The Society of Behavioral Sleep Medicine (SBSM) COVID-19 Task Force: Objectives and Summary Recommendations for Managing Sleep during a Pandemic

COVID-19-Related News Consumption Linked with Stress and Worry, but Not Sleep Quality, Early in the Pandemic

Beginning in early 2020, the novel coronavirus was the subject of frequent and sustained news coverage. Building on prior literature on the stress-inducing effects of consuming news during a large-scale crisis, we used network analysis to investigate the association between coronavirus disease 2019 (COVID-19) news consumption, COVID-19-related psychological stress, worries about oneself and one's loved ones getting COVID-19, and sleep quality. Data were collected in March 2020 from 586 adults (45.2% female; 72.9% White) recruited via Amazon Mechanical Turk in the U.S. Participants completed online surveys assessing attitudes and behaviors related to COVID-19 and a questionnaire assessing seven domains of sleep quality. Networks were constructed using partial regularized correlation matrices. As hypothesized, COVID-19 news consumption was positively associated with COVID-19-related psychological stress and concerns about one's loved ones getting COVID-19. However, there were very few associations between COVID-19 news consumption and sleep quality indices, and gender did not moderate any of the observed relationships. This study replicates and extends previous findings that COVID-19-news consumption is linked with psychological stress related to the pandemic, but even under such conditions, sleep quality can be spared due to the pandemic allowing for flexibility in morning work/school schedules.

Sleep During the Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has significantly affected childhood sleep. Decreased sleep quality and duration, more bedtime resistance, difficulty initiating and maintaining sleep, and higher rates of parasomnias have all been noted. The mental health crisis with doubling rates of anxiety and depression has also had a profound influence on youth sleep. The pediatric sleep medicine field has responded to the COVID-19 pandemic by adapting existing practices for safety and greatly expanding telemedicine services. Research and training considerations are further discussed.

Sleep Quality Impairment Is Associated With Pandemic Attitudes During the Coronavirus Disease 2019 (COVID-19) Circuit Breaker Lockdown in England: A Cross-Sectional Study

Objectives

The COVID-19 pandemic has been associated with sleep quality impairment and psychological distress, and the general public has responded to the pandemic and quarantine requirements in a variety of ways. We aimed to investigate whether sleep quality is low during a short-term (circuit break) quarantine restriction, and whether sleep quality is associated with respondents' overall attitudes to the pandemic using a validated scale.

Design and Setting

Online cross-sectional study in England in November 2020.

Participants

The study included 502 respondents over the age of 18.

Measurements

Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), and pandemic attitudes were assessed using the Oxford Pandemic Attitudes Scale–COVID-19 (OPAS-C), a validated 20-item, 7-domain scale that assesses pandemic-related stress, fear, loneliness, sense of community, sense of exaggerated concern, non-pharmaceutical interventions, and vaccine hesitancy. Unadjusted and multivariable logistic regression odds ratios of association were assessed between the dependent variable of poor sleep quality (PSQI>5) and risk factors, including OPAS-C score, age, sex, educational status, and income.

Results

The mean (SD) PSQI score was 7.62 (3.49). Overall, 68.9% of respondents met criteria for poor sleep quality using the PSQI cutoff of >5. The mean (SD) OPAS-C score was 60.3 (9.1). There was a significantly increased odds of poor sleep quality in the highest vs. lowest OPAS-C quartiles (OR 4.94, 95% CI [2.67, 9.13], p < 0.0001). Age, sex, income, political leaning, employment status, and education attainment were not associated with poor sleep quality.

Conclusions

More than two-thirds of respondents met criteria for poor sleep quality. The odds of poor sleep quality increased in a dose-response relationship with pandemic attitudes (such as higher levels of pandemic-related stress, fear, or loneliness). The association between poor sleep quality and pandemic attitudes suggests opportunities for public health and sleep medicine interventions, and highlights the need for further research.

The COVID-19 infodemic at your fingertips. Reciprocal relationships between COVID-19 information FOMO, bedtime smartphone news engagement, and daytime tiredness over time

Considering that insufficient sleep has long been regarded as a significant public health challenge, the COVID-19 pandemic and its co-evolving infodemic have further aggravated many people's sleep health. People's engagement with pandemic-related news, particularly given that many people are now permanently online via smartphones, has been identified as a critical factor for sleep health, such that public health authorities have recommended limited news exposure. This two-wave panel survey, conducted with a representative sample in Austria during its first COVID-19 lockdown, examines (a) how fear of missing out on pandemic-related news (i.e., COVID-19 information FOMO) is reciprocally related to smartphone-based bedtime news engagement, as well as (b) how both bedtime news engagement and COVID-19 information FOMO predict daytime tiredness. Partial metric measurement invariant structural equation modeling revealed that COVID-19 information FOMO and bedtime news engagement are reciprocally associated over time, indicating a potentially harmful reinforcing loop. However, results further suggested that COVID-19 information FOMO may be the primary driver of daytime tiredness, not smartphone-based bedtime news engagement. These findings suggest that a perceived loss of (informational) control over the pandemic outbreak more strongly than poor sleep habits accounts for depleted energy resources during lockdown. However, given the initial evidence for a reinforcing loop, this effect pattern may change in the long term.

Sleep disorders and mental health in hospital workers during the COVID-19 pandemic: a cross-sectional multicenter study in Northern Italy

INTRODUCTION

From the beginning of the COVID-19 pandemic, healthcare workers had to face unprecedented emergency needs associated with an extraordinary amount of psychological distress. In this cross-sectional multicenter study, we investigated sleep disturbances, and the level of anxiety and depression among the healthcare and non-healthcare staff of three hospitals in Milan (Italy) during the COVID-19 outbreak. Moreover, we explored potential predisposing factors for affective symptoms and poor sleep.

METHODS

Between June and July 2020, we administered an online questionnaire to evaluate the presence of sleep disorders (Pittsburgh Sleep Quality Index), insomnia (Sleep Condition Indicator), anxiety (State Trait Anxiety Inventory), and depression (Beck Depression Inventory-II). We used univariate and multivariate analysis to evaluate the association between the personal conditions and sleep and affective disorders.

RESULTS

The 964 participants reported high rates of sleep disorders (80.3%)-mainly insomnia (30.5%)-anxiety (69.7%), and depression (32.8%). The multivariate analysis showed a strong association of sleep disorders, especially insomnia, with female gender (p = 0.004), divorced marital status (p = 0.015), self-isolation (p = 0.037), and chronic diseases (p = 0.003). Anxiety was significantly associated with teleworking (p = 0.001), while depressive symptoms were associated with self-isolation (p = 0.028), modified work schedules (p = 0.03), and chronic diseases (p = 0.027).

CONCLUSION

In hospital workers, the high prevalence of sleep and psychiatric symptoms during the COVID-19 outbreak appears to be determined mainly by modifications of personal or work habits. Teleworking was associated with increased anxiety. An accurate planning of hospital activities and a psychological support are needed to prevent and manage sleep and mental disorders.

Disrupted Sleep During a Pandemic

The COVID-19 pandemic affected sleep in several people. Though most of the studies argued that age, gender, employment, finances, responsibilities, and exposure to sunlight governed sleep-wake schedule and sleep disturbances, there is also scientific evidence to suggest that these issues could have aroused because of the infiltration of the central nervous system (CNS) by SARS-CoV-2. Sleep disturbances must be addressed during the pandemic as sleep disturbances and systemic inflammation run in a vicious cycle; quality of sleep and timing of vaccination can influence the immune response to vaccination and subjects having obstructive sleep apnea (OSA) are at higher risk for having SARS-CoV-2 infection-related complications.

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.

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.

Measuring the Effects of Social Isolation and Dissatisfaction on Depressive Symptoms during the COVID-19 Pandemic: The Moderating Role of Sleep and Physical Activity

Social distancing was universally implemented to reduce the spread of the COVID-19 virus. Long-term social distancing can lead to increased feelings of social isolation or dissatisfaction with one's daily interpersonal interactions, which can subsequently result in reduced psychological health (e.g., greater depression). The present study quantified this association, and the extent to which it was moderated by measures of sleep and physical activity, by surveying 3658 adults (mean age = 46.0 years) from across the United States. Participants answered questions related to their social experiences, sleep, physical activity, and depressive symptoms during the early stages of the pandemic (March-June 2020). Results showed that social isolation and social dissatisfaction were associated with greater depressive symptoms. As predicted, self-reported sleep quality and physical activity moderated these associations, such that lower sleep quality and physical activity exacerbated their effect on depressive symptoms.

Are Sleep Problems Related to Psychological Distress in Healthy Aging during the COVID-19 Pandemic? A Review

The SARS-CoV-2 pandemic, characterized by home confinement and other restrictive measures to reduce the spread of the infection, led to significant changes in people's habits and lifestyle. One of the most common problems is the worsening of sleep quality or quantity, which could have negative effects on psychological wellbeing, particularly in older adults. The purposes of the present literature review considering healthy aging subjects are (a) to examine the existing research on sleep alterations during the current pandemic and (b) to highlight possible relationships between sleep problems and psychological distress. A systematic search strategy was implemented according to PRISMA guidelines in the international literature online databases, up to 1 July 2021. After identification and screening phases, 11 articles were included in this review. The studies found possible associations between sleep problems and mood changes-particularly in terms of depression and anxiety. In addition, altered sleep patterns seemed to be related to changes in individual aspects, lifestyle, and attitudes adopted by older adults during the COVID-19 lockdown. Thus, the pandemic could affect the sleep and psychological wellbeing of the older population, even in healthy aging.

Sleep disturbances in children with cystic fibrosis, primary ciliary dyskinesia and typically developing children during COVID-19 pandemic

AIM

We aimed to investigate sleep disturbances in children with cystic fibrosis (CF) and primary ciliary dyskinesia (PCD) and typically developing (TD) children during the COVID-19 pandemic.

METHODS

Primary care givers of children with CF and PCD aged 3-16 years were asked to enrol in the study. Primary care givers of TD children were included as control group. The Sleep Disturbance Scale for Children (SDSC) was used, and questions related to sleep habits during the pandemic were asked. Results of the three groups were compared.

RESULTS

Primary care givers of 33 children with CF, 16 children with PCD and 66 TD children were included in the study. There were no differences in terms of age and gender between the three groups. Changes in sleep patterns during the pandemic were more common among TD children and their families, with 75% of the children and 80% of their families sleeping later than before. The sleep initiation and maintenance disorder scores were higher in TD children (P = 0.001), whereas the sleep breathing disorder scores were higher in children with PCD (P = 0.001), and the sleep hyperhidrosis scores were higher in children with CF and PCD (P = 0.011). No relationships were found between sleep parameters and clinical findings of children with lung disease.

CONCLUSIONS

Children's sleep habits have changed during the pandemic. Children with chronic lung diseases and even TD children may experience sleep disturbances during this period.

Changes in sleep duration, timing, and variability during the COVID-19 pandemic: Large-scale Fitbit data from 6 major US cities

The COVID-19 pandemic has resulted in societal-level changes to sleep and other behavioral patterns. Objective data would allow for a greater understanding of sleep-related changes at the population level. About 163,524 active Fitbit users from 6 major US cities contributed data, representing areas particularly hard-hit by the pandemic (Chicago, Houston, Los Angeles, New York, San Francisco, and Miami). Sleep variables extracted include nightly and weekly mean sleep duration and bedtime, and variability (standard deviation) of sleep duration and bedtime. Deviation from similar timeframes in 2018 and 2019 were examined, as were changes in these sleep metrics during the pandemic, relationships to changes in resting heart rate, and changes during re-opening in May and June. Overall, compared to 2019, mean sleep duration in 2020 was higher among nearly all groups, mean sleep phase shifted later for nearly all groups, and mean sleep duration and bedtime variability decreased for nearly all groups (owing to decreased weekday-weekend differences). Over the course of January to April 2020, mean sleep duration increased, mean bedtime shifted later, and mean sleep duration variability decreased. Changes in observed resting heart rate correlated positively with changes in sleep and negatively with activity levels. In later months (May and June), many of these changes started to drift back to historical norms.

Shift work is associated with increased risk of COVID-19: Findings from the UK Biobank cohort

Despite the strong evidence on circadian rhythm disruption in shift workers and consequent increased vulnerability for infection, longitudinal association between shift work and COVID-19 infection is unexplored. In this study, data from UK Biobank participants who were tested for COVID-19 infection (16 March to 7 September 2020) were used to explore the link between shift work and COVID-19 infection. Using the baseline occupational information, participants were categorised as non-shift workers, day shift workers, mixed shift workers and night shift workers. Multivariable regression models were used to assess the association between shift work and COVID-19 infection. Among the 18,221 participants (9.4% positive cases), 11.2% were health workers, and 16.4% were involved in shift-work-based jobs. Ethnic minorities (18%) and people in night-shift-based jobs (18.1%) had a significantly higher prevalence of COVID-19 infection than others. Adjusted logistics regression model suggest that, compared with their counterparts, people employed in a night-shift-based job were 1.85-fold (95% CI: 1.42-2.41) more likely to have COVID-19 infection. Sensitivity analysis focusing on people working in a non-healthcare setting suggests that people in shift-work-based jobs had 1.81-fold (95% CI: 1.04%-3.18%) higher odds of COVID-19 infection than their counterparts. Shift workers, particularly night shift workers, irrespective of their occupational group, seem to be at high risk of COVID-19 infection. If similar results are obtained from other studies, then it would mandate to revisit the criteria for defining high-risk groups for COVID-19 and implementing appropriate interventions to protect people in shift-based jobs.

Sleep and Psychological Difficulties in Italian School-Age Children During COVID-19 Lockdown

Objective

On March 10, 2020, the Italian Government ordered a national lockdown to limit the viral transmission of coronavirus disease 2019 infections. This study investigated how these restrictive measures have impacted sleep quality, timing, and psychological difficulties in school-age children and their mothers during the lockdown.

Methods

In an online survey, 299 mothers reported their sleep habits, experience of time, and psychological difficulties as well as those of their children (6–10 years old) during and, retrospectively, before the lockdown.

Results

During the lockdown, children showed a marked delay in sleep timing—that is, later bedtime and rise time—and a mild worsening in sleep quality. They were less prone to respect daily routines or to keep track of the passage of time. They showed increased emotional, conduct, and hyperactive symptoms, and the increase in these psychological difficulties was predicted by the change in sleep quality, boredom, and mothers’ psychological difficulties. In addition, mothers showed a delayed sleep timing and worsening of sleep quality during the lockdown, in varying degrees depending on their working conditions. Mothers who kept working regularly outside their homes during lockdown reported more regular sleep patterns, whereas mothers who stopped working showed more emotional symptoms and relevant changes in their perception of time.

Conclusions

Overall, given the evidence of the adverse behavioral and psychological impact of home confinement and social restrictions, effective measures needed to be in place to mitigate long-term effects on children and their mothers, especially those who have had to stop working during lockdown.

Cluster analysis of insomnia symptoms during COVID-19 pandemic: a general population web-based survey in Iran

Objective

To investigate the prevalence of insomnia and its different phenotypes as well as their association with fear of COVID-19 in the general population.

Material and Methods

This was a cross-sectional study conducted using an online survey (e-poll). All available participants who completed the online survey form were included in the current study. All individuals with a history of sleep problems were excluded. A questionnaire package consisted of insomnia severity index (ISI), and FCV-19 for corona fear was administered for all participants. Insomnia was defined as ISI≥8. Insomnia phenotypes were considered as: (a) DIS: difficulty initiating sleep; (b) DMS: difficulty maintaining sleep; (c) EMA: early morning awakening; and (d) combined insomnia.

Results

A total of 1,223 participants [827 (67.6%) female, mean age=39.82±10.75 years old], enrolled in the current survey. Based on ISI, 675 (55.2% [95%CI=52.40-57.98]) were categorized into the insomnia group. Insomnia was more prevalent in females (p=0.006), participants with 50 years old or higher (p=0.04), or high fear of COVID-19 (p<0.0001). Totally, 67.4%, 66.4%, and 55% of all participants had DIS, DMS, and EMA, respectively, in the current outbreak. Besides, 79% had impaired daily functioning, 51.6% had impaired quality of life, and 62% were worried about their sleep problem. Notably that a considerable percentage of individuals with normal ISI scores had at least one insomnia phenotype or impaired daily functioning and quality of life. Further analyses revealed a significant increasing trend in all four insomnia phenotypes prevalence with an increase in fear of COVID-19 (all p-values<0.0001).

Conclusion

Individuals with higher age, female gender, or higher fear of COVID-19 are at higher risk of all types of insomnia as well as impaired daytime performance or quality of life.

Influence of Confinement by COVID-19 on the Quality of Sleep and the Interests of University Students

PURPOSE

To check for changes in sleep in three temporary times: before COVID-19 lockdown in university students, and also twenty days and forty days afterwards, as well as to see how it has influenced in their daily activities.

MATERIALS AND METHODS

A longitudinal study was conducted with a sample of 75 participants from different Spanish universities. The Pittsburgh Sleep Quality Index and the Adapted Interest List were administered to evaluate the main variables of the study.

RESULTS

About 70.7% of the sample showed worse sleep quality at 20 days, almost twice as much as before confinement (37.3%), there were more problems falling asleep (F(2, 75) = -3.14, p = 0.002), and more difficulty getting back to sleep when waking up at night (F(2.75) = 2.08, p = 0.037) at 40 days of lockdown. In addition, as confinement time went on, students showed less activities. Factors such as working, in addition to studying, and relaxing activities (reading, listening to music) were associated with better sleep quality.

CONCLUSION

Sleep quality worsened during lockdown in university students, as well as both 20 and 40 days later. Staying busy during the day (not only studying but also working) and spending free time on relaxing activities are related to better sleep quality.