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

The Effect of Virtual Mindfulness-Based Interventions on Sleep Quality: A Systematic Review of Randomized Controlled Trials

PURPOSE OF REVIEW

We summarized peer-reviewed literature investigating the effect of virtual mindfulness-based interventions (MBIs) on sleep quality. We aimed to examine the following three questions: (1) do virtual MBIs improve sleep quality when compared with control groups; (2) does the effect persist long-term; and (3) is the virtual delivery method equally feasible compared to the in-person delivery method?

RECENT FINDINGS

Findings suggest that virtual MBIs are equivalent to evidence-based treatments, and to a limited extent, more effective than non-specific active controls at reducing some aspects of sleep disturbance. Overall, virtual MBIs are more effective at improving sleep quality than usual care controls and waitlist controls. Studies provide preliminary evidence that virtual MBIs have a long-term effect on sleep quality. Moreover, while virtual MBI attrition rates are comparable to in-person MBI attrition rates, intervention adherence may be compromised in the virtual delivery method. This review highlights virtual MBIs as a potentially effective alternative to managing sleep disturbance during pandemic-related quarantine and stay-at-home periods. This is especially relevant due to barriers of accessing in-person interventions during the pandemic. Future studies are needed to explore factors that influence adherence and access to virtual MBIs, with a particular focus on diverse populations.

The impact of the end of COVID confinement on pandemic dreams, as assessed by a weekly sleep diary: a longitudinal investigation in Italy

The Coronavirus 2019 pandemic strongly affected our sleep and dream activity. Many cross‐sectional studies highlighted increased dream recall frequency, and revealed a great presence of pandemic‐related oneiric contents. Here, we present the first prospective study carried out on an Italian sample. One‐hundred subjects were requested to fill out a web‐survey including socio‐demographic information, and questionnaires collecting sleep and clinical measures during lockdown. A final sample of 90 subjects participated in the longitudinal protocol lasting 2 weeks: (a) the first week (April 28–May 4) of full lockdown; and (b) the second week (May 5–May 11) of easing of restrictions. Subjects were asked to record at home their dream experiences, and complete a sleep‐dream diary each morning. Statistical comparisons showed that participants had higher numbers of awakenings, lower ease of falling asleep, higher dream recall and lucid dream frequency during lockdown than post‐lockdown. Further, subjects reported more dreams, including “being in crowded places” during post‐lockdown than lockdown. The poorer sleep quality during lockdown is quite consistent with previous findings. The relationship between traumatic events and dream recall frequency confirmed the idea of pandemic as “collective trauma”. Also, we hypothesized that the greater presence of lucid dreams during confinement could reflect the attempt to cope with the waking pandemic‐experiences. Finally, the presence of crowded places into dream scenarios during the second week of our protocol appears consistent with the continuity‐hypothesis, as the possibility to access places frequented by other people could represent a relevant experience after a long period of confinement.

A year in review: sleep dysfunction and psychological distress in healthcare workers during the COVID-19 pandemic

The Covid-19 outbreak has taken a substantial toll on the mental and physical wellbeing of healthcare workers (HCWs), impacting healthcare systems at a global scale. One year into the pandemic, the need to establish the prevalence of sleep dysfunction and psychological distress in the face of COVID-19, identify risk and protective factors and explore effective countermeasures remains of critical importance. Despite implicit limitations relating to the quality of available studies, a plethora of evidence to-date suggests that a considerable proportion of HCWs experience significant sleep disturbances (estimated to afflict every two in five HCWs) as well as mood symptoms (with more than one in five reporting high levels of depression or anxiety). Younger age, female gender, frontline status, fear or risk of infection, occupation, current or past mental health concerns, and a lower level of social support were all associated with a greater risk of disturbed sleep and adverse psychological outcomes. Furthermore, 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 predictors of traumatic stress/PTSD and burnout in HCWs. Finally, we highlight the role of resilience and tailored interventions in order to mitigate vulnerability and prevent long-term physical and psychological implications. Indeed, promoting psychological resilience through an enhanced social support network has proven crucial for HCWs in coping under these strenuous circumstances. Future research should aim to provide high quality information on the long-term consequences and the effectiveness of applied interventions.

Circadian disturbances, sleep difficulties and the COVID-19 pandemic

The COVID-19 pandemic has imposed extraordinary and unpredictable changes on our lifestyle for an unknown duration. Consequently, core aspects of wellbeing including behavior, emotion, cognition, and social interactions are negatively affected. Sleep and circadian rhythms, with an extensive impact on physiology, behavior, emotion, and cognition are affected too. We provided an updated overview of the impact of the COVID-19 pandemic on circadian rhythms and sleep based on the results of published studies (n = 48) in three sections. First, we focus on circadian misalignment due to the pandemic in the general population (including shift workers, health staff, students) and COVID-19 patients and summarize the most critically contributing factors to circadian misalignment. Next, we address sleep difficulties and poor sleep quality during the pandemic, their contributing factors, rate and prevalence, and their effects on both the general population and COVID-19 patients. Finally, we summarize the currently applied/recommended interventions for aligning circadian rhythms and improving sleep quality in both, the general population, and COVID-19 patients during the pandemic situation. Briefly, circadian misalignment and sleep difficulties are common consequences of the pandemic in the general population (with elderly, students, children, health and night-work shifters as risk groups) and COVID-19 patients. Home confinement and its physiological, circadian, and psychological derivates are central to these difficulties. Symptoms severity, treatment progress, recovery duration, and even diagnosis of COVID-19 patients are considerably affected by circadian and sleep difficulties. Behavioral interventions for normalizing the factors that contribute to circadian and sleep difficulties are helpful.

The impact of the COVID-19 pandemic on stress, mental health and coping behavior in German University students - a longitudinal study before and after the onset of the pandemic

BACKGROUND

The COVID-19 pandemic has led to massive restrictions in public and private lives, including a shut-down of face-to-face teaching at universities in Germany. We aimed to examine the impact of these changes on perceived stress, mental health and (study-)related health behavior of students in a longitudinal study.

METHODS

For two timepoints - the year before the COVID-19 pandemic (2019, n = 1377) and the year during the COVID-19 pandemic (2020, n = 1867) - we surveyed students of all faculties at one German university for perceptions and preventive behavior regarding the COVID-19 pandemic using standard instruments for stress, anxiety, depression, and behavior and experience patterns.

RESULTS

About 90% of students (n = 1633) in 2020 did not have a known contact infected with SARS-CoV-2, while 180 (9.8%) did have one. Only 10 respondents (0.5%) reported an infection with SARS-CoV-2. Wearing masks and washing hands more often were practiced by ≥80% of students. Taking more care about cleanliness (51.8%) and using disinfectants (39.2%) were practiced much less. A higher percentage of female compared with male students and medical/health science students compared with science, technology, engineering, and mathematics students engaged more frequently in specific or nonspecific preventive measures. More than three quarters (77.1%) of all students rated their general health as (very) good. There were no significant differences in general health, stress, and depression between 2019 and 2020 in the students who responded at both timepoints. The distribution of behavior and experience patterns for this group showed a slight but significant difference from 2019 to 2020, namely decreasing proportions of students with a healthy pattern and a risk pattern for overexertion. Students with different behavior and experience patterns showed marked differences in perceptions and reaction to the COVID-19 pandemic as well as psychosocial stress and symptoms, with higher scores for mental health symptoms and lower scores in preventive behavior regarding risk patterns.

CONCLUSION

Despite massive alterations to students' lives in 2020, there were only moderate consequences for mental health compared with 2019 in the total student group of this German university. However, identifying students at risk would offer opportunities to foster mental health in relevant subgroups.

The effect of COVID-19 lockdowns on sleep time perception: Comparing actigraphy and sleep diary measures

COVID-19 has become a long-term problem, and global pandemic conditions may persist for years. Researchers are providing mounting evidence of relationships between COVID-19 lockdowns and sleep problems. However, few studies have investigated the impact of home isolation on sleep time perception, especially in comparable social isolation situations with similar pressures. Subjective sleep time perception parameters were derived from sleep diaries. Objective parameters were derived from actigraphy. Subjective and objective data were obtained between February 17 and February 27, 2020 from 70 adult participants subject to COVID-19 related lockdown provisions in China. We divided participants into a home stayers (HS) group (subject to full stay-at home orders) and an area-restricted workers (ARW) group (permitted to work at their nearby workplaces). The HS group demonstrated significantly delayed actigraphy-defined sleep onset time compared to self-reported sleep onset time; this effect was absent in the ARW group. Between-group differences in actigraphy-defined sleep onset time and significant between-group differences for actigraphy-defined and self-reported wake-up time were observed. HS group participants also presented significantly delayed actigraphy-defined wake-up time compared with self-reported wake-up time. No significant effect was found on total sleep time perception. Moreover, sleep/wake time misperception were found to be associated with daylight exposure and physical activity levels respectively. To the extent they are generalizable, these results suggest that lockdown restrictions can affect sleep onset and wake-up time perception but not total sleep time perception. Public health policy should consider such effects in the present pandemic situation and in future emergent public health situations.

Prolonged Stress Causes Depression in Frontline Workers Facing the COVID-19 Pandemic-A Repeated Cross-Sectional Study in a COVID-19 Hub-Hospital in Central Italy

The COVID-19 pandemic has severely tested the mental health of frontline health care workers. A repeated cross-sectional study can provide information on how their mental health evolved during the various phases of the pandemic. The intensivists of a COVID-19 hub hospital in Rome were investigated with a baseline survey during the first wave of the pandemic in April 2020, and they were contacted again in December 2020, during the second wave. Of the 205 eligible workers, 152 responded to an online questionnaire designed to measure procedural justice, occupational stress (effort/reward imbalance), sleep quality, anxiety, depression, burnout, job satisfaction, happiness, and turnover intention. Workers reported a further increase in workload and compassion fatigue, which had already risen during the first wave, and a marked reduction in the time devoted to meditation and mental activities. A low level of confidence in the adequacy of safety procedures and the need to work in isolation, together with an increased workload and lack of time for meditation, were the most significant predictors of occupational stress in a stepwise linear regression model. Occupational stress was, in turn, a significant predictor of insomnia, anxiety, low job satisfaction, burnout, and intention to leave the hospital. The number of workers manifesting symptoms of depression increased significantly to exceed 60%. Action to prevent occupational risks and enhance individual resilience cannot be postponed.

The Impact of Quarantine on Sleep Quality and Psychological Distress During the COVID-19 Pandemic

PURPOSE

We investigated the impact of isolation on sleep quality and psychological distress during the COVID-19 pandemic in Saudi Arabia.

METHODS

An online survey was conducted on 353 (88 isolated and 265 not isolated) individuals from May to June 2020. Subjective sleep quality was determined using the Pittsburgh sleep quality index (PSQI), and psychological distress measured using the Kessler psychological distress scale (K10).

RESULTS

The mean age of the isolated group was 28.6 years versus 27.5 years for the non-isolated group, with male participants accounting for 37% in both groups. The mean PSQI score was 8.5±3.6 and 8.4±3.5 for the isolated and non-isolated groups, respectively (P= 0.92). The mean K-10 score was 27.6± 9.4 and 25.3± 9.5 for the isolated and non-isolated groups, respectively (P= 0.04). Poor sleep (PSQI ≥6) was reported in 235 (66.6%) and psychological distress (K-10 ≥20) in 244 (69.1%) participants. Isolation was not associated with poor sleep (OR: 0.73 (95% CI: 0.41-1.3), P=0.29), but was statistically significant with psychological distress (OR: 2.12 (95% CI: 1.10-4.08), P=0.03).

CONCLUSION

Poor sleep and psychological distress symptoms were highly prevalent in our study population. Isolation may influence psychological distress but not sleep quality during the COVID-19 pandemic.

Covid-19 and changes in sleep health in the Blackfeet Community

We examined changes in psychological outcomes related to the COVID-19 pandemic (ie psychological stress, perceived control, and perceived ability to cope) and changes in sleep health in the American Indian Blackfeet community over 4 months (August 24, 2020-November 30, 2020). American Indian adults residing on the Blackfeet reservation (n = 167) completed measures of perceived control over contracting COVID-19, perceived ability to cope with pandemic stressors, psychological stress linked to the pandemic, and a measure of sleep health each month. Linear-effects mixed models were used to examine changes in our outcomes. Community members who reported more control over contracting the virus had better sleep health relative to those who reported less control (B = 0.72, SE = 0.29, p = 0.015). Further, during months when individuals felt they had more control over contracting the virus compared to their average perceived control levels, they had better sleep health relative to their own average (B = 1.06, SE = 0.13, p < 0.001). Average sleep health was the lowest in October, 2020, the month during which COVID-19 incidence was at its highest on the reservation. Declines in sleep health linked to low levels of control over contracting COVID-19 may exacerbate high incidence of chronic mental and physical health conditions in tribal communities. Interventions which highlight strategies known to reduce risk of contracting the virus, may increase perceived control and sleep health, and thus may improve downstream health outcomes for this at-risk population.

Sleep quality and associated factors in the context of COVID-19, among prehospital emergency personnel, in North-Eastern Greece

BACKGROUND

The stressful conditions that emerged during the Coronavirus disease 2019 (COVID-19) pandemic have had a negative impact on sleep quality in large part of the healthcare worker population. This study aimed to assess the self-reported quality of sleep among members of the Emergency Ambulance Service personnel of the National Emergency Center in the region of Thrace, Northeastern Greece, and to investigate its associations with perceived stress, feelings, and perceptions of well-being during the COVID-19 pandemic.

METHODS

The study was conducted from March to May 2021 using an online structured questionnaire, and the collected data included: socio-demographic characteristics, occupational and medical history, distress and mental health issues due to COVID-19 and the following self-administrated instruments: Pittsburgh Sleep Quality Index (PSQI), WHO-5 Well-Being Index (WHO-5), and Perceived Stress Scale-14 items (PSS-14).

RESULTS

Among the 74 participants, 71 % were poor sleepers (i.e., PSQI >5). The majority (83 % of the sample) reported feelings of stigma due to their occupation, with the proportion being higher among women (100 % vs 78 % in men, p =0.05) and poor sleepers (95 % vs 65 % in good sleepers, p =0.03). Poor sleepers had significantly lower WHO-5 scores than good sleepers (13.8 ± 4.9 vs 16.9 ± 5.8, p =0.04) and were experiencing significantly more anxiety and/or sadness at the time they answered the questionnaire (69.1 % vs 35.3 %, p =0.02). Perceived stress was significantly positively correlated with the "Latency" dimension of the PSQI (p =0.03).

CONCLUSIONS

Poor sleep quality and feelings of stigmatization were prevalent for most of the sample. Poor sleep quality was associated more frequently with reported feelings of stigmatization, anxiety and/or sadness, and impaired well-being. HIPPOKRATIA 2021, 25 (3):126-133.

Brain Mechanisms of COVID-19-Sleep Disorders

2020 and 2021 have been unprecedented years due to the rapid spread of the modified severe acute respiratory syndrome coronavirus around the world. The coronavirus disease 2019 (COVID-19) causes atypical infiltrated pneumonia with many neurological symptoms, and major sleep changes. The exposure of people to stress, such as social confinement and changes in daily routines, is accompanied by various sleep disturbances, known as 'coronasomnia' phenomenon. Sleep disorders induce neuroinflammation, which promotes the blood-brain barrier (BBB) disruption and entry of antigens and inflammatory factors into the brain. Here, we review findings and trends in sleep research in 2020-2021, demonstrating how COVID-19 and sleep disorders can induce BBB leakage via neuroinflammation, which might contribute to the 'coronasomnia' phenomenon. The new studies suggest that the control of sleep hygiene and quality should be incorporated into the rehabilitation of COVID-19 patients. We also discuss perspective strategies for the prevention of COVID-19-related BBB disorders. We demonstrate that sleep might be a novel biomarker of BBB leakage, and the analysis of sleep EEG patterns can be a breakthrough non-invasive technology for diagnosis of the COVID-19-caused BBB disruption.

Predictors for Depression, Sleep Disturbance, and Subjective Pain among Inpatients with Depressive Disorders during the COVID-19 Pandemic: A Cross-Sectional Study

The coronavirus disease 2019 (COVID-19) pandemic can have a negative impact on patients with mood disorders. The aim of this study is to explore the societal influence of COVID-19 and associated impacts on levels of depression, sleep disturbance, and subjective pain among patients with mood disorders. This cross-sectional study recruited inpatients with depression and bipolar disorder. Levels of depression, sleep disturbance, subjective pain, and related demographic variables were collected through self-reported questionnaires. Potential factors associated with levels of depression, sleep disturbance, and subjective pain were identified using univariate linear regression and further entered into a stepwise multivariate linear regression model to identify the independent predictors. A total of 119 participants were included in the analysis, of whom 50.42% had bipolar disorder and 49.58% had unipolar depression. Multivariate analysis showed that a higher level of depression was associated with female subjects, subjects with partners, present history of psychological trauma, and drinking alcohol. Sleep disturbance was associated with subjects with partners and drinking alcohol. A higher level of subjective pain was associated with a higher level of social anxiety and a history of psychological trauma. The current study identified several predictors of psychological burden and subjective pain among inpatients with depression during the COVID-19 pandemic. Further investigations are warranted to extend the application and generalizability of our results.

COVID-19 uncertainty and sleep: the roles of perceived stress and intolerance of uncertainty during the early stage of the COVID-19 outbreak

BACKGROUND

The COVID-19 pandemic brings unprecedented uncertainty and stress. This study aimed to characterize general sleep status among Chinese residents during the early stage of the outbreak and to explore the network relationship among COVID-19 uncertainty, intolerance of uncertainty, perceived stress, and sleep status.

METHODS

A cross-sectional correlational survey was conducted online. A total of 2534 Chinese residents were surveyed from 30 provinces, municipalities, autonomous regions of China and regions abroad during the period from February 7 to 14, 2020, the third week of lockdown. Final valid data from 2215 participants were analyzed. Self-report measures assessed uncertainty about COVID-19, intolerance of uncertainty, perceived stress, and general sleep status. Serial mediation analysis using the bootstrapping method and path analysis were applied to test the mediation role of intolerance of uncertainty and perceived stress in the relationship between uncertainty about COVID-19 and sleep status.

RESULTS

The total score of sleep status was 4.82 (SD = 2.72). Age, place of residence, ethnicity, marital status, infection, and quarantine status were all significantly associated with general sleep status. Approximately half of participants (47.1%) reported going to bed after 12:00 am, 23.0% took 30 min or longer to fall asleep, and 30.3% slept a total of 7 h or less. Higher uncertainty about COVID-19 was significantly positively correlated with higher intolerance of uncertainty (r = 0.506, p < 0.001). The mediation analysis found a mediating role of perceived stress in the relationship between COVID-19 uncertainty and general sleep status (β = 0.015, 95%C.I. = 0.009-0.021). However, IU was not a significant mediator of the relationship between COVID-19 uncertainty and sleep (β = 0.009, 95%C.I. = - 0.002-0.020). Moreover, results from the path analysis further showed uncertainty about COVID-19 had a weak direct effect on poor sleep (β = 0.043, p < 0.05); however, there was a robust indirect effect on poor sleep through intolerance of uncertainty and perceived stress.

CONCLUSIONS

These findings suggest that intolerance of uncertainty and perceived stress are critical factors in the relationship between COVID-19 uncertainty and sleep outcomes. Results are discussed in the context of the COVID-19 pandemic, and practical policy implications are also provided.

Impact of COVID-19 pandemic on sleep in children and adolescents: a systematic review and meta-analysis

Objective

This systematic review and meta-analysis were conducted to study the prevalence and pattern of sleep disturbances in children and adolescents during the COVID-19 pandemic.

Methods

MEDLINE, EMBASE, and Web of Science were searched for original studies describing sleep abnormalities in children and adolescents with or without pre-existing neurobehavioral disorders during the COVID-19 pandemic. The pooled estimates for various sleep abnormalities were calculated using a random-effect model.

Results

Of 371 articles screened, 16 studies were included. Among these, five studies were in preschool children, two were in children with pre-existing neurobehavioral disorders and the remaining were in school going children and adolescents. The outcome measures used for sleep were markedly heterogeneous across the studies.

The pooled prevalence of any sleep disturbance in children during the pandemic was 54%(95%CI:50–57%). Interestingly, the prevalence in pre-school children was lower than pre-pandemic times (RR = 0.87; 95% CI:0.58–1.30) but this was not statistically significant. The pooled prevalence of children not meeting sleep recommendation was 49% (95%CI: 39–58%).

Conclusion

The prevalence of sleep problems in children and adolescents during the COVID-19 pandemic is alarming. Pre-school children had a trend towards relatively fewer sleep disturbances due to home confinement measures in comparison with pre-pandemic times. Sleep duration recommendations were not met in nearly half of healthy children. However, these conclusions need to be seen in light of limited literature on the topic, few included studies done in heterogenous populations, and dubious quality of inferences drawn from these studies which were predominantly online surveys.

Prospero registration id

CRD42020213788.

Sleep in Older Adults and Its Possible Relations With COVID-19

Since the beginning of the COVID-19 pandemic, older adults have been found to be a highly vulnerable group, with a higher prevalence of severe cases and negative outcomes. Research has focused on the reasons why older adults are at greater risk; Sleep-related factors have been suggested as one possible explanation for this. An individual's sleep pattern undergoes significant changes over the course of their life. In older adults a specific sleep profile can be observed, one characterized by advanced sleep timing, a morningness preference, longer sleep-onset latency, shorter overall sleep duration, increased sleep fragmentation, reduced slow-wave sleep and, increased wake time after sleep onset. Additionally, an increased prevalence of sleep disorders can be observed, such as obstructive sleep apnea and insomnia. Previous research has already linked sleep disorders (especially sleep apnea) with COVID-19, but few studies have focused specifically on the older population. We believe that the intrinsic sleep patterns of older adults, and the prevalence of sleep disorders in this population, may be important factors that could explain why they are at a greater risk of negative COVID-19 outcomes. In this review, we discuss the relationship between sleep and COVID-19 among older adults, focusing on three different aspects: (1) Sleep-related issues that might increase the likelihood of getting infected by SARS-COV-2; (2) Sleep disturbances that might increase the predisposition to worse COVID-19 prognosis and outcomes; and (3) COVID-19-related aspects affecting community-dwelling older adults, such as social isolation, quarantine, and home confinement, among others, that might impact sleep.

Demographic, psychological, chronobiological, and work-related predictors of sleep disturbances during the COVID-19 lockdown in Italy

The first COVID-19 contagion wave caused unprecedented restraining measures worldwide. In Italy, a period of generalized lockdown involving home confinement of the entire population was imposed for almost two months (9 March-3 May 2020). The present is the most extensive investigation aimed to unravel the demographic, psychological, chronobiological, and work-related predictors of sleep disturbances throughout the pandemic emergency. A total of 13,989 Italians completed a web-based survey during the confinement period (25 March-3 May). We collected demographic and lockdown-related work changes information, and we evaluated sleep quality, insomnia and depression symptoms, chronotype, perceived stress, and anxiety using validated questionnaires. The majority of the respondents reported a negative impact of confinement on their sleep and a delayed sleep phase. We highlighted an alarming prevalence of sleep disturbances during the lockdown. Main predictors of sleep disturbances identified by regression models were: female gender, advanced age, being a healthcare worker, living in southern Italy, confinement duration, and a higher level of depression, stress, and anxiety. The evening chronotype emerged as a vulnerability factor, while morning-type individuals showed a lower predisposition to sleep and psychological problems. Finally, working from home was associated with less severe sleep disturbances. Besides confirming the role of specific demographic and psychological factors in developing sleep disorders during the COVID-19 pandemic, we propose that circadian typologies could react differently to a particular period of reduced social jetlag. Moreover, our results suggest that working from home could play a protective role against the development of sleep disturbances during the current pandemic emergency.

Sleep problems during COVID-19 pandemic and its' association to psychological distress: A systematic review and meta-analysis

BACKGROUND

The emerging novel coronavirus disease 2019 (COVID-19) has become one of the leading cause of deaths worldwide in 2020. The present systematic review and meta-analysis estimated the magnitude of sleep problems during the COVID-19 pandemic and its relationship with psychological distress.

METHODS

Five academic databases (Scopus, PubMed Central, ProQuest, ISI Web of Knowledge, and Embase) were searched. Observational studies including case-control studies and cross-sectional studies were included if relevant data relationships were reported (i.e., sleep assessed utilizing the Pittsburgh Sleep Quality Index or Insomnia Severity Index). All the studies were English, peer-reviewed papers published between December 2019 and February 2021. PROSPERO registration number: CRD42020181644.

FINDINGS

168 cross-sectional, four case-control, and five longitudinal design papers comprising 345,270 participants from 39 countries were identified. The corrected pooled estimated prevalence of sleep problems were 31% among healthcare professionals, 18% among the general population, and 57% among COVID-19 patients (all p-values < 0.05). Sleep problems were associated with depression among healthcare professionals, the general population, and COVID-19 patients, with Fisher's Z scores of -0.28, -0.30, and -0.36, respectively. Sleep problems were positively (and moderately) associated with anxiety among healthcare professionals, the general population, and COVID-19 patients, with Fisher's z scores of 0.55, 0.48, and 0.49, respectively.

INTERPRETATION

Sleep problems appear to have been common during the ongoing COVID-19 pandemic. Moreover, sleep problems were found to be associated with higher levels of psychological distress. With the use of effective programs treating sleep problems, psychological distress may be reduced. Vice versa, the use of effective programs treating psychological distress, sleep problems may be reduced.

FUNDING

The present study received no funding.

Sleep disturbances and non-cyclical breast pain: where to break the vicious cycle?

Purpose

This study aimed to assess the sleep quality of patients with the complaint of non-cyclical breast pain (NCBP), compare them to a healthy control group, and analyze the interrelationship of sleep quality with pain, anxiety, depression, and quality of life.

Methods

This cross-sectional study was conducted in consecutive women presenting to the general surgery clinic between May 2020 and December 2020. Patients diagnosed with NCBP formed one group for study and 44 receiving routine well-woman care formed the control group. Evaluations were undertaken using the Nottingham Health Profile (NHP), short-form McGill Pain Questionnaire (SF-MPQ), Hospital Anxiety and Depression Scale (HADS), and Pittsburgh Sleep Quality Index (PSQI).

Results

Of 160 consecutive patients, 116 were diagnosed with NCBP and 44 controls. Poor sleep quality (PSQI > 5) was present in 59% (n = 69) of the women with NCBP and 38% (n = 17) of the controls (p = 0.018). According to PSQI global score, overall sleep quality was significantly lower in the NCBP group compared to the control group (p < 0.007). Sleep latency, sleep duration, and daytime dysfunction were the major components determining the PSQI global score (p = 0.004, p = 0.004, and p < 0.001, respectively). The correlation matrix revealed a statistically significant correlation between the HAD-A, HAD-D, and SF-MSQ and NHP subgroups and PSQI global score in the NCBP group (p < 0.001) whereas this significant correlation was detected with only the NHP subgroups among the controls.

Conclusions

A considerable proportion of NCBP patients, regardless of sensory or affective characteristics and trajectory of pain, experience significant sleep disturbances. Further studies should be conducted to evaluate the existence of central sensitization syndrome in NCBP patients to determine the required pharmacological treatment.

COVID-19 lockdown and poor sleep quality: Not the whole story

A growing body of evidence consistently describes the side‐effects of coronavirus disease 2019 lockdown on mental health and sleep quality. We conducted a longitudinal web‐based survey of 217 Italian participants at two time points: lockdown and subsequent follow‐up. To thoroughly investigate lockdown‐related changes in sleep quality, we first evaluated variations in overall sleep quality assessed by the Pittsburgh Sleep Quality Index. We then examined sleep changes in specific components of sleep quality. Results revealed a clear dissociation of sleep effects, as a function of the specific domain considered, with longer sleep latency, worse sleep efficiency, and massive sleep medication use during forced confinement. On the other hand, we simultaneously observed an increased sleep duration and better daytime functioning. Our present findings highlight the importance of an accurate examination of sleep quality during lockdown, as the effects were not uniform across populations and different sleep domains.

Prevalence of mental health symptoms and its effect on insomnia among healthcare workers who attended hospitals during COVID-19 pandemic: A survey in Dhaka city

Background

During the COVID-19 pandemic, the high workload, risk of infection, and safety issues for family members may pose a threat to the mental health of healthcare workers (HCWs) working in hospital settings. The study aimed to find out the prevalence of anxiety, depression, and insomnia symptoms were among HCWs, as well as the factors related to these mental health issues.

Methods

We conducted an online survey of HCWs employed in Dhaka city from June 6 to July 6, 2020. Symptoms of anxiety, depression, and insomnia were measured using the Generalized Anxiety Disorder, the depression module of the Patient Health Questionnaire, and the Insomnia Severity Index, respectively. The related factors of anxiety, depression, and insomnia symptoms were identified using three regression models.

Results

This research included responses from 294 HCWs (mean ± standard deviation age: 28.86 ± 5.5 years; 43.5% were female). Anxiety, depression, and insomnia symptoms were found in 20.7%, 26.5%, and 44.2% of HCWs, respectively. The variable financial difficulties was commonly found as an associated factor for anxiety, depression, and insomnia symptoms. Female HCWs were more prone to mental health symptoms and insomnia compared to male HCWs (Adjusted odds ratio- AOR = 2.20, 95% CI = 1.27-3.79). The depression symptoms among HCWs were found to be a factor for insomnia (AOR = 6.321, 95% CI = 3.158-12.650).

Conclusion

In the current pandemic, the high prevalence of mental health symptoms among HCWs indicates that this occupational group being associated with increased mental distress. Increasing financial support for HCWs and providing support to female workers in care facilities could help to alleviate the burden of mental illness. Supportive, training, and educational strategies, particularly through knowledge and communication platforms, could be recommended to the care facilities, which can reduce the burden of mental health symptoms among HCWs.

Relationship between the fear of COVID-19 disease and sleep quality: the mediating role of stress

The whole world almost came to a standstill due to the COVID-19 pandemic. In response to this pandemic, most psychological responses have been at a higher prevalence such as stress, anxiety, depression, lower mental well-being, poor sleep quality, along with the fear of contracting the COVID-19 disease. Related to these psychological responses, previous studies have suggested an association between COVID-19 fear and stress as well as stress and sleep quality. The present study aimed to assess the association between COVID-19 fear and sleep quality and investigate the possible mediating effect of perceived stress during this pandemic. The data were collected, utilizing a self-report online questionnaire, from a sample of 521 Bangladeshi adults. Results showed significant gender differences in COVID-19 fear, stress, and sleep quality and also a significant association between these variables. Mediation results revealed that stress fully mediated the association between COVID-19 fear and sleep quality for males and partially mediated it for females. These results suggest that women are in a more vulnerable position in this pandemic. These findings would be helpful to mental health professionals and policy makers to address the psychological problems induced by the current pandemic.

Lifestyle habits of adults during the COVID-19 pandemic lockdown in Cyprus: evidence from a cross-sectional study

BACKGROUND

The COVID-19 pandemic and the widespread adoption of virus control measures have inevitably disrupted efforts to address lifestyle risk factors for non-communicable diseases (NCD). This study aimed to explore the effects of COVID-19 lockdown on all lifestyle medicine pillars, namely diet, physical activity, sleep, stress, social support and use of risky substances.

METHODS

This was a cross-sectional study on a convenient sample of adults who resided in Cyprus during the Spring 2020 lockdown. Participants completed an anonymous online questionnaire comprised of six validated tools regarding the following lifestyle behaviours before and during lockdown: adherence to the Mediterranean diet, physical activity, stress and social support levels, sleep pattern and use of risky substances such as smoking and alcohol. Paired before and during lockdown comparisons for each lifestyle pillar were undertaken using Wilcoxon Signed-Rank test and Bowker symmetry Test where response was numerical (non-parametric data) and categorical respectively. Furthermore, stratified analyses for sociodemographic characteristics were performed.

RESULTS

Out of 745 participants, 74% were female and median age was 39 years. Overall participants reported significantly higher perceived stress score (22 v 25, p <  0.01), lower social support score (71 v 68, p <  0.001), and worse sleep quality score (4 v 5, p <  0.01) during lockdown. Mediterranean diet (MD) adherence was moderate and increased significantly only in those practicing religious fasting (score of 6 v 7, p <  0.01). Total minutes spent sitting increased (120 v 180, p <  0.01) although overall physical activity score did not significantly change. Smoking intensity increased during lockdown whilst frequency of alcohol consumption decreased (ptrend = 0.03 and <  0.01, respectively).

CONCLUSION

Various lifestyle factors were adversely affected by the COVID-19 lockdown in Cyprus. Evidence from this study supports development of holistic lifestyle interventions during and following the pandemic to reduce short and long-term NCD risks by building on lifestyle behaviour strengths and addressing longstanding and emerging gaps and needs.

Meal and Sleep Timing before and during the COVID-19 Pandemic: A Cross-Sectional Anonymous Survey Study from Sweden

The COVID-19 pandemic and related restrictions, such as stay-at-home-orders, have significantly altered daily routines and lifestyles. Given their importance for metabolic health, we herein compared sleep and meal timing parameters during vs. before the COVID-19 pandemic based on subjective recall, in an anonymous Swedish survey. Among 191 adults (mean age: 47 years; 77.5% females), we show that social jetlag, i.e., the mismatch in sleep midpoint between work and free days, was reduced by about 17 min during the pandemic compared with the pre-pandemic state (p < 0.001). Concomitantly, respondents’ sleep midpoint was shifted toward morning hours during workdays (p < 0.001). A later daily eating midpoint accompanied the shift in sleep timing (p = 0.001). This effect was mainly driven by a later scheduled first meal (p < 0.001). No difference in the timing of the day’s last meal was found (p = 0.814). Although our survey was limited in terms of sample size and by being cross-sectional, our results suggest that the delay in sleep timing due to the COVID-19 pandemic was accompanied by a corresponding shift in the timing of early but not late meals.

Boston College daily sleep and well-being survey data during early phase of the COVID-19 pandemic

While there was a necessary initial focus on physical health consequences of the COVID-19 pandemic, it is becoming increasingly clear that many have experienced significant social and mental health repercussions as well. It is important to understand the effects of the pandemic on well-being, both as the world continues to recover from the lasting impact of COVID-19 and in the eventual case of future pandemics. On March 20, 2020, we launched an online daily survey study tracking participants' sleep and mental well-being. Repeated reports of sleep and mental health metrics were collected from participants ages 18-90 during the initial wave of the pandemic (March 20 - June 23, 2020). Given both the comprehensive nature and early start of this assessment, open access to this dataset will allow researchers to answer a range of questions regarding the psychiatric impact of the COVID-19 pandemic and the fallout left in its wake.

Sleeping under the waves: A longitudinal study across the contagion peaks of the COVID-19 pandemic in Italy

After the March–April 2020 coronavirus disease 2019 (COVID‐19) outbreak, a second contagion wave afflicted Europe in the autumn. The present study aimed to evaluate sleep health/patterns of Italians during this further challenging situation. A total of 2,013 Italians longitudinally participated in a web‐based survey during the two contagion peaks of the COVID‐19 outbreak. We investigated the risk factors for sleep disturbances during the second wave, and we compared sleep quality and psychological well‐being between the two assessments (March–April and November–December 2020). Female gender, low education, evening chronotype, being a high‐risk person for COVID‐19 infection, reporting negative social or economic impact, and evening smartphone overuse predicted a higher risk of poor sleep and insomnia symptoms during the second wave. Advanced age, living with a high‐risk person for COVID‐19 infection, and having a relative/friend infected with COVID‐19 before the prior 2 weeks were risk categories for poor sleep quality. Living with children, having contracted COVID‐19 before the prior 2 weeks, being pessimistic about the vaccine and working in healthcare, were risk factors for insomnia symptoms. The follow‐up assessment highlighted reduced insomnia symptoms and anxiety. Nevertheless, we found reduced sleep duration, higher daytime dysfunction, advanced bedtime and wake‐up time, and a shift to morningness, confirming the alarming prevalence of poor sleepers (~60%) and severe depression (~20%) in a context of increased perceived stress. The present study showed a persistent impact of the COVID‐19 pandemic on sleep and mental health. Large‐scale interventions to counteract the chronicity and exacerbation of sleep and psychological disturbances are necessary, especially for the at‐risk categories.

Current Activities Centered on Healthy Living and Recommendations for the Future: A Position Statement from the HL-PIVOT Network

We continue to increase our cognizance and recognition of the importance of healthy living (HL) behaviors and HL medicine (HLM) to prevent and treat chronic disease. The continually unfolding events precipitated by the coronavirus disease 2019 (COVID-19) pandemic have further highlighted the importance of HL behaviors, as indicated by the characteristics of those who have been hospitalized and died from this viral infection. There has already been recognition that leading a healthy lifestyle, prior to the COVID-19 pandemic, may have a substantial protective effect in those who become infected with the virus. Now more than ever, HL behaviors and HLM are essential and must be promoted with a renewed vigor across the globe. In response to the rapidly evolving world since the beginning of the COVID-19 pandemic, and the clear need to change lifestyle behaviors to promote human resilience and quality of life, the HL for Pandemic Event Protection (HL-PIVOT) network was established. The 4 major areas of focus for the network are: (1) knowledge discovery and dissemination; (2) education; (3) policy; (4) implementation. This HL-PIVOT network position statement provides a current synopsis of the major focus areas of the network, including leading research in the field of HL behaviors and HLM, examples of best practices in education, policy, and implementation, and recommendations for the future.

The Coronavirus Pandemic: A Possible Model of the Direct and Indirect Impact of the Pandemic on Sleep Quality in Italians

PURPOSE

This study aimed to assess the direct and indirect impact of COVID-19-related aspects on self-reported sleep quality, considering the moderator role of some psychological variables.

METHODS

During the first weeks of the lockdown in Italy, 2286 respondents (1706 females and 580 males; age range: 18-74 years) completed an online survey that collected sociodemographic information and data related to the experience with the COVID-19 pandemic. Some questionnaires assessed sleep quality, psychological well-being, general psychopathology, Post-Traumatic Stress Disorders symptoms, and anxiety. The path analysis was adopted.

RESULTS

The study confirms a direct effect of some aspects ascribable to the pandemic, with a mediator role of the psychological variables. Lower sleep quality was directly related to the days spent at home in confinement and the knowledge of people affected by the COVID-19. All the other aspects related to the COVID-19 pandemic influenced sleep quality through the mediator effect of psychological variables.

CONCLUSION

This study highlighted that the psychological condition of the population has been influenced by the COVID-19 pandemic and the government actions taken to contain it, but it has also played an important role in mediating the quality of sleep, creating a vicious circle on people's health. The results suggest that a health emergency must be accompanied by adequate social support programs to mitigate the fear of infection and promote adequate resilience to accept confinement and social distancing. Such measures would moderate psychological distress and improve sleep quality.

People with dyssomnia showed increased vulnerability to CoVID-19 pandemic: a questionnaire-based study exploring the patterns and predictors of sleep quality using the latent class analysis technique in Indian population

INTRODUCTION

CoVID-19 pandemic and the subsequent lockdown have impacted the sleep quality and the overall wellbeing of mankind. The present epidemiological study measured various aspects of sleep disturbance such as sleep quality, daytime impairments, negative emotionality, sleep hygiene, and well-being associated with CoVID-19 pandemic among the Indian population.

METHODS

This cross-sectional voluntary online survey (using Google form) was communicated across the country from 4th June to 3rd July 2020 through mail and social media applications. The responses received (N = 450) were categorized and validated using the latent class analysis and logistic regression tests respectively, and the classes and subclasses derived were profiled. These techniques are used for the first time in a CoVID-19 sleep study.

RESULTS

Out of the three classes derived from the LCA, people with severe dyssomnia belonging to class 1 (33.3%) showed high daytime impairments, negative emotionality and high vulnerability towards CoVID-19 pandemic measures. In addition, the two subclasses derived from the severe dyssomnia group; one with negative emotionality predominance and the other with excessive daytime sleepiness, were similarly affected by CoVID-19 measures. People with moderate dyssomnia (class 2, 28.5%) showed frequent arousals with daytime impairments and the majority (38.2%) which fell in to class 3, the 'no dyssomnia' category, were not impacted by CoVID-19 pandemic.

CONCLUSION

People with existing sleep problems or those who were vulnerable to the same were the ones affected by CoVID-19 pandemic. Those with inadequate emotional coping styles have showed heightened vulnerability. Proper medical and cognitive interventions are highly recommended for this population. No or moderate dyssomnia categories (class 3 and 2 respectively) were less impacted by CoVID-19.

Sleep Disordered Breathing Diagnosis and Treatment During the COVID-19 Pandemic: A Nationwide Survey in China

BACKGROUND AND OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has markedly impacted the distribution of medical resources and healthcare delivery systems. The objective of this study was to investigate the influence of the pandemic on the diagnosis and treatment of sleep-disordered breathing (SDB) in China.

METHODS

A retrospective online survey of sleep centers from the assembly of SDB of the Chinese Thoracic Society was conducted from July 1 to July 20, 2020. The questionnaire focused on four main aspects: 1) general information about the centers; 2) changes in SDB management activities, including patient volumes, diagnostic and positive airway pressure (PAP) titration procedures, and follow-up methods, from February to June 2020, compared with before; 3) the application of telemedicine and sleep specialists' self-assessments of knowledge and their perspectives on telemedicine; and 4) changes in medical staff active in sleep services during the pandemic compared with before.

RESULTS

Fifty-three (96%) of the sleep centers responded to the survey. During the early stage of the outbreak, SDB medical services were dramatically reduced to 5-10% of the pre-epidemic level, and laboratory-based polysomnograms and manual titration were almost cancelled. With the subsidence of COVID-19, SDB medical services gradually resumed to approximately half of the pre-pandemic level by June. However, a second wave of COVID-19 in Beijing significantly reduced the recovery of SDB services. The application of polygraphy has increased significantly. Home-initiated PAP and telemedicine still accounted for a small part of SDB management during the pandemic.

CONCLUSION

The COVID-19 pandemic has greatly challenged SDB management in China. Polygraphy played a major role in SDB diagnosis during the pandemic. Home-based SDB management and telemedicine have not been well implemented. The second surge of COVID-19 in Beijing cut back on the recovering SDB service to the early outbreak level, which may give us an impetus to restructure our sleep health service.

Nomophobia is Associated with Insomnia but Not with Age, Sex, BMI, or Mobile Phone Screen Size in Young Adults

PURPOSE

NOMOPHOBIA (NO MObile PHone PhoBIA) or problematic smartphone use is a psychological disorder in which people are afraid of being cut off from their mobile phones. Currently, there has been no direct assessment of mobile phone screen size in the home setting and its effect on nomophobia and related symptoms, such as insomnia. Thus, we investigated the association between nomophobia, insomnia, and mobile phone screen size in a young adult population in Bahrain.

PATIENTS AND METHODS

Using a descriptive, cross-sectional design, we surveyed participants aged 18 to 35 between August and September 2020 using an online questionnaire. Participants completed demographic questions and questions about personal mobile phones, the Nomophobia Questionnaire (NMP-Q), and the Insomnia Severity Index (ISI). The mobile phone screen size was determined using an open-source online database. Crude and adjusted regression analyses were fitted to examine the associations between the study variables.

RESULTS

A total of 549 individuals, 54% females, were included in the final analyses. One hundred and fourteen participants (21%) had severe nomophobia, and 81 (14%) had clinical insomnia. A strong positive pair-wise linear association was observed between NMP-Q and ISI β 0.15, P = 0.001. Age, sex, BMI, and mobile phone screen size showed no association with the NMP-Q.

CONCLUSION

Nomophobia is very prevalent in young adult men and women, and it is closely associated with insomnia, regardless of mobile phone screen size, suggesting that mobile phone screen size should not be used as a proxy for hazardous usage.

Child and Parent Physical Activity, Sleep, and Screen Time During COVID-19 and Associations With Mental Health: Implications for Future Psycho-Cardiological Disease?

The COVID-19 pandemic has afforded the opportunity for some to improve lifestyle behaviours, while for others it has presented key challenges. Adverse changes in global lifestyle behaviours, including physical activity, sleep, and screen time can affect proximal mental health and in turn distal cardiovascular outcomes. We investigated differences in physical activity, sleep, and screen time in parents and children during early stages of the COVID-19 pandemic in Australia compared to pre-COVID-19 national data; and estimated associations between these movement behaviours with parent and child mental health. Cross-sectional baseline data from the COVID-19 Pandemic Adjustment Study (CPAS; N = 2,365) were compared to nationally representative pre-pandemic data from the Longitudinal Study of Australian Children (LSAC; N = 9,438). Participants were parents of children aged ≤ 18 years, residing in Australia. Parents provided self-report measures of mental health, physical activity and sleep quality, and reported on child mental health, physical activity and screen time. Children in CPAS had significantly more sleep problems and more weekend screen time. Their parents had significantly poorer sleep quality, despite increased weekly physical activity. Children's sleep problems were significantly associated with increased mental health problems, after accounting for socioeconomic status, physical activity, and screen time. Poorer parent sleep quality and lower levels of physical activity were significantly associated with poorer mental health. Monitoring this cohort over time will be important to examine whether changes in movement behaviour are enduring or naturally improve with the easing of restrictions; and whether these changes have lasting effects on either parent or child mental health, and in turn, future risk for CVD.

The Bidirectional Associations Between Insomnia and Psychotic-Like Experiences Before and During the COVID-19 Pandemic

STUDY OBJECTIVES

Previous literature supports that insomnia is predictive of subsequent psychotic-like experiences (PLEs) in the general population. However, there is a lack of empirical data on the reverse causality between the two variables and on the correlation between the symptom severity of insomnia and PLEs. This study aimed to explore the bidirectional associations between insomnia and PLEs before and during the COVID-19 pandemic.

METHODS

A total of 938 students aged 14-25 years completed both waves of the survey before and during the pandemic (the first wave: October 2019 to November 2019; the second wave: April 2020 to May 2020). PLEs were assessed using the 15-item positive subscale of the community assessment of psychic experiences (CAPE-P15), and insomnia was assessed using three questions on difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening.

RESULTS

Students with baseline insomnia were more likely to exhibit new-onset PLEs during the pandemic (OR: 5.13, 95% CI: 2.54-10.38), while no significant predictive effect of insomnia was found for the persistence and severity of PLEs. Meanwhile, baseline PLEs not only predicted the presence of insomnia during the pandemic (OR: 2.14, 95% CI: 1.25-3.65) but also correlated with its severity (B: 0.89, 95% CI: 0.47-1.31).

CONCLUSION

The study provides the first piece of evidence for the bidirectional association between insomnia and PLEs in the general population. However, although insomnia has an important predictive role in the occurrence of PLEs, it does not predict the persistence and development of PLEs, suggesting that there is a more complex mechanism underlying the process.

The Prevalence of Psychological Distress and Its Relationship to Sleep Quality in Saudi Arabia's General Population During the COVID-19 Pandemic

BACKGROUND

We aimed to examine the effect of the COVID-19 pandemic and associated mitigation measures on sleep quality and psychological distress in Saudi Arabia.

METHODS

Subjective sleep quality over the preceding 30 days was measured using the Pittsburgh Sleep Quality Index (PSQI). In addition, Kessler Psychological Distress Scale (K10) was used to assess the psychological distress.

RESULTS

The study included 836 participants. The median age was 28 years, 624 (74.64%) were females, and 158 (18.90%) were healthcare workers. Factors associated with poor sleep were recent changes in the sleep habits p = 0.004), anxiety or fear because of coronavirus news on social media p = 0.02), fear because there was no approved drug to treat COVID-19 p = 0.03), and unaware of the presence of chronic diseases p = 0.03). Female gender p = 0.02), fear or anxiety because of coronavirus news on social media p = 0.04), recent change in sleep habits (OR: 1.97 (1.15-3.39); p = 0.01), fear because there is no approved drug to treat COVID-19 p = 0.001), monthly income <1000 SR p = 0.01), and isolation p = 0.01) were associated with distress. PSQI and K10 scores were significantly correlated p < 0.001).

CONCLUSION

Poor sleep and psychological distress are common during the COVID-19 outbreak in Saudi Arabia. Identifying factors associated with poor sleep and psychological distress would help develop specific intervention programs that enhance mental health and sleep quality during pandemics.