georgia. Data were collected through an online survey (n = 1117). The prevalence rate of probable insomnia disorder was 24.2%. Clinically relevant somatic and cognitive pre-sleep arousal was present in 49.8% and 58.0% of participants, and high levels of anxiety, depression and social isolation were found in 47.0%, 37.3%, 47.2% of respondents, respectively. We observed high prevalence rates of worse sleep quality, delayed bedtimes and risetimes, longer sleep latencies, higher awakenings and shorter sleep durations, relative to the pre-pandemic period. COVID-19-infected participants showed more severe sleep and mental problems. Specific predictors differentially affected insomnia, somatic and cognitive pre-sleep arousal. Depression and COVID-19 infection emerged as vulnerability factors for pre-sleep arousal, which, in turn, was associated with a higher predisposition to insomnia disorder. We confirm the strong deteriorating impact of the COVID-19 pandemic on sleep and psychosocial well-being during the second wave lockdown period. The specific association between pre-sleep arousal, insomnia, and psychosocial factors is of clinical relevance for the prevention of severity and persistence of sleep and mental problems across the repeated lockdown/reopening waves. Modulation of pre-sleep arousal may prove beneficial to implement targeted interventions.

Working Mode and Physical Activity as Factors Determining Stress and Sleep Quality during COVID-19 Pandemic Lockdown in Poland

The coronavirus pandemic and related government restrictions have a significant impact on peoples’ everyday functioning and working, which influences their physical and mental health. The aim of the study was to examine the associations between stress and sleep quality of people of different working modes: working in the workplace (WP), working remotely (RW), and nonworking (NW) in relation to their physical activity (PA) during COVID-19 pandemic lockdown in Poland. It was an online survey performed during governmental lockdown in April 2020. The data were collected form 1959 adults using International Physical Activity Questionnaire—Short Form (IPAQ-SF), Pittsburgh Sleep Quality Index (PSQI), and Perceived Stress Scale (PSS). The conducted analysis included t-Student test, analysis of variance (ANOVA), and mediation analysis (MANOVA). A moderate level of stress was reported in 57% of participants, and 34% of them reported a high stress level. Poor sleep quality was reported in 64% of participants. Total PA performed daily was, on average, 184.8 ± 170.5 min/day for WP, 120.6 ± 124.4 min/day for RW, and 124.6 ± 114.7 min/day for NW (p < 0.001). There was a relationship observed between the stress and sleep quality vs. PA habit and working mode, with p < 0.05. Being physically active can be beneficial to perceive less stress and sleep disturbances influencing sleep quality, especially in remotely or nonworking people. Planning future pandemic restrictions, the policymakers should be aware of the appropriate guidelines of work planning and PA recommendations for people of different working modes.

Psychological Wellbeing, Worry, and Resilience-Based Coping during COVID-19 in Relation to Sleep Quality

The current study evaluated the impact of psychological wellbeing on sleep quality during the onset of the COVID-19 pandemic. A novel empirical model tested variables that mediate and moderate this impact. First, a relationship was established between psychological wellbeing during the COVID-19 pandemic and sleep quality. Second, resilience-based coping associated with the COVID-19 pandemic was tested as a mediator of the impact of psychological wellbeing on sleep quality. Third, dispositional rumination, mindfulness, and worry were compared as moderators of the impact of psychological wellbeing on sleep quality. Fourth, a moderated mediated model was tested for each moderator. Online survey data was collected from 153 adults in the United States. Results demonstrated that coping with the COVID-19 pandemic partially mediated the impact of psychological wellbeing on sleep quality. Worry, but not rumination or mindfulness, moderated the impact. A moderated mediation model failed to demonstrate significance, indicating that the data are best represented by distinct mediation and moderation models. Thus, interventions aimed at improving sleep quality should prioritize concurrent reduction in worry and increase in resilience-based coping strategies. This study provides practical and theoretical contribution to the literature by demonstrating relationships between key variables and contextualizing how the model can be used for assessments and interventions during widespread crises.

Experiencing the Unprecedented COVID-19 Lockdown: Abu Dhabi Older Adults' Challenges and Concerns

This study focused on older adults (60+ years old) of both genders in Abu Dhabi during the COVID-19 pandemic before vaccines were made available (age ranged from 60 years to 75 years). They faced more strict rules of movement restriction and isolation that might have resulted in certain psychological feelings and social reactions. The main objective was to understand Abu Dhabi older adults’ psychological feelings during the pandemic and to identify their main concerns and challenges considering the various COVID-19-related policies and restrictions. The psychological feelings focused on fear, loneliness, sadness, irritability, emotional exhaustion, depressive symptoms, sleeping disorders, overeating, and excessive screen use. The objectives also included the changes in the psychological feelings concerning time. Other objectives covered better understanding the differences in (some activities) compared to the other age categories. Data were gathered through an online survey of community members from February to July 2020 as part of government initiatives (Department of Community Development). Responses were collected from 574 older adults in Abu Dhabi (60.1% male and 39.9% female). The analysis mainly used descriptive analysis, t-tests, analysis of variance (ANOVA), and simple trend analysis. For all tests, a p-value less than 0.05 was used for significance. The results pointed to the significant rise in feelings related to excessive screen use, fear, loneliness, and stress. The most significant concerns were related to more restrictions being imposed and not being able to see the grandchildren.The impact of new technologies on their quality of life was significantly reflected by respondents. The influence of the pandemic on older adults’ health and weight was also investigated. Analysis of variance, t-tests, and regression analysis with relevant tests were employed. The relevant results showed that some negative psychological feelings were common among older adults during the pandemic. However, the psychological feelings did not portray significant changes with time, except for sleeping disorders and overeating. Overall, older adults scored significantly different from other age groups on many challenges, concerns, and views regarding new technologies during the pandemic. No significant differences were observed regarding gender and marital status for the challenges and concerns. The research summarizes some policy guidance while noting some limitations of this study and future research directions.

Sleep Quality, Insomnia Symptoms, and Depressive Symptomatology among Italian University Students before and during the Covid-19 Lockdown

The COVID-19 pandemic led world authorities to adopt extraordinary measures to counteract the spread of the virus. The Italian government established a national lockdown from 9 March to 3 May 2020, forcing people in their homes and imposing social distancing. During the pandemic emergency, university students emerged as a vulnerable category. Indeed, higher rates of sleep problems and mental disorders were reported in this population. However, these outcomes were derived from cross-sectional investigations adopting retrospective assessments. Retrospective evaluations suffer from different biases, putatively leading to erroneous outcomes. To overcome this limitation, we adopted a between-subject approach comparing a sample of 240 Italian undergraduate university students assessed in 2016 (mean age ± standard deviation, 20.39 ± 1.42, range 18–25; 80.42% females), with an age/gender-matched sample of university students assessed during the third week of lockdown in Spring 2020. We evaluated sleep quality, insomnia symptoms, and depressive symptomatology using validated questionnaires. We found worse sleep quality, a delayed bedtime, and more severe insomnia and depression symptoms in the students sampled under COVID-19 restrictive measures. We suggest paying special attention to this at-risk population during the current pandemic emergency and applying preventive and supportive interventions to limit the exacerbation of sleep and psychological problems.

The Association Between Sleep Disturbances and Erectile Dysfunction During the COVID-19 Pandemic

INTRODUCTION

There is increasing concern about the impact of the SARS-CoV-2 pandemic on mental and physical health. Among the many possible outcomes of COVID-19, reports of sleep disturbances, and erectile dysfunction are becoming prevalent worldwide.

OBJECTIVES

We sought to evaluate the recent literature on this subject to produce a narrative review of the topic.

METHODS

We performed an extensive literature search to identify recent scientific findings on this subject.

RESULTS

To date, the precise mechanisms that trigger pandemic related sexual dysfunction are not completely understood, although it has been suggested that psychogenic effects play an important role, in addition to the direct effects of the disease itself on those infected. There is evidence that the stress induced by the pandemic has had a significant impact on sleep, and sleep disturbances are known to induce erectile dysfunction. Other mechanisms which trigger this phenomenon, such as hormonal changes and previous health conditions, have been suggested to be associated with SARS-CoV-2 infection, and these factors may have a potential link to sleep disturbance.

CONCLUSION

The combined effect of COVID-19 and the psychogenic disorders triggered by isolation, grief, and anxiety might be associated with the increased prevalence of erectile dysfunction. This feature might be worsened by the onset of pre-existing or pandemic-induced sleep disorders. However, few studies explored this subject. Understanding this phenomenon is important for the strategic planning of treatments that could improve the quality of life of the population. Andersen ML, Tufik S. The Association Between Sleep Disturbances and Erectile Dysfunction During the COVID-19 Pandemic. Sex Med Rev 2021;XX:XXX-XXX.

Accept Anxiety to Improve Sleep: The Impact of the COVID-19 Lockdown on the Relationships between Mindfulness, Distress, and Sleep Quality

It has been recently proposed that mindfulness can improve sleep quality through the mediating role on psychological distress and that acceptance may play a pivotal role in mindfulness beneficial effects. The aim of the present work was to understand the effects of the COVID-19 lockdown on dispositional mindfulness, sleep, and distress, and on their relationships. In particular, we wanted to test the hypothesis that the detrimental effects of lockdown on sleep depended on mindfulness and distress (including anxiety and depression) and that the acceptance facet of mindfulness played the leading role. A longitudinal study based on self-report questionnaires was conducted on 39 Italian adults (M age = 35.03, SD = 14.02; 21 men) assessing mindfulness, distress, and sleep quality before (23 December 2019–8 March 2020) and during (27 April 2020–10 May 2020) the first Italian COVID-19 lockdown. Lockdown decreased mindfulness while increasing distress and sleep problems. Path analysis showed that the effects of lockdown on sleep were fully mediated by mindfulness and distress. Furthermore, a more detailed analysis showed that these effects were mainly dependent on the acceptance component of mindfulness working through anxiety. The present study confirms, in the context of the COVID-19 lockdown, a model according to which mindfulness, and specifically acceptance, influences sleep through the mediating role of distress.

Testing an early online intervention for the treatment of disturbed sleep during the COVID-19 pandemic in self-reported good and poor sleepers (Sleep COVID-19): study protocol for a randomised controlled trial

Background

Theoretical models of insomnia suggest that stressful life events, such as the COVID-19 pandemic, can cause acute insomnia (short-term disruptions to sleep). Early interventions may prevent short-term sleep problems from progressing to insomnia disorder. Although cognitive behavioural therapy for insomnia (CBT-I) is effective in treating insomnia disorder, this can be time and resource-intensive. Further, online interventions can be used to deliver treatment to a large number of individuals. The objective of this study is to investigate if an online behavioural intervention, in the form of a leaflet, which has been successfully used alongside CBT-I for acute insomnia, can reduce symptoms of acute insomnia in poor sleepers.

Methods

A total of 124 self-reported good and poor sleepers will be enrolled in an online stratified randomised controlled trial. After baseline assessments (T1), participants will complete a 1-week pre-intervention sleep monitoring period (T2) where they will complete daily sleep-diaries. Poor sleepers (n = 62) will be randomly allocated to an invention or wait-list group, where they will receive the intervention (T3), or will do so after a 28-day delay. Good sleepers (n = 62) will be randomly assigned to an intervention or no intervention group. All participants will complete a 1-week post intervention sleep monitoring period using daily sleep diaries (T4). Participants will be followed up at 1 week (T5), 1 month (T6) and 3 months (T7) post intervention. The primary outcome measure will be insomnia severity, measured using the Insomnia Severity Index. Secondary outcome measures will include subjective mood and subjective sleep continuity, measured using sleep diaries. Data will be analysed using an intention-to-treat approach.

Discussion

It is expected that this online intervention will reduce symptoms of acute insomnia in self-reported short-term poor sleepers, and will also prevent the transition to poor sleep in good sleepers. We expect that this will demonstrate the feasibility of online interventions for the treatment and prevention of acute insomnia. Specific advantages of online approaches include the low cost, ease of administration and increased availability of treatment, relative to face-to-face therapy.

Trial registration

ISRCTN43900695 (Prospectively registered 8th of April 2020).

COVID-19, circadian rhythms and sleep: from virology to chronobiology

Various aspects of our physiology and immune response to pathogens are under 24 h circadian control and its role in clinical and research practice is becoming increasingly recognized. Severe acute respiratory syndrome coronavirus-2, the causative agent of Coronavirus disease 2019 (COVID-19) has affected millions of people to date. Cross-disciplinary approaches and collaborative efforts have led to an unprecedented speed in developing novel therapies and vaccines to tackle the COVID-19 pandemic. Circadian misalignment and sleep disruption have a profound impact on immune function and subsequently on the ability of individuals to combat infections. This review summarizes the evidence on the interplay between circadian biology, sleep and COVID-19 with the aim to identify areas of translational potentials that may inform diagnostic and therapeutic strategies in this pandemic.

College students' sleep difficulty during COVID-19 and correlated stressors: A large-scale cross-sessional survey study

Objective

Sleep difficulty is one of the main concerns during the COVID-19 pandemic. This study examined factors related to vaccination and physical and psychological health conditions, and sleep difficulty in college students in China.

Methods

An online, cross-sectional, anonymous survey was used to investigate college students' perceived sleep difficulty and relevant components (i.e., physical health condition, psychological distress, knowledge of vaccine, and autonomy of vaccine uptake). Hierarchical ordinal logistic regression was conducted to examine the proposed model with the control of participants' demographics (i.e., gender and age).

Results

Valid data of 3,145 students from 43 universities in mainland China was collected in January 2021. The average age of participants was 20.8 years old (S. D. = 2.09). The majority were single (97.4%), and about half were male (49.8%). Results showed that participants had less psychological distress when they had more knowledge about the COVID-19 vaccine and more autonomy to decide whether to receive it. In addition, participants with better physical health experienced less sleep difficulty. In contrast, those with more psychological distress experienced more sleep difficulty.

Conclusions

These findings can inform healthcare providers about the relationship between different factors and difficulty sleeping and aid them in developing interventions addressing sleep difficulties associated with the global pandemic. Health authorities also can improve vaccine uptake and reduce hesitancies in future vaccination campaigns based on the study results showing that greater vaccine knowledge and autonomy reduced psychological distress.

The Effects of a Brief Lifestyle Intervention on the Health of Overweight Airline Pilots during COVID-19: A 12-Month Follow-Up Study

The aim of this study was to perform a 12-month follow-up of health parameters after a 17-week lifestyle intervention in overweight airline pilots. A parallel-group (intervention and control) study was conducted amongst 72 overweight airline pilots (body mass index > 25) over a 12-month period following the emergence of COVID-19. The intervention group (n = 35) received a personalized dietary, sleep, and physical activity program over a 17-week period. The control group (n = 37) received no intervention. Measurements for subjective health (physical activity, sleep quality and quantity, fruit and vegetable intake, and self-rated health) via an electronic survey, and objective measures of body mass and blood pressure were taken at baseline and at 12 months. Significant interactions for group × time from baseline to 12-months were found for all outcome measures (p < 0.001). Body mass and mean arterial pressure significantly decreased in the intervention group when compared to the control group (p < 0.001). Outcome measures for subjective health (physical activity, sleep quality and quantity, fruit and vegetable intake, and self-rated health) significantly increased in the intervention group when compared to the control group (p < 0.001). Results provide preliminary evidence that a brief three-component healthy sleep, diet and physical activity intervention can elicit and sustain long-term improvements in body mass and blood pressure management, health behaviors, and perceived subjective health in pilots and may support quality of life during an unprecedented global pandemic.

Mental Health Interest and Its Prediction during the COVID-19 Pandemic Using Google Trends

This study aimed to analyze and predict interest in mental health-related queries created in Google Trends (GT) during the COVID-19 pandemic. The Google Trends tool collected data on the Google search engine interest and provided real-time surveillance. Five key phrases: “depression”, “insomnia”, ”loneliness”, “psychologist”, and “psychiatrist”, were studied for the period from 25 September 2016 to 19 September 2021. The predictions for the upcoming trend were carried out for the period from September 2021 to September 2023 and were estimated by a hybrid five-component model. The results show a decrease of interest in the search queries “depression” and “loneliness” by 15.3% and 7.2%, respectively. Compared to the period under review, an increase of 5.2% in “insomnia” expression and 8.4% in the “psychiatrist” phrase were predicted. The expression “psychologist” is expected to show an almost unchanged interest. The upcoming changes in the expressions connected with mental health might be explained by vaccination and the gradual removal of social distancing rules. Finally, the analysis of GT can provide a timely insight into the mental health interest of a population and give a forecast for a short period trend.

Investigating Poor Sleep Quality and Associated Factors During the COVID-19 Pandemic: A Population-Based Survey in Bangladesh

Background: The coronavirus disease 2019 (COVID-19) pandemic has adversely affected the sleep quality of individuals, and is a poorly investigated area. This study aimed to investigate the prevalence estimate of poor sleep quality and its associated factors among Bangladeshi residents during the COVID-19 pandemic. Methods: An online cross-sectional survey was carried out from July 20 to August 5, 2020, involving 975 Bangladeshi residents (male: 54.2%; mean age: 26.7 ± 9.4 years; age range: 18-75 years). A self-reported questionnaire was answered by the respondents, covering information on demographic characteristics, perceived physical health status, COVID-19-related factors, COVID-19-induced anxiety assessment, and sleep quality. To assess sleep quality, the Bangla version of the Pittsburgh Sleep Quality Index was used. Logistic regression models were performed to analyze the factors associated with sleep quality. Results: The prevalence estimate of poor sleep quality was 55.1% among the Bangladeshi people during the COVID-19 pandemic. As per the multiple regression analysis, poor sleep quality was significantly higher among respondents who reported female gender, moderate/poor health status, indirect contact with COVID-19 infected patients, decreased household income due to the COVID-19 pandemic, fear of infection, and COVID-19-induced anxiety. Conclusion: Poor sleep quality was slightly prevalent among general people in Bangladesh during the COVID-19 pandemic. The findings indicate an immediate response for this vulnerable group to improve the sleep quality during the public health emergency of COVID-19.

Persistence of the Effects of the COVID-19 Lockdown on Sleep: A Longitudinal Study

The effects of the COVID-19 pandemic on sleep have been widely documented, but longitudinal evaluations during different phases of the “COVID-19 era” are needed to disentangle the specific consequences of the r145estrictive measures on sleep variables. The aim of this study was to assess the immediate effect of the lockdown’s end on sleep and sleep-related dimensions in an Italian sample, also considering the stress and depressive symptoms. We used an online survey to longitudinally collect data on sociodemographic, environmental, clinical, sleep, and sleep-related variables in two time points: during and immediately after the lockdown. The final sample included 102 participants. The large prevalence of poor sleep quality, clinically relevant pre-sleep arousal, and depressive symptoms, as well as poor sleep quality and pre-sleep arousal score observed during the lockdown, remained stable after its end. On the other hand, the prevalence of moderate-to-severe event-related stress and intrusive symptom scores exhibited a drastic reduction after the end of home confinement. Both bedtime and rise time were anticipated after the lockdown, while sleep quality exhibited only a trend of post-lockdown sleep disturbance reduction. Our findings point to a reduced stress level (specific for the intrusive symptomatology) after the end of the lockdown and persistence of sleep problems, suggesting two non-mutually exclusive hypotheses: (a) the strict restrictive measures are not the main cause of sleep problems during the pandemic and (b) home confinement induces long-lasting effects on sleep observable after its end, and a longer period of time might be needed to observe an improvement.

Distinct Circadian Assessments From Wearable Data Reveal Social Distancing Promoted Internal Desynchrony Between Circadian Markers

Mobile measures of human circadian rhythms (CR) are needed in the age of chronotherapy. Two wearable measures of CR have recently been validated: one that uses heart rate to extract circadian rhythms that originate in the sinoatrial node of the heart, and another that uses activity to predict the laboratory gold standard and central circadian pacemaker marker, dim light melatonin onset (DLMO). We first find that the heart rate markers of normal real-world individuals align with laboratory DLMO measurements when we account for heart rate phase error. Next, we expand upon previous work that has examined sleep patterns or chronotypes during the COVID-19 lockdown by studying the effects of social distancing on circadian rhythms. In particular, using data collected from the Social Rhythms app, a mobile application where individuals upload their wearable data and receive reports on their circadian rhythms, we compared the two circadian phase estimates before and after social distancing. Interestingly, we found that the lockdown had different effects on the two ambulatory measurements. Before the lockdown, the two measures aligned, as predicted by laboratory data. After the lockdown, when circadian timekeeping signals were blunted, these measures diverged in 70% of subjects (with circadian rhythms in heart rate, or CRHR, becoming delayed). Thus, while either approach can measure circadian rhythms, both are needed to understand internal desynchrony. We also argue that interventions may be needed in future lockdowns to better align separate circadian rhythms in the body.

Sleep Dysfunction in COVID-19 Patients: Prevalence, Risk Factors, Mechanisms, and Management

During the COVID-19 pandemic, the need to establish the prevalence of sleep dysfunction and psychological distress, identify predisposing and protective factors, and explore effective management strategies remains an important priority. Evidence to date suggests that a considerable proportion of COVID-19 patients experience significant sleep disturbances (estimated to afflict up to 50-75%) as well as psychological distress such as depression, anxiety, and traumatic stress. Duration of hospitalization, pre-existing mental health concerns, lower absolute lymphocyte count, and increased neutrophil-to-lymphocyte ratio have been all associated with a greater risk of sleep dysfunction in infected and hospitalized patients. Furthermore, in this review, we discuss the link between sleep deprivation, susceptibility to viral infections, and psychosocial wellbeing in relevance to COVID-19 and summarize the existing evidence regarding the presence and role of sleep apnea in infected individuals. Finally, we highlight the importance of suitable interventions in order to prevent and manage sleep dysfunction and avoid long-term physical and psychological implications. Future research should aim to provide high-quality information including in high risk, underserved, or difficult to reach populations and on the long-term consequences and effectiveness of applied interventions.

Pre-sleep arousal and sleep quality during the COVID-19 lockdown in Italy

Objective

The COVID-19 pandemic has strongly affected daily habits and psychological wellbeing, and many studies point to large modifications in several sleep and sleep-related domains. Nevertheless, pre-sleep arousal during the pandemic has been substantially overlooked. Since hyperarousal represents one of the main factors for the development and the perpetuation of chronic insomnia disorder, the assessment of variables associated with high levels of pre-sleep arousal during the pandemic is clinically relevant. The study aimed to assess the prevalence and predictors of perceived sleep quality and pre-sleep arousal in an Italian sample during the COVID-19 lockdown.

Methods

We used an online survey to collect self-reported sociodemographic, environmental, clinical, sleep, and sleep-related data. Our final sample included 761 participants.

Results

Beyond a high frequency of poor sleep quality, depressive and stress symptoms, our results show that almost half of the sample suffered from clinically relevant levels of at least one component (ie, cognitive, somatic) of pre-sleep arousal. Subjects with greater pre-sleep arousal exhibited poorer sleep quality. Also, sleep quality was strongly associated with somatic and cognitive pre-sleep arousal. Regarding the predictors of sleep and sleep-related measures, depressive and event-related stress symptoms were the main factors associated with both poor sleep quality and pre-sleep arousal components. Moreover, specific sociodemographic and environmental variables were uniquely related to sleep quality, cognitive or somatic pre-sleep arousal.

Conclusions

These findings suggest that the assessment of specific sleep-related factors (ie, pre-sleep arousal), together with more global measures of sleep quality, may be crucial to depict the complex impact of the pandemic on sleep, and to help prevent and counteract the spread of insomnia symptoms.

Risk Perception, Perception of Collective Efficacy and Sleep Quality in Chinese Adults during COVID-19 Pandemic in Hong Kong: A Cross-Sectional Study

Background: Only a few studies have studied the link between risk perception and sleep in the context of the COVID-19 pandemic. The purpose of our study is to propose and test a theoretical model to understand the relationships between COVID-19 risk appraisals—risk perception and perception of collective coordinated defense (PCCD) in particular—and subjective sleep quality in Chinese adults in Hong Kong during the COVID-19 pandemic. COVID-19-related fear and rumination were examined as potential mediators of the relationships. Methods: Data were collected using a self-report online questionnaire from a convenience sample of 224 Chinese adults during the fourth wave of the COVID-19 pandemic in Hong Kong. Results: Risk perception and PCCD were found to predict poor sleep quality. Mediation analysis showed that both fear and rumination mediated the relationship between risk perception and sleep quality, whereas only fear mediated the relationship between PCCD and sleep quality. The model was an excellent fit to the data and accounted for 44% of the variance in sleep quality in Chinese adults. This study indicated that both perception of high risks of contracting COVID-19 and anticipations of collective disease preventive efforts had adverse effects on subjective sleep quality via increasing COVID-19-related fear. Conclusions: These findings underscore the need for addressing sleep problems induced by psychological consequences of the pandemic. While policy makers often deliver public messaging campaigns that frame disease prevention as a collective goal, developing evidence-based coping strategies to combat COVID-19 adverse impacts on psychological health is equally important.

Impact of COVID-19 Infection on Quality of Sleep

Introduction: Some studies have highlighted the effect of COVID-19 infection on the quality of sleep; however, the data is limited. In this study, we investigated the prevalence of insomnia in patients who recently recovered from the COVID-19 infection to evaluate the prevalence and extent of its impact.

Methods: This longitudinal study was conducted from January 2021 to March 2021. A total of 500 patients admitted to the intensive care unit or isolation unit of COVID-19 were included in the study at the time of their discharge. The pre-COVID-19 sleep quality of the participants was inquired using the Pittsburgh Sleep Quality Index (PSQI). Post-COVID sleep quality was assessed at a 30-day follow-up. Sleep quality was considered poor if the global score was ≥5. Participants that failed to follow up were not included in the study.

Results: The mean PSQI score was significantly higher in the post-COVID-19 group compared to the pre-COVID-19 group (6.28 ± 2.11 vs. 3.22 ± 0.80; p-value <0.0001). The percentage of participants with a PSQI score of ≥5 was significantly higher in the post-COVID-19 group compared to the pre-COVID-19 group (45.1% vs. 12.1%; p-value <0.0001).

Conclusion: Insomnia has a significant prevalence in recovered COVID-19 patients after 30 days of follow-up. Hence, patients need to be counseled to follow up in case they experience poor sleep. To avoid the long-term negative impact on patients experiencing insomnia, timely identification and treatment are important.

A systematic review and meta-analysis of poor sleep, insomnia symptoms and stress in undergraduate students

University students experience high prevalence of mental health problems and exacerbation of mental health difficulties, including sleep disturbances and stress during their studies. Stress and poor sleep quality and/or insomnia are interlinked outcomes for this population. The aim was to conduct a systematic review, and meta-analyses, of the relationships between sleep quality and/or insomnia with stress in students. Full-text articles of studies exploring the associations of stress with poor sleep quality and/or insomnia in undergraduate students using validated tools and published in peer-reviewed journals were eligible for inclusion. Thirty-four studies, resulting in 37 effect sizes, included and all were suitable for meta-analysis. The weighted pooled effect size between sleep quality and stress was for 0.39 (25 studies, n = 10,065), whereas a slightly higher pooled association of 0.41 was demonstrated for insomnia and stress (12 studies, n = 5564.5). Pooled associations show moderate effects for associations between sleep quality, insomnia and stress in undergraduate students. High heterogeneity in meta-analyses was found, suggesting the findings should be considered cautiously. Future research should focus on longitudinal studies exploring sleep difficulties across the academic year, whilst university services should consider psychoeducation for stress and sleep in university students, especially during transition to university.

Sleep, Dreams, and Nightmares During the COVID-19 Pandemic

The COVID-19 pandemic has affected the sleep and dreams of many individuals. Some have experienced improvements, while others have had more complaints. The changes to daily life such as working from home and spending more time indoors in confinement may have disturbed the circadian rhythms of some individuals. There were many reports of a shift towards a later bedtime during the pandemic, with several studies showing that in general, females experienced worse sleep than males, including more nighttime awakenings and nightmares. Increased dream and nightmare frequency during the pandemic has been shown in multiple studies. It has been postulated that because dreams are often guided by the dominant emotional state, that dreams and nightmares related to pandemic themes are a result of specific stressors related to COVID-19. Those experiencing unwanted sleep disturbances and nightmares could stand to benefit from mindfulness and relaxation practices that can ease stress and anxiety before bedtime. Striving to maintain a regular sleep schedule and enhance exposure to daylight-particularly during the first half of the day-may also be helpful.

Chronic circadian phase advance in male mice induces depressive-like responses and suppresses neuroimmune activation

Altered working and sleeping schedules during the COVID-19 pandemic likely impact our circadian systems. At the molecular level, clock genes form feedback inhibition loops that control 24-hr oscillations throughout the body. Importantly, core clock genes also regulate microglia, the brain resident immune cell, suggesting circadian regulation of neuroimmune function. To assess whether circadian disruption induces neuroimmune and associated behavioral changes, we mimicked chronic jetlag with a chronic phase advance (CPA) model. 32 adult male C57BL/6J mice underwent 6-hr light phase advance shifts every 3 light/dark cycles (CPA) 14 times or were maintained in standard light/dark cycles (control). CPA mice showed higher behavioral despair but not anhedonia in forced swim and sucrose preferences tests, respectively. Changes in behavior were accompanied by altered hippocampal circadian genes in CPA mice. Further, CPA suppressed expression of brain-derived neurotrophic factor (BDNF) and pro-inflammatory cytokine interleukin-1 beta in the hippocampus. Plasma corticosterone concentrations were elevated by CPA, suggesting that CPA may suppress neuroimmune pathways via glucocorticoids. These results demonstrate that chronic circadian disruption alters mood and neuroimmune function, which may have implications for shift working populations such as frontline health workers.

Day-to-day associations between nightly sleep and next-day well-being amid the COVID-19 pandemic in North America

OBJECTIVE

Sleep may be especially important for maintaining health and well-being in daily life amid the stress of the coronavirus disease 2019 (COVID-19) pandemic. This preregistered study examined the associations of sleep quality, duration, and efficiency with next-day physical symptoms, affect, and stressors during the COVID-19 pandemic in North America, in addition to evaluating individual differences in COVID-19 threat as a moderator.

METHOD

From mid-March to early August 2020, 1025 adults from Canada and the United States aged 18-91 reported COVID-19 threat at baseline and subsequently completed twice-daily diaries for one week about their sleep, negative affect, stressors, and physical symptoms.

RESULTS

Within-persons, nights with better-than-usual sleep quality predicted lower next-day negative affect, physical symptoms, and stressor occurrence. Better-than-usual sleep efficiency and longer-than-usual sleep duration also predicted lower next-day physical symptoms. COVID-19 threat ratings moderated several of these associations, such that individuals with higher COVID-19 threat showed weaker within-person associations of sleep duration and efficiency with next-day well-being, compared to individuals with lower-to-moderate levels of COVID-19 threat. For the reversed direction of association, stressor occurrence predicted shorter-than-usual sleep that night, but no other links between daily well-being and subsequent sleep were observed.

DISCUSSION

Sleep quality, efficiency, and duration were important predictors of daily health and well-being during the COVID-19 pandemic, but the protective associations between sleep and next-day well-being were attenuated among people with higher COVID-19 threat. These findings highlight the role of heightened stress contexts when considering the benefits of sleep on daily health and well-being.

Health, Lifestyle, and Psycho-Social Determinants of Poor Sleep Quality During the Early Phase of the COVID-19 Pandemic: A Focus on UK Older Adults Deemed Clinically Extremely Vulnerable

Background: Several studies have assessed the impact of COVID-19-related lockdowns on sleep quality across global populations. However, no study to date has specifically assessed at-risk populations, particularly those at highest risk of complications from coronavirus infection deemed "clinically-extremely-vulnerable-(COVID-19CEV)" (as defined by Public Health England). Methods: In this cross-sectional study, we surveyed 5,558 adults aged ≥50 years (of whom 523 met criteria for COVID-19CEV) during the first pandemic wave that resulted in a nationwide-lockdown (April-June 2020) with assessments of sleep quality (an adapted sleep scale that captured multiple sleep indices before and during the lockdown), health/medical, lifestyle, psychosocial and socio-demographic factors. We examined associations between these variables and sleep quality; and explored interactions of COVID-19CEV status with significant predictors of poor sleep, to identify potential moderating factors. Results: Thirty-seven percent of participants reported poor sleep quality which was associated with younger age, female sex and multimorbidity. Significant associations with poor sleep included health/medical factors: COVID-19CEV status, higher BMI, arthritis, pulmonary disease, and mental health disorders; and the following lifestyle and psychosocial factors: living alone, higher alcohol consumption, an unhealthy diet and higher depressive and anxiety symptoms. Moderators of the negative relationship between COVID-19CEV status and good sleep quality were marital status, loneliness, anxiety and diet. Within this subgroup, less anxious and less lonely males, as well as females with healthier diets, reported better sleep. Conclusions: Sleep quality in older adults was compromised during the sudden unprecedented nation-wide lockdown due to distinct modifiable factors. An important contribution of our study is the assessment of a "clinically-extremely-vulnerable" population and the sex differences identified within this group. Male and female older adults deemed COVID-19CEV may benefit from targeted mental health and dietary interventions, respectively. This work extends the available evidence on the notable impact of lack of social interactions during the COVID-19 pandemic on sleep, and provides recommendations toward areas for future work, including research into vulnerability factors impacting sleep disruption and COVID-19-related complications. Study results may inform tailored interventions targeted at modifiable risk factors to promote optimal sleep; additionally, providing empirical data to support health policy development in this area.

Network Analysis of Insomnia in Chinese Mental Health Professionals During the COVID-19 Pandemic: A Cross-Sectional Study

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic is associated with increased risk of insomnia symptoms (insomnia hereafter) in health-care professionals. Network analysis is a novel approach in linking mechanisms at the symptom level. The aim of this study was to characterize the insomnia network structure in mental health professionals during the COVID-19 pandemic.

PATIENTS AND METHODS

A total of 10,516 mental health professionals were recruited from psychiatric hospitals or psychiatric units of general hospitals nationwide between March 15 and March 20, 2020. Insomnia was assessed with the insomnia severity index (ISI). Centrality index (ie, strength) was used to identify symptoms central to the network. The stability of network was examined using a case-dropping bootstrap procedure. The network structures between different genders were also compared.

RESULTS

The overall network model showed that the item ISI7 (interference with daytime functioning) was the most central symptom in mental health professionals with the highest strength. The network was robust in stability and accuracy tests. The item ISI4 (sleep dissatisfaction) was connected to the two main clusters of insomnia symptoms (ie, the cluster of nocturnal and daytime symptoms). No significant gender network difference was found.

CONCLUSION

Interference with daytime functioning was the most central symptom, suggesting that it may be an important treatment outcome measure for insomnia. Appropriate treatments, such as stimulus control techniques, cognitive behavioral therapy and relaxation training, could be developed. Moreover, addressing sleep satisfaction in treatment could simultaneously ameliorate daytime and nocturnal symptoms.

Clinical Predictors of COVID-19 Severity and Mortality: A Perspective

The COVID-19 pandemic has caused huge socio-economic losses and continues to threat humans worldwide. With more than 4.5 million deaths and more than 221 million confirmed COVID-19 cases, the impact on physical, mental, social and economic resources is immeasurable. During any novel disease outbreak, one of the primary requirements for effective mitigation is the knowledge of clinical manifestations of the disease. However, in absence of any unique identifying characteristics, diagnosis/prognosis becomes difficult. It intensifies misperception and leads to delay in containment of disease spread. Numerous clinical research studies, systematic reviews and meta-analyses have generated considerable data on the same. However, identification of some of the distinct clinical signs and symptoms, disease progression biomarkers and the risk factors leading to adverse COVID-19 outcomes warrant in-depth understanding. In view of this, we assessed 20 systematic reviews and meta-analyses with an intent to understand some of the potential independent predictors/biomarkers/risk factors of COVID-19 severity and mortality.

Dreams and Nightmares during the First and Second Wave of the COVID-19 Infection: A Longitudinal Study

Recent literature shows that the Coronovirus-19 (COVID-19) pandemic has provoked significant changes in dreaming. The current study intends to provide an update about dream variable changes during the second wave of COVID-19. A total of 611 participants completed a web survey from December 2020 to January 2021. Statistical comparisons showed that subjects had lower dream-recall frequency, nightmare frequency, lucid-dream frequency, emotional intensity, and nightmare distress during the second than the first wave of the pandemic. Dreams had a higher negative tone during the second than first wave. We revealed significant differences concerning post-traumatic growth, sleep-related post-traumatic stress disorder (PTSD) symptoms and sleep measures between groups obtained as a function of the changes in the oneiric frequency between the first and second waves. We also found significant correlations between qualitative/emotional dream features and COVID-19-related factors (job change, forced quarantine, having COVID-19 infected relatives/friends, or asking for mental health help). Overall, we found that the second wave affected fewer quantitative features of dream activity and there was less emotional intensity. Moreover, we confirmed the relationship between nightmares and the high risk of PTSD when subjects were grouped as a function of the increasing/decreasing frequency. Finally, our findings are partly coherent with the continuity hypothesis between oneiric and waking experiences.

Current Management of Residual Excessive Daytime Sleepiness Due to Obstructive Sleep Apnea: Insights for Optimizing Patient Outcomes

Although excessive daytime sleepiness (EDS) attributable to obstructive sleep apnea (OSA) can be resolved by consistent usage of and effective treatment (often with the use of continuous positive airway pressure therapy), 12–58% of patients report residual EDS (REDS). While REDS is difficult to treat, a proportion of cases are possibly due to reversible issues, and wake-promoting medications can prove useful for the remaining cases. Given the challenges associated with effective management of REDS and its relationship to multiple comorbidities, multidisciplinary management of patients with REDS is often recommended. Here we aim to bridge the knowledge gap on the burden, risk factors, prevalence, and potential pathophysiologic mechanisms of REDS in patients with OSA after first-line treatment. The roles of primary care physicians and sleep specialists, as well as the importance of the use of objective assessment tools for the evaluation of REDS and the effective management of comorbidities, are discussed. An update of approved treatments and emerging candidate treatments is also presented.

Sleep patterns of US healthcare workers during the first wave of the COVID-19 pandemic

Purpose

During the first few months of the COVID-19 outbreak, healthcare workers (HCW) faced levels of personal risk, emotional distress, and professional strain not seen in their lifetimes. This study described how these stressors influenced various aspects of their sleep patterns.

Methods

From May 19 to June 20, 2020, an electronic, cross-sectional survey was administered to a convenience sample of in- and outpatient HCW in a large, nonprofit healthcare system. Respondents described the pandemic’s initial impact on personal and professional life and various sleep dimensions: regularity, efficiency, duration, timing, quality, and daytime sleepiness.

Results

Two hundred seven providers responded, representing 17 different healthcare roles. Most (82%) were women with a median age of 39 years (IQR1–3, 31–53). A majority of respondents (81%) worked in an inpatient setting, with half (46%) primarily on the “frontline.” Approximately one-third of respondents (37%) were physicians and one-quarter (28%) were nurses. Overall, 68% of HCW reported at least one aspect of sleep worsened during the beginning of the pandemic; the most impacted were daytime sleepiness (increased in 43%) and sleep efficiency (worse in 37%). After adjusting for COVID exposure and burnout, frontline providers had twofold higher odds of poor pandemic sleep, aOR 2.53, 95%CI 1.07–5.99. Among frontline providers, physicians were fivefold more likely to develop poor pandemic sleep compared to nurses (OR 5.73, 95%CI 1.15–28.57).

Conclusions

During the initial wave of COVID-19, a majority of HCW reported a decline in sleep with an increase in daytime sleepiness and insomnia. Frontline workers, specifically physicians, were at higher risk.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11325-021-02515-9.

Knowledge and Lifestyle Behaviors Related to COVID-19 Pandemic in People over 65 Years Old from Southern Italy

BACKGROUND

Control measures adopted during the COVID-19 pandemic had a considerable impact on human daily life and lifestyles. Adherence to the recommended measures is influenced by knowledge and attitudes towards the disease. This cross-sectional study aimed to assess the level of knowledge regarding COVID-19, the related control measures, and lifestyle behaviors adopted during the pandemic in a sample of elderly Italian people.

METHODS

A web-based questionnaire investigating socio-demographic characteristics, knowledge of COVID-19, the related preventive measures, and lifestyle changes that occurred during the pandemic, were distributed to ≥65 years old people living in South Italy.

RESULTS

A satisfactory level of knowledge about COVID-19 and the related control measures has been found in the enrolled sample. However, a decrease in physical activity, as well as worsening sleeping and dietary habits, were found in roughly 60% of participants. Females were impacted greater by these lifestyle changes.

CONCLUSIONS

Participants in this study showed a good level of knowledge regarding COVID-19 and its prevention. Nevertheless, they reported an increase in unhealthy habits that may have important health consequences in the long term and should be addressed by public health interventions targeted at older people.

Identification Performance During Quarantine by COVID-19 Pandemic: Influence of Emotional Variables and Sleep Quality

The COVID-19 pandemic has caused major disruptions in people's lives around the globe. Sleep habits and emotional balance have been disturbed in a way that could be comparable to the havoc caused by a deep personal crisis or a traumatic experience. This unfortunate situation provides a unique context in which to study the impact of these imbalances on cognitive processes. In particular, the field of eyewitness science could benefit from these conditions, since they are also often present in crime victims, but can only be generated in the laboratory up to a certain ethical and practical limit. For several decades, eyewitness studies have tried to discover what variables affect people's ability to properly recognize faces. However, the disparity of experimental designs and the limitations of laboratory work could be contributing to the lack of consensus around several factors, such as sleep, anxiety, and depression. Therefore, the possibility of observing the influence of these agents in natural contexts could shed light on this discussion. Here, we perform simple and repeated lineups with witnesses of mock-crime, considering the conditions related to the COVID-19 pandemic, which to some extent allow emulating the deterioration in general well-being that often afflicts crime victims. For this, 72 participants completed symptomatology scales, and watched a video portraying a staged violent episode. Subsequently, they gave testimony and participated in two lineups, in which we manipulated the presence/absence of the perpetrator, to recreate critical scenarios for the appearance of false recognitions. We found an increase in recognition errors in those individuals who did not have access to the perpetrator during the Initial lineup. Additionally, the conditions of the pandemic appear to have adversely affected the ability to witness and accurately perform lineups. These results reaffirm the need to move toward the standardization of research practices and methods for assessing testimonial evidence, especially in relation to the results of the lineups. Considering the degree of fallibility of these processes can lead to a reduction of wrongful convictions.

Mental Health during the COVID-19 Crisis in Africa: A Systematic Review and Meta-Analysis

We aim to provide a systematic review and meta-analysis of the prevalence rates of mental health symptoms among major African populations during the COVID-19 pandemic. We include articles from PubMed, Embase, Web of Science, PsycINFO, and medRxiv between 1 February 2020 and 6 February 2021, and pooled data using random-effects meta-analyses. We identify 28 studies and 32 independent samples from 12 African countries with a total of 15,071 participants. The pooled prevalence of anxiety was 37% in 27 studies, of depression was 45% in 24 studies, and of insomnia was 28% in 9 studies. The pooled prevalence rates of anxiety, depression, and insomnia in North Africa (44%, 55%, and 31%, respectively) are higher than those in Sub-Saharan Africa (31%, 30%, and 24%, respectively). We find (a) a scarcity of studies in several African countries with a high number of COVID-19 cases; (b) high heterogeneity among the studies; (c) the extent and pattern of prevalence of mental health symptoms in Africa is high and differs from elsewhere-more African adults suffer from depression rather than anxiety and insomnia during COVID 19 compared to adult populations in other countries/regions. Hence, our findings carry crucial implications and impact future research to enable evidence-based medicine in Africa.

Mental Health during the COVID-19 Crisis in Africa: A Systematic Review and Meta-Analysis

We aim to provide a systematic review and meta-analysis of the prevalence rates of mental health symptoms among major African populations during the COVID-19 pandemic. We include articles from PubMed, Embase, Web of Science, PsycINFO, and medRxiv between 1 February 2020 and 6 February 2021, and pooled data using random-effects meta-analyses. We identify 28 studies and 32 independent samples from 12 African countries with a total of 15,071 participants. The pooled prevalence of anxiety was 37% in 27 studies, of depression was 45% in 24 studies, and of insomnia was 28% in 9 studies. The pooled prevalence rates of anxiety, depression, and insomnia in North Africa (44%, 55%, and 31%, respectively) are higher than those in Sub-Saharan Africa (31%, 30%, and 24%, respectively). We find (a) a scarcity of studies in several African countries with a high number of COVID-19 cases; (b) high heterogeneity among the studies; (c) the extent and pattern of prevalence of mental health symptoms in Africa is high and differs from elsewhere-more African adults suffer from depression rather than anxiety and insomnia during COVID 19 compared to adult populations in other countries/regions. Hence, our findings carry crucial implications and impact future research to enable evidence-based medicine in Africa.

The prevalence of insomnia among health care workers amid the COVID-19 pandemic: An umbrella review of meta-analyses

BACKGROUND

Health care workers (HCWs) during the COVID-19 pandemic experience numerous psychological problems, including stress and anxiety. These entities can affect their sleep quality and predispose them to insomnia. The aim of the present study was to investigate the prevalence of insomnia among HCWs during the COVID-19 crisis via an umbrella review.

METHODS

The PRISMA guideline was used to conduct this review. By searching relevant keywords in databases of Scopus, PubMed, Web of Science, and Google Scholar, studies that reported the prevalence of insomnia among HCWs during the COVID-19 pandemic (January 2020 to the end of January 2021) and had been published in English were identified and evaluated. The random effects model was used for meta-analysis, and the I² index was used to assess heterogeneity. The Egger test was used to determine publication bias. Based on the results of the primary search, 96 studies were identified, and ultimately 10 eligible studies entered the meta-analysis phase.

RESULTS

The results of the umbrella review of meta-analyses showed that the prevalence of insomnia among HCWs during the COVID-19 pandemic was 36.36% (95% CI: 33.36-39.36, I² = 59.6%, p = 0.006).

CONCLUSIONS

The results of this umbrella review of meta-analyses showed a relatively high prevalence of insomnia among HCWs during the COVID-19 pandemic. As insomnia can be associated with other psychological problems, policymakers and health managers should regularly screen HCWs for psychological disorders as well as a possible tendency for suicide. Furthermore, by treating insomnia, one can reduce the incidence of these psychological disorders.

Changes in sleep pattern and dream activity across and after the COVID-19 lockdown in Italy: A longitudinal observational study

A large body of evidence has documented the impact of the global COVID‐19 outbreak – and especially the lockdown period – on sleep quality and quantity. Here, we present the first Italian longitudinal study on sleep and COVID‐19 considering four different time points collected during lockdown (from 29 March 2020 to 3 May 2020) and a subsequent follow‐up period (October 2020). We used an online survey to collect socio‐demographic and COVID‐19 related information. Subjects were also asked to complete a sleep diary at each time point of the study. Our longitudinal sample included 147 participants. Statistical comparison across time intervals showed remarkable changes in sleep patterns during and after the lockdown. In particular, during lockdown we observed longer sleep latency, less ease of falling asleep, a higher total bedtime, and a lower dream frequency. The week‐by‐week evaluation described relatively stable patterns in the observed measures during the lockdown period, except for dream frequency, affected by a rapid increase in the early phase of lockdown. Our findings are in line with the current literature. Furthermore, the prospective longitudinal investigation comprising several time points offered the possibility of (a) observing the temporal dynamics and the different entities of such changes over time, and (b) reducing the typical memory bias for these studies.

The Impact of COVID-19 on Individuals with Hearing and Visual Disabilities during the First Pandemic Wave in Italy

BACKGROUND

The COVID-19 pandemic has imposed radical behavioral and social changes in the general population, significantly impacting the lives of individuals affected by disabilities. The aim of this study was to investigate the impact of COVID-19 on non-institutionalized subjects with sensorineural disabilities during the first COVID-19 wave in Italy.

METHODS

A 39-item online national survey was disseminated from 1 April 2020 to 31 June 2020 via social media throughout Italy to communities of individuals with proven severe sensorineural disabilities, affiliated to five national patient associations. The survey collected extensive information on the socio-demographic profile, health, everyday activities, and lifestyle of individuals with hearing and visual disabilities.

RESULTS

One hundred and sixty-three respondents with hearing (66.9%) and visual (33.1%) disabilities returned a usable questionnaire. The mean age of interviewees was 38.4 ± 20.2 years and 56.3% of them were females. Despite the vast majority of respondents (77.9%) perceiving their health status as unchanged (68.8% of interviewees with hearing deficits vs. 96.3% of those with visual impairments), about half the interviewees reported sleep disorders during lock-down, more likely those with visual deficits. Remote services were seemingly more effective for business than school activities. Furthermore, although just 18.8% of respondents rated remote rehabilitation care unsatisfactory, only 12.8% of interviewees felt supported by health and social services during the COVID-19 emergency. The vast majority of respondents were concerned about the future and the risk of SARS-CoV-2 contagion, particularly individuals with hearing impairments. Among the various risk mitigation measures, facemasks caused the greatest discomfort due to communication barriers, particularly among interviewees affected by hearing disabilities (92.2% vs. 45.7%). The most common request (46.5%) of respondents to reduce the inconveniences of the COVID-19 emergency country lock-down was improving the access to and delivery of health and social services for individuals with sensorineural disabilities (19.3%), followed by the use of transparent masks (17.5%).

CONCLUSIONS

Although health protection measures such as face masks and social distancing play a key role in preventing and controlling the spread of SARS-CoV-2, the unmet needs of disabled individuals should be carefully considered, especially those affected by sensory disabilities. Tailored access to health and social services for individuals affected by sensorineural disabilities should be implemented. Additional actions should include the use of to face masks to reduce communication barriers linked to hearing-impairment, as well as the improvement of remote services, especially distance learning at school.

How our Dreams Changed During the COVID-19 Pandemic: Effects and Correlates of Dream Recall Frequency - a Multinational Study on 19,355 Adults

OBJECTIVE

Many have reported odd dreams during the pandemic. Given that dreams are associated with mental health, understanding these changes could provide crucial information about wellbeing during the pandemic. This study explored associations between COVID-19 and dream recall frequency (DRF), and related social, health, and mental health factors.

METHODS

We conducted a cross-sectional web survey of 19,355 individuals in 14 countries from May to July 2020. We collected data on COVID-19, mental health, sleep and DRF during the pandemic. We performed McNemar Tests to compare low (<3 nights per week) and high DRF (≥3 nights per week) before and during COVID-19 and to evaluate changes in sleep variables segmented by DRF. Chi-square tests were conducted to compare characteristics between low and high DRF. Logistic regression analyses were conducted to examine associations between various independent variables and DRF.

RESULTS

Reports of high DRF during the pandemic were higher than before the pandemic (P<0.001). Female gender (aOR=1.25, 95% CI 1.10-1.41), nightmares (aOR=4.22, 95% CI 3.45-5.17), sleep talking (aOR= 2.36, 1.73-3.23), sleep maintenance problems (aOR=1.34, 95% CI 1.15-1.56), symptoms of REM sleep behavior disorder (RBD; aOR=1.24, 95% CI 1.09-1.41) and repeated disturbing thoughts (posttraumatic stress disorder (PTSD) symptoms) were associated with high DRF. Age group 55-64 years (aOR=0.69, 95% CI 0.58-0.83) reported less high DRF than younger participants. Unadjusted OR showed associations between depression, anxiety, and DRF; however, in adjusted regression depression (aOR= 0.71, 0.59-0.86) and anxiety (aOR=0.79, 95% CI 0.66-0.94) were negatively associated with high DRF.

CONCLUSION AND RELEVANCE

DRF was higher than pre-pandemic levels across four continents. DRF was associated with gender and parasomnias like nightmares and RBD symptoms, sleep maintenance problems, PTSD symptoms and negatively associated with depression and anxiety. The results implicate that COVID-19 is reflected in our dreams as an expression of the emotional intensity of the pandemic.

Outdoor daylight exposure and longer sleep promote wellbeing under COVID-19 mandated restrictions

Light is an important regulator of daily human physiology in providing time‐of‐day information for the circadian clock to stay synchronised with the 24‐hr day. The coronavirus disease 2019 (COVID‐19) pandemic led to social restrictions in many countries to prevent virus spreading, restrictions that dramatically altered daily routines and limited outdoor daylight exposure. We previously reported that sleep duration increased, social jetlag decreased, and mid‐sleep times delayed during social restrictions (Global Chrono Corona Survey, N = 7,517). In the present study, we investigated in the same dataset changes in wellbeing and their link to outdoor daylight exposure, and sleep–wake behaviour. In social restrictions, median values of sleep quality, quality of life, physical activity and productivity deteriorated, while screen time increased, and outdoor daylight exposure was reduced by ~58%. Yet, many survey participants also reported no changes or even improvements. Larger reductions in outdoor daylight exposure were linked to deteriorations in wellbeing and delayed mid‐sleep times. Notably, sleep duration was not associated with outdoor daylight exposure loss. Longer sleep and decreased alarm‐clock use dose‐dependently correlated with changes in sleep quality and quality of life. Regression analysis for each wellbeing aspect showed that a model with six predictors including both levels and their deltas of outdoor daylight exposure, sleep duration and mid‐sleep timing explained 5%–10% of the variance in changes of wellbeing scores (except for productivity). As exposure to daylight may extenuate the negative effects of social restriction and prevent sleep disruption, public strategies during pandemics should actively foster spending more daytime outdoors.

The Impact of COVID-19 Pandemic on Italian University Students' Mental Health: Changes across the Waves

To reduce the spread of COVID-19, the Italian government imposed a rigid lockdown and, for a whole year, continued to declare stringent rules to curb the community spread. This study provides an overview of university students' symptomatology and help-seeking behaviour before and during the pandemic. It aims to evaluate the impact of the different phases of the pandemic on students' mental health. We collected data in four-time points between March 2019 and March 2021. A total of 454 students (F = 85; M = 15) were included in the study. Students answered a socio-demographic and a standardized questionnaire (i.e., SCL-90-R) to evaluate a broad range of symptomatology. The results suggest that students experienced moderate to severe levels of depressive, obsessive-compulsive and anxiety symptomatology. About 14% of the sample met the criteria for at least one mental health disorder, but most were not receiving mental health care. During the lockdown, compared with other phases, female students reported worse symptoms in the obsessive-compulsive, interpersonal sensitivity, depression, paranoid ideation, and psychoticism dimensions. The increasing symptomatology disappeared after the lifting of the lockdown. The results showed no difference in the male groups. Preventive and support strategies should be improved in the university context.