Modeling the Effects of Stress, Anxiety, and Depression on Rumination, Sleep, and Fatigue in a Nonclinical Sample

How should we manage fatigue in on-call workers? A review of guidance materials and a systematic review of the evidence-base

On-call work is known to contribute to disrupted sleep, fatigue, and an increased risk of incidentor injury. This review aimed to a) identify current on-call management strategies that are suggested or required by regulatory bodies, and b) determine if there is empirical evidence to support these strategies in managing the fatigue of on-call workers. A grey literature search produced 65 relevant guidance materials. A systematic inductive thematic process identified consistent strategies included in these materials: 1) regularity/predictability of shifts, 2) fatigue management policy, 3) prescriptive rule sets, 4) fitness for work assessment, 5) on-the-day control measures, 6) risk assessment, 7) training and education, and 8) call management. Subsequently, a systematic review identified 17 original studies on the effectiveness of fatigue management strategies in on-call workers. Very little research has been done on fatigue management strategies for on-call workers outside of some prescriptive hours of work limitations. These limitations generally reduced fatigue, but often had the unintended consequence of increasing workload, which may inadvertently increase overall risk. Training, education, and call management (e.g., protected naps during on-call periods) also had some supporting evidence. The current gap in evidence emphasises the critical need for research on tailored on-call fatigue management strategies.

Telemedicine-medical "snack community"-PHS ecosystem: Insights into the double-edged sword role of telemedicine in clinical practice and medical education during the COVID-19 pandemic and beyond

Telemedicine has gained tremendous development during the COVID-19 pandemic. With deblocking and opening, telemedicine accelerates the evolvution of the medical "snack community" and undermines the perception of medical students and staff, which promotes the incidence of psychosocial-related disorders. Moreover, the inconsistent telemedicine adaptability between medical workers and patients aggravates the doctor-patient conflict due to the aging population and COVID-19 squeal. Telemedicine is colliding with the national healthcare system, whose synchronization with conventional medical service is crucial to coordinate the relationship among medical payment, patient privacy and qualifications of clinicians. This study puts more emphasis on the double-edged sword role of telemedicine in clinical practice and medical education during the COVID-19 pandemic and beyond. Overall, while telemedicine has demonstrated its utility in health care throughout the COVID pandemic, it is pretty critical to continue evaluating the efficacy and limitations of telemedicine in order to maintain equal access to medical service and high-quality medical education. A new concept as telemedicine-medical "snack community"-PHS ecosystem, where the psychological health education system and partners healthcare system with enough bandwidth, especially 5G technology, could optimize the effect of telemedicine on medical practice and education, is proposed.

The Roles of Stress, Sleep, and Fatigue on Depression in People with Visual Impairments

The study aimed to investigate the mediating effect of fatigue and the moderating effect of sleep quality on stress and depressive symptoms among people with visual impairments. A total of 155 participants completed the online survey. The Perceived Stress Scale, the Fatigue Symptom Inventory, the Centre for Epidemiological Studies-Depression Inventory (CES-D), and the Pittsburgh Sleep Quality Index (PSQI) were used. Descriptive analysis, correlations, and moderated mediation modelling were conducted using R software. From the mediator variable (FSI) model (F = 22.427, R2 = 56.5, p < .001) and the dependent variable (CES-D) model (F = 35.912, R2 = 70.5, p < .001), after controlling for age, sex, employment, and education, sleep quality positively predicted fatigue levels (β = 2.422, p = .009), and fatigue positively predicted depressive symptoms (β = .152, p < .001). Sleep quality is an essential component of psychological well-being in people with visual impairments.

Mediating Role of Rumination Between Anger and Anxious-Depressive Symptomatology in Family Members of People with Gambling Disorder

Gambling disorder is characterized by a behavioural pattern of dysfunctional gambling that persists despite its negative implications in different areas of people's daily life. One of the most negatively affected areas is the one related to family members. This study aimed, firstly, to study the differences between family members of people with gambling disorder and a general population sample in anger (state, trait, expression-out, expression-in. control-out and control-in), rumination (brooding, reflection and total), and anxiety and depression. The second aim was to analyse the correlation between these variables in the family members of people with gambling disorder, and thirdly, to analyse the mediating role of rumination between anger, anxiety and depression. This study consisted of 170 people, of whom 87 were family members of people with a gambling disorder, and 83 were from the general population. Instruments measuring anger, anxiety, depression, and ruminative responses were administered. Results showed that family members had significantly higher scores in anger (state), depression, anxiety, rumination (total and brooding). Also, results showed that anger correlated positively and significantly with rumination, depression and anxiety, which also correlated positively and significantly with each other. Third, rumination mediated the relationship between the following variables: anger (state) and depression; anger (trait) and anxiety and depression; anger (external expression) and anxiety and depression. A complete mediating effect was found in the latter case and a partial mediating effect in the first two cases. In conclusion, it is found that having a family member with a gambling disorder may increase levels of anger, anxiety, depression and rumination. Furthermore, it is shown that working on rumination may reduce depression and anxiety in family members of gamblers.

The Mediating Role of Depression and of State Anxiety οn the Relationship between Trait Anxiety and Fatigue in Nurses during the Pandemic Crisis

The coronavirus pandemic (COVID-19) is a global health crisis with a particular emotional and physical impact on health professionals, especially nurses. The aim of this study was to investigate the prevalence of anxiety, depression and fatigue and their possible relationships among nurses during the pandemic. The study population consisted of nurses from five tertiary-level public hospitals in Athens who completed the Fatigue Assessment Scale (FAS), Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) questionnaires. Gender, age and years of work experience were recorded. The study was conducted from mid-November to mid-December 2021. The sample included 404 nurses (69 males and 335 females) with a mean age of 42.88 years (SD = 10.90) and 17.96 (SD = 12.00) years of work experience. Symptoms of fatigue were noted in 60.4% of participants, while 39.7% had symptoms of depression, 60.1% had abnormal scores on state anxiety and 46.8% on trait anxiety, with females showing higher scores on all scales (p < 0.05). High positive correlations (p < 0.01) were found between the FAS, BDI, State Anxiety and Trait Anxiety scales. Regression analysis showed that 51.7% of the variance in FAS scores can be explained by trait anxiety, an additional 6.2% by the BDI and 1.2% by state anxiety. Mediation analysis showed that state anxiety and BDI mediate the relationship between trait anxiety and FAS. Finally, BDI was found to exert a moderating role in the relationship between trait anxiety and fatigue. In conclusion, our study showed that nurses continue to experience high rates of anxiety, depression and fatigue. The variation in fatigue appears to be significantly dependent on trait anxiety. Depressive symptomatology and state anxiety exert a parallel positive mediation on the relationship between trait anxiety and fatigue, with depression exhibiting a moderating role in this relationship.

How and for Whom Is Mobile Phone Addiction Associated with Mind Wandering: The Mediating Role of Fatigue and Moderating Role of Rumination

With the increasing prevalence of mobile phone addiction, mobile phone addiction has been considered a prominent risk factor for internalizing or externalizing problems, such as psychological distress and irrational procrastination. However, few studies shed light on the effect of mobile phone addiction on mind wandering and the underlying mechanisms. This study speculated that the direct effect of mobile phone addiction on mind wandering may be linked to fatigue and that the level of an individual's personality characteristics, such as rumination, may influence both the direct and indirect effects of mobile phone addiction on mind wandering. To test these hypotheses, we recruited 1811 college students to complete the self-report questionnaires. The results indicated that mobile phone addiction was positively associated with mind wandering. This direct effect could be mediated by fatigue, and both the direct and indirect effects of mobile phone addiction on mind wandering could be moderated by rumination. Specifically, both the direct and indirect effects were stronger for students with high rumination. These findings enrich our understanding of how, why, and for whom mobile phone addiction is correlated with mind wandering.

COVID-19 stressors and health behaviors: A multilevel longitudinal study across 86 countries

Anxiety associated with the COVID-19 pandemic and home confinement has been associated with adverse health behaviors, such as unhealthy eating, smoking, and drinking. However, most studies have been limited by regional sampling, which precludes the examination of behavioral consequences associated with the pandemic at a global level. Further, few studies operationalized pandemic-related stressors to enable the investigation of the impact of different types of stressors on health outcomes. This study examined the association between perceived risk of COVID-19 infection and economic burden of COVID-19 with health-promoting and health-damaging behaviors using data from the PsyCorona Study: an international, longitudinal online study of psychological and behavioral correlates of COVID-19. Analyses utilized data from 7,402 participants from 86 countries across three waves of assessment between May 16 and June 13, 2020. Participants completed self-report measures of COVID-19 infection risk, COVID-19-related economic burden, physical exercise, diet quality, cigarette smoking, sleep quality, and binge drinking. Multilevel structural equation modeling analyses showed that across three time points, perceived economic burden was associated with reduced diet quality and sleep quality, as well as increased smoking. Diet quality and sleep quality were lowest among respondents who perceived high COVID-19 infection risk combined with high economic burden. Neither binge drinking nor exercise were associated with perceived COVID-19 infection risk, economic burden, or their interaction. Findings point to the value of developing interventions to address COVID-related stressors, which have an impact on health behaviors that, in turn, may influence vulnerability to COVID-19 and other health outcomes.

Le sommeil des étudiants français en période de COVID-19 : influence des deux premiers confinements sur la quantité et la qualité de sommeil

La pandémie de la COVID-19 a entraîné deux périodes de confinement pendant l’année 2020 qui ont amené à des modifications des habitudes de vie. L’objectif de notre étude est d’évaluer l’impact des confinements sur la quantité (i.e., horaires et temps passé au lit) et la qualité (i.e., difficultés et parasomnies) du sommeil chez des étudiants français. Au cours du premier et du second confinement, les étudiants ont été invités à répondre à un questionnaire en ligne composé de 23 questions. Ce questionnaire s’intéressait aux horaires réels et idéaux de lever et de coucher, au temps passé au lit, ainsi qu’aux parasomnies et difficultés liées au sommeil. Les résultats obtenus ont montré que les étudiants dormaient plus tardivement et passaient plus de temps au lit le week-end qu’en semaine, ces effets étant plus marqués pendant le premier confinement que pendant le second. La majorité des étudiants a rapporté avoir un sommeil de mauvaise qualité, des difficultés d’endormissement, des réveils précoces, ainsi qu’une sensation de manque de sommeil. Les parasomnies les plus fréquentes se sont caractérisées par des épisodes de cauchemars et de somniloquie. Les difficultés liées au sommeil et les parasomnies rapportées étaient plus importantes pendant le second confinement qu’au cours du premier. La dette de sommeil était toujours présente au cours des confinements. Les difficultés de sommeil et les parasomnies rapportées ont témoigné d’un sommeil de mauvaise qualité chez les étudiants durant ces périodes. Des hypothèses explicatives ainsi que des perspectives de prévention quant à l’hygiène du sommeil sont discutées.

Prevalence and Risk Factors for Fatigue in Adults With Inflammatory Bowel Disease: A Systematic Review With Meta-Analysis

BACKGROUND AND AIMS

Inflammatory bowel disease (IBD) is a chronic relapsing and remitting disease with high morbidity, substantial health care costs, and increasing incidence. Fatigue is one of the most common symptoms that impacts quality of life and is a leading concern for patients with IBD. The aim of this study was to determine the global prevalence, risk factors, and impact of fatigue in adults with IBD.

METHODS

A systematic review and meta-analysis was conducted. Data were retrieved from Medline, Embase, CINAHL, and PsycINFO from database inception to October 2019. A pooled prevalence of fatigue was calculated using a random-effects model. Stratified meta-analyses explored sources of between-study heterogeneity. Study quality was assessed using an adapted checklist from Downs and Black.

RESULTS

The search yielded 4524 studies, of which 20 studies were included in the systematic review and meta-analysis. Overall, the studies were of good quality. The pooled prevalence of fatigue was 47% (95% confidence interval, 41%-54%), though between-study heterogeneity was high (I² = 98%). Fatigue prevalence varied significantly by the definition of fatigue (chronic: 28%; high: 48%; P < .01) and disease status (active disease: 72%; remission: 47%; P < .01). Sleep disturbance, anxiety, depression, and anemia were the most commonly reported fatigue-related risk factors.

CONCLUSIONS

The prevalence of fatigue in adults with IBD is high, emphasizing the importance of additional efforts to manage fatigue to improve the care and quality of life for patients with IBD.

The relationship between repetitive negative thinking, sleep disturbance, and subjective fatigue in women with Generalized Anxiety Disorder

Objectives

Fatigue is a prominent symptom of Generalized Anxiety Disorder (GAD). However, the pathways contributing to elevated fatigue in GAD are poorly understood. Sleep disturbance, also prominent in GAD, only partially explains elevated fatigue in GAD. Repetitive negative thinking (RNT) is a cognitive feature of both GAD and sleep disturbance, and RNT has recently also been associated with elevated fatigue. Therefore, this study assessed whether elevated fatigue in GAD is accounted for by a combination of sleep quality and RNT.

Design

Between‐group, correlational design in 64 primarily university‐educated women with and without a GAD diagnosis.

Methods

Women completed self‐report questionnaires assessing RNT experienced in the past few days, previous night’s sleep quality, and current physical and mental fatigue. Hierarchical linear regressions were conducted to assess whether the relationship between GAD status and fatigue is accounted for by RNT and sleep quality.

Results

Women with GAD reported lower sleep quality, and higher RNT and physical and mental fatigue, compared to women without GAD. Sleep quality partly accounted for group differences in both types of fatigue (β’s > −0.4), whereas RNT fully accounted for group differences in both types of fatigue (β’s > 0.29). The relationship between RNT and both types of fatigue was fully accounted for by sleep quality (β’s > −0.39).

Conclusions

These findings indicate that heightened RNT amongst women with GAD may be associated with elevated physical and mental fatigue via its detrimental effects on sleep quality. Interventions that reduce RNT may help to alleviate fatigue symptoms in women with GAD.

Practitioner points

Women with Generalized Anxiety Disorder (GAD) have elevated fatigue and repetitive negative thinking (RNT), and poorer self‐reported sleep quality, relative to women without GAD.

Whereas sleep quality only partially accounts for elevated fatigue in GAD, RNT fully accounts for elevated fatigue, and the relationship between RNT and fatigue is fully accounted for by sleep quality.

These findings provide novel evidence that women with GAD may have elevated fatigue because of the detrimental effects of RNT on sleep.

These findings suggest that targeting RNT in treatment for GAD may help to reduce fatigue in GAD, by improving sleep quality.

Adult hippocampal neurogenesis shapes adaptation and improves stress response: a mechanistic and integrative perspective

Adult hippocampal neurogenesis (AHN) represents a remarkable form of neuroplasticity that has increasingly been linked to the stress response in recent years. However, the hippocampus does not itself support the expression of the different dimensions of the stress response. Moreover, the main hippocampal functions are essentially preserved under AHN depletion and adult-born immature neurons (abGNs) have no extrahippocampal projections, which questions the mechanisms by which abGNs influence functions supported by brain areas far from the hippocampus. Within this framework, we propose that through its computational influences AHN is pivotal in shaping adaption to environmental demands, underlying its role in stress response. The hippocampus with its high input convergence and output divergence represents a computational hub, ideally positioned in the brain (1) to detect cues and contexts linked to past, current and predicted stressful experiences, and (2) to supervise the expression of the stress response at the cognitive, affective, behavioral, and physiological levels. AHN appears to bias hippocampal computations toward enhanced conjunctive encoding and pattern separation, promoting contextual discrimination and cognitive flexibility, reducing proactive interference and generalization of stressful experiences to safe contexts. These effects result in gating downstream brain areas with more accurate and contextualized information, enabling the different dimensions of the stress response to be more appropriately set with specific contexts. Here, we first provide an integrative perspective of the functional involvement of AHN in the hippocampus and a phenomenological overview of the stress response. We then examine the mechanistic underpinning of the role of AHN in the stress response and describe its potential implications in the different dimensions accompanying this response.

Fatigue, Depression, Cardiovascular Risk, and Self-Rated Health: Comparing a Community Sample of Adults to Those With a History of Myocardial Infarction

This cross-sectional descriptive study was designed to compare fatigue, depression, cardiovascular risk, and self-rated health in community dwelling adults (CDA) without a history of myocardial infarction (MI) compared to adults who had experienced an MI 3 to 7 years ago. A convenience sample (n = 40) of CDA completed: demographic health form, Revised Piper Fatigue Scale, and CES-D. Age-matched controls (n = 40) were randomly selected from the Recurrence of Myocardial Infarction (ROMI) study. Most (N = 80) were White (66%) with a mean age of 58.3 (SD = 11.5; range 21-83). The ROMI group reported more diabetes, hypercholesterolemia, obesity, and hypertension, and had higher fatigue (t(61) = 4.51, p < .001). No differences were noted in depression scores (p = .952). Higher fatigue and depression scores were correlated with poorer self-rated health: r = .544 (p < .001) and r = .295 (p = .008).

A mindfulness meditation mobile app improves depression and anxiety in adults with sleep disturbance: Analysis from a randomized controlled trial

OBJECTIVE

The objective of this study was to 1) determine the effects of a meditation app on depression and anxiety in adults with sleep disturbance, and 2) explore the potential mediating effects of fatigue, daytime sleepiness, and pre-sleep arousal on the relationship between use of the meditation app and changes in depression and anxiety.

METHODS

Participants were 239 adults with elevated insomnia symptoms (i.e., scores ≥ 10 on the Insomnia Severity Index) and limited or no previous experience with meditation. Depression, anxiety, fatigue, daytime sleepiness, and pre-sleep arousal were assessed at baseline, four weeks, and eight weeks. Repeated-measures ANCOVAs assessed intervention effects on depression and anxiety. Mediation models were estimated using the PROCESS macro.

RESULTS

Participants in the meditation group had more improvement in depression and anxiety symptoms during the intervention period than did those in the control group. Changes in somatic and cognitive pre-sleep arousal at mid-intervention fully mediated effects on depression and partially mediated effects on anxiety. There were no significant indirect effects of fatigue and daytime-sleepiness on changes in mental health.

CONCLUSIONS

A meditation app may improve depression and anxiety in adults with sleep disturbance, with effects being driven by improvements in pre-sleep arousal. Future studies should consider targeting pre-sleep arousal to improve mental health in this population.

Bedtime Procrastination Partially Mediates the Impact of Personality Characteristics on Daytime Fatigue Resulting From Sleep Deficiency

Getting good and sufficiently long sleep at night is important for health, effective functioning, and well-being. However, insufficient or delayed sleep are important and growing social problems that can lead to fatigue, poor performance, deterioration of well-being, circadian rhythm disturbances, and health problems. One of the significant determinants of sleep deprivation is bedtime procrastination, which is understood as the individual tendency to postpone going to bed in the absence of any external circumstances that force one to do so. Nowadays, this phenomenon is widespread in various social groups, especially among students. Despite the high prevalence of bedtime procrastination, its relationship with personality characteristics has not yet been thoroughly studied. The presented research aimed to identify the possible impact of the basic dispositional personality traits and trait-like personality characteristics on bedtime procrastination and daytime fatigue resulting from a deficiency of sleep at night. The responses from 399 university students who voluntarily took part in an internet survey were analyzed. The severity of bedtime procrastination was assessed using the Bedtime Procrastination Scale. Five basic dispositional personality traits (extraversion, neuroticism, conscientiousness, agreeableness, and openness/intellect) and their components (aspects) were measured using the International Personality Item Pool - Big Five Aspects Scale. Self-esteem and general self-efficacy were assessed using the Rosenberg Self-Esteem Scale and the General Self-Efficacy Scale. Perceived locus of control was measured using the Delta Questionnaire. The direct and indirect relationships between personality variables and daytime fatigue were investigated using linear regression models with bedtime procrastination as a mediator variable. Industriousness and orderliness, both of which are aspects of conscientiousness, were found to be indirectly associated with daytime fatigue as a consequence of their impact on bedtime procrastination. Volatility and withdrawal, both of which are aspects of neuroticism, were found to be directly related to daytime fatigue without the intermediary impact of bedtime procrastination. Self-esteem was shown to be associated with experiencing daytime fatigue, both directly and indirectly through bedtime procrastination. General self-efficacy and external locus of control were associated with daytime fatigue only directly, without the intermediary role of bedtime procrastination. The results of our research indicate that personality factors may not only play an important role in shaping sleep-related health behaviors, but they also affect well-being during the day.

Subjective sleep quality and characteristics across the menstrual cycle in women with and without Generalized Anxiety Disorder

OBJECTIVE

Past studies have found that various psychiatric symptoms fluctuate over the menstrual cycle. Sleep disturbance is a transdiagnostic feature of psychiatric conditions and is associated with several symptoms that exhibit menstrual fluctuations. Although some evidence indicates that subjective sleep quality changes over the menstrual cycle in healthy women, no studies have investigated whether sleep fluctuates over the menstrual cycle in psychiatric populations, other than premenstrual dysphoric disorder.

METHODS

The present study used a mixed between- within-groups design to compare self-reported sleep characteristics (sleep onset latency, number and duration of night-time awakenings, and total sleep time), sleep quality, insomnia symptoms, and daytime sleepiness in women with (n = 31) and without (n = 32) generalized anxiety disorder (GAD) at two time points within a single menstrual cycle - the early-follicular (low ovarian hormones) and mid-luteal (high ovarian hormones) phases.

RESULTS

Women with GAD reported lower sleep quality, more insomnia symptoms, and more daytime sleepiness (η_p² = 0.13-0.14), but comparable sleep characteristics, compared to women without GAD. In both groups, sleep variables remained stable over the menstrual phases examined. Within-person changes in estradiol and progesterone between the two menstrual phases were mostly not associated with within-person changes in sleep variables, except that larger increases in estradiol were associated with a reduction in the number of night-time awakenings from the early-follicular to mid-luteal phases (β = -0.26).

CONCLUSION

These findings indicate that subjective sleep disturbance, unlike other psychiatric symptoms, may not be modulated by the menstrual cycle and ovarian hormones during the phases examined in this study.

The Relationship Between Perceived Stress and Subjective Cognitive Decline During the COVID-19 Epidemic

During the outbreak of the COVID-19 epidemic, fear of disease and its consequences, recommended lifestyle changes, and severe restrictions set by governments acted as stressors and affected people's mood, emotions, mental health, and wellbeing. Many studies conducted during this crisis focused on affective and physiological responses to stress, but few studies examined how the crisis affected cognition. The present cross-sectional study examined the relationship between physiological, affective, and cognitive responses to the epidemic. In an online survey conducted at the height of the first wave of the epidemic in Slovenia (April 15-25, 2020), 830 Slovenian residents aged 18-85 years reported the effects of stressors (confinement, problems at home, problems at work, lack of necessities, and increased workload), experienced emotions, generalized anxiety, perceived stress, changes in health, fatigue and sleep quality, and perceived changes in cognition during the epidemic. Risk factors for stress (neuroticism, vulnerability, general health, gender, and age) were also recorded. We hypothesized that stressors and stress risk factors will be related to subjective cognitive decline, with negative emotions, generalized anxiety, perceived stress, and physical symptoms acting as mediator variables. On average, the results showed a mild subjective cognitive decline during the epidemic. In structural equation modeling, 34% of its variance was predicted by the mediator variables, with negative emotions and physical symptoms having the largest contribution. Stress risk factors were predictably related to the four mediator variables. Among the stressors, confinement showed the strongest effect on the four mediator variables, implying the importance of thoughtful communication about necessary restrictive measures during emergency circumstances. The results of this study indicate that the possibility of altered cognitive function should be considered when planning work and study activities during the epidemic.

Characterization of Sleep Disturbances in Children and Adolescents with Down Syndrome and Their Relation with Cognitive and Behavioral Features

Despite sleep disturbances are common among youths with Down syndrome (DS), the cognitive and behavioral features associated with sleep problems have not yet been studied extensively. The present study investigated the presence of sleep disturbances in a group of children and adolescents with DS and their cognitive and behavioral correlates. Seventy-one children and adolescents with DS underwent a neuropsychological evaluation, whereas parents completed questionnaires for the screening of the child's sleep, emotional and behavioral problems. We found no association between sleep disturbances and sex, nonverbal IQ, nor adaptive abilities. However, we found that age was positively associated with disorders in initiating and maintaining sleep (DIMS) and disorders of excessive somnolence (DOES), while body mass index was related with DOES. We also detected a relationship between visual-motor integrations and DIMS, as well as multiple associations between sleep disturbances and psychopathological and behavioral problems, mainly externalizing symptoms. The present study provided a detailed characterization of sleep problems in relation to several features of youths with DS. The proper identification of sleep disturbances profile in the DS population could support the process of clinical evaluation, in particular for psychopathological aspects.

The prevalence of fatigue among Chinese nursing students in post-COVID-19 era

BACKGROUND

Due to the COVID-19 outbreak, all teaching activities in nursing schools were suspended in China, and many nursing students were summoned to work in hospitals to compensate for the shortage of manpower. This study examined the prevalence of fatigue and its association with quality of life (QOL) among nursing students during the post-COVID-19 era in China.

METHODS

This was a multicenter, cross-sectional study. Nursing students in five Chinese universities were invited to participate. Fatigue, depressive and anxiety symptoms, pain and QOL were measured using standardized instruments.

RESULTS

A total of 1,070 nursing students participated. The prevalence of fatigue was 67.3% (95% CI [64.4-70.0]). Multiple logistic regression analysis revealed that male gender (P = 0.003, OR = 1.73, 95% CI [1.20-2.49]), and being a senior nursing student (second year: OR = 2.20, 95% CI [1.46-3.33], P < 0.001; third year: OR = 3.53, 95% CI [2.31-5.41], P < 0.001; and fourth year OR = 3.59, 95% CI [2.39-5.40], P < 0.001) were significantly associated with more severe fatigue. In addition, moderate economic loss during the COVID-19 pandemic (OR = 1.48, 95% CI [1.08-3.33], P < 0.015; compared to low loss), participants with more severe depressive (OR = 1.48, 95% CI [1.22-1.78], P < 0.001) and anxiety symptoms (OR = 1.12, 95% CI [1.05-1.20], P = 0.001), and more severe pain (OR = 1.67, 95%CI [1.46-1.91], P < 0.001) were significantly associated with reported more severe fatigue. After controlling for covariates, nursing students with fatigue had a lower overall QOL score compared to those without (F (1, 1070) = 31.4, P < 0.001).

CONCLUSION

Fatigue was common among nursing students in the post-COVID-19 era. Considering the negative impact of fatigue on QOL and daily functioning, routine physical and mental health screening should be conducted for nursing students. Effective stress-reduction measures should be enforced to assist this subpopulation to combat fatigue and restore optimal health.

Is correlation between plasma and salivary cortisol levels an important indicator of stress?: A meta-analysis study

The purpose of this study was to examine the practical importance of the correlation values between plasma and salivary cortisol levels using meta-analysis study. In this way, researchers focusing on cortisol levels in different individuals can use more systemic, practical and reliable evidence than using just salivary or plasma cortisol levels separately. For this purpose, correlational studies from 2000 up to now were collected and analyzed by meta-analysis. Results based on 18 effect sizes (n = 743) revealed that effect sizes of the correlations between plasma and salivary cortisol levels represented large effects. The overall combined effect size (Hedges's = 1.55) also represented a large effect. This finding indicates the practical importance of the correlation values for stress studies. The use of the correlation values for examining the cortisol levels in stress studies will be discussed in detail.

Use of the Consumer-Based Meditation App Calm for Sleep Disturbances: Cross-Sectional Survey Study

Background

Over 30% of Americans report regular sleep disturbance, and consumers are increasingly seeking strategies to improve sleep. Self-guided mindfulness mobile apps may help individuals improve their sleep. Despite the recent proliferation of sleep content within commercially available mindfulness apps, there is little research on how consumers are using these apps for sleep.

Objective

We conducted a cross-sectional survey among subscribers to Calm, a popular, consumer-based, mindfulness-based meditation app, and described and compared how good sleepers, poor sleepers, and those with self-reported insomnia use the app for sleep.

Methods

Participants who were paying subscribers of Calm and had used a sleep component of Calm in the last 90 days were invited to complete an investigator-developed survey that included questions about sleep disturbance and the use of Calm for sleep. Based on self-reports of sleep disturbances and of insomnia diagnosis, participants were categorized as “good sleepers,” “poor sleepers,” or “those with insomnia diagnosis.” Chi-square tests compared reasons for downloading the app and usage patterns across participants with and without sleep disturbance.

Results

There was a total of 9868 survey respondents. Approximately 10% of participants (1008/9868, 10.21%) were good sleepers, 78% were poor sleepers (7565/9868, 77.66%), and 11% reported a diagnosis of insomnia (1039/9868, 10.53%). The sample was mostly White (8185/9797, 83.55%), non-Hispanic (8929/9423, 94.76%), and female (8166/9578, 85.26%). The most common reasons for sleep disturbances were racing thoughts (7084/8604, 82.33%), followed by stress or anxiety (6307/8604, 73.30%). Poor sleepers and those with insomnia were more likely than good sleepers to have downloaded Calm to improve sleep (χ²₂=1548.8, P<.001), reduce depression or anxiety (χ²₂=15.5, P<.001), or improve overall health (χ²₂=57.6, P<.001). Respondents with insomnia used Calm most often (mean 5.417 days/week, SD 1.936), followed by poor sleepers (mean 5.043 days/week, SD 2.027; F₂=21.544, P<.001). The most common time to use Calm was while lying down to sleep (7607/9686, 78.54%), and bedtime use was more common among poor sleepers and those with insomnia (χ²₂=382.7, P<.001). Compared to good and poor sleepers, those with insomnia were more likely to use Calm after waking up at night (χ²₂=410.3, P<.001). Most participants tried to use Calm on a regular basis (5031/8597, 58.52%), but regular nighttime use was most common among those with insomnia (646/977, 66.1%), followed by poor sleepers (4040/6930, 58.30%; χ²₂=109.3, P<.001).

Conclusions

Of the paying subscribers to Calm who have used one of the sleep components, approximately 90% have sleep difficulties, and 77% started using Calm primarily for sleep. These descriptive data point to areas of focus for continued refinement of app features and content, followed by prospective trials testing efficacy of consumer-based meditation mobile apps for improving sleep.

The Restorative Effect of the Natural Environment on University Students' Psychological Health

The present study evaluated the effect of a three-week intervention aimed at improving psychological health in university students. Participants included 200 Australian students randomly assigned to an experimental or waitlist control group, with 42 adhering to intervention instructions. Participants in the experimental group read a story about someone who used the natural environment to decrease stress and burnout levels and to increase their perceived satisfaction with life. They were then instructed to spend 20 minutes each week, for three weeks, in any chosen natural environment. Waitlist control participants received intervention instructions three weeks later. Restorativeness was positively associated with life satisfaction and negatively related to stress and burnout. Experimental participants, compared to waitlist control participants, experienced a significant decrease in stress; however, the intervention had no effect on life satisfaction or burnout. More research is still needed to determine the practical significance of nature exposure on university students' psychological health.