Insomnia,anxiety, and depression during the COVID-19 pandemic: an international collaborative study

Importance and study objectiveThe COVID-19 pandemic has produced unprecedented changes in social, work, and leisure activities, which all have had major impact on sleep and psychological well-being. This study documented the prevalence of clinical cases of insomnia, anxiety, and depression and selected risk factors (COVID-19, confinement, financial burden, social isolation) during the first wave of the pandemic in 13 countries throughout the world.Design and participantsInternational, multi-center, harmonized survey of 22 330 adults (mean age = 41.9 years old, range 18–95; 65.6% women) from the general population in 13 countries and four continents. Participants were invited to complete a standardized web-based survey about sleep and psychological symptoms during the first wave of the COVID-19 pandemic from May to August 2020.ResultsClinical insomnia symptoms were reported by 36.7% (95% CI, 36.0–37.4) of respondents and 17.4% (95% CI, 16.9–17.9) met criteria for a probable insomnia disorder. There were 25.6% (95% CI, 25.0–26.2) with probable anxiety and 23.1% (95% CI, 22.5–23.6) with probable depression. Rates of insomnia symptoms (>40%) and insomnia disorder (>25%) were significantly higher in women, younger age groups, and in residents of Brazil, Canada, Norway, Poland, USA, and United Kingdom compared to residents from Asian countries (China and Japan, 8% for disorder and 22%–25% for symptoms) (all Ps < 0.01). Proportions of insomnia cases were significantly higher among participants who completed the survey earlier in the first wave of the pandemic relative to those who completed it later. Risks of insomnia were higher among participants who reported having had COVID-19, who reported greater financial burden, were in confinement for a period of four to five weeks, and living alone or with more than five people in same household. These associations remained significant after controlling for age, sex, and psychological symptoms.Conclusion and relevanceInsomnia, anxiety, and depression were very prevalent during the first wave of the COVID-19 pandemic. Public health prevention programs are needed to prevent chronicity and reduce long-term adverse outcomes associated with chronic insomnia and mental health problems.     

Linking insomnia and OCD symptoms during the coronavirus pandemic: Examination of prospective associations

There is considerable concern in the mental health community about the psychological consequences of the coronavirus pandemic and who may be most vulnerable. Obsessive-compulsive disorder (OCD) symptoms may be particularly sensitive to the context of the pandemic. Previous research suggests insomnia symptoms may contribute to increased OCD symptoms over time, particularly during times of stress, such as the pandemic. The present study examined pre-coronavirus outbreak insomnia symptoms as a predictor of post-coronavirus outbreak OCD symptoms in a sample of community adults who completed a 2016 survey study and were re-contacted on April 1, 2020 (N = 369). Results revealed a small significant increase in OCD symptoms following the coronavirus outbreak and a small significant decrease in insomnia symptoms. Pre-coronavirus outbreak insomnia symptoms significantly predicted increases in post-coronavirus outbreak OCD symptoms. Similar results were found for specific OCD symptom facets with the exception of washing and hoarding symptoms, which were unrelated to pre-coronavirus insomnia symptoms. There was no evidence for a reverse effect of prior OCD symptoms on insomnia symptoms during the pandemic. These findings suggest those with insomnia symptoms prior to the coronavirus pandemic may be vulnerable to increases in some OCD symptoms during the pandemic. The implications for preventing adverse psychological responses during the coronavirus pandemic are discussed.     

新冠肺炎疫情常态化防控下社区居民心理健康状况及相关因素

目的 调查在新冠肺炎疫情常态化防控下社区居民的心理健康状况并分析其相关因素。方法 本研究为横断面调查,采用滚雪球抽样法,于2020年8月28日-9月7日通过问卷星网络平台向居民发放调查问卷。采用患者健康问卷抑郁量表（PHQ-9）、广泛性焦虑量表（GAD-7）、失眠严重程度指数量表（ISI）及中文版知觉压力量表（CPSS）评估居民的心理健康状况。结果 476名居民抑郁、焦虑、失眠及高水平压力症状检出率分别为32.35%、21.22%、24.58%及48.74%。男性高水平压力症状检出率高于女性（χ²=5.269）,未婚、离异或丧偶居民的抑郁及焦虑症状检出率均高于已婚居民（χ²=5.251、8.851）,有心理服务需求的居民抑郁、焦虑、失眠及高水平压力症状检出率均高于无此需求的居民（χ²=46.316、66.934、20.153、21.576）,差异均有统计学意义（P<0.05或0.01）。相关分析显示,社区居民年龄与CPSS评分呈负相关（r=-0.171,P<0.01）,睡眠时间与PHQ-9、GAD-7及ISI评分均呈负相关（r=-0.210、-0.247、-0.297,P均<0.01）,关注疫情信息时长与ISI评分呈负相关（r=-0.097,P<0.05）。结论 在疫情常态化防控下,居民的抑郁、焦虑、失眠及高水平压力症状仍较常见。男性和年轻居民更有可能出现高水平压力症状,睡眠时间短和有心理服务需求的居民更有可能出现抑郁、焦虑及失眠症状,关注疫情信息时长越短越有可能出现失眠症状。     

Cross-sectional survey following a longitudinal study on mental health and insomnia of people with sporadic COVID-19

BACKGROUNDIn the post-pandemic era, the emergence of sporadic cases of coronavirus disease 2019 (COVID-19) and the scale of the pandemic are unpredictable. Therefore, the impact of sporadic cases of COVID-19 and isolation measures on mental health and sleep in different groups of people need to be analyzed. AIMTo clarify the severity of psychological problems and insomnia of staff and community residents around a hospital with sporadic cases of COVID-19, and their relationship with quarantine location and long-term changes.METHODSA cross-sectional survey was conducted on community residents and medical staff. Many of these medical staff had been subjected to different places of quarantine. Community residents did not experience quarantine. Hospital anxiety and depression scale (HADS), acute stress disorder scale (ASDS) and insomnia severity index (ISI) were used to evaluate anxiety and depression, acute stress disorder symptoms, and the severity of insomnia. Additionally, we conducted a 1-year follow-up study on medical staff, with related scales measurement immediately after and one year after the 2-wk quarantine period.RESULTSWe included 406 medical staff and 226 community residents. The total scores of ISI and subscale in HADS of community residents were significantly higher than that of medical staff. Further analysis of medical staff who experienced quarantine showed that 134 were quarantined in hotels, 70 in hospitals and 48 at home. Among all subjects, the proportions of HADS, ASDS and ISI scores above normal cutoff value were 51.94%, 19.17% and 31.11%, respectively. Multivariable logistic regression analysis found that subjects with higher total ASDS scores had a greater risk to develop anxiety and depression. The total ISI score for medical staff in hotel quarantine was significantly higher than those in home quarantine. Total 199 doctors and nurses who completed the 1-year follow-up study. Compared with baseline, HADS and ASDS scores decreased significantly one year after the end of quarantine, while ISI scores did not change significantly. CONCLUSIONSporadic COVID-19 cases had a greater psychological impact on residents in surrounding communities, mainly manifested as insomnia and depressive symptoms. Hotel quarantine aggravated the severity of insomnia in medical staff, whose symptoms lasted ≥ 1 year.     

Development and initial validation of the COVID Stress Scales

Research and clinical observations suggest that during times of pandemic many people exhibit stress- or anxiety-related responses that include fear of becoming infected, fear of coming into contact with possibly contaminated objects or surfaces, fear of foreigners who might be carrying infection (i.e., disease-related xenophobia), fear of the socio-economic consequences of the pandemic, compulsive checking and reassurance-seeking regarding possible pandemic-related threats, and traumatic stress symptoms about the pandemic (e.g., nightmares, intrusive thoughts). We developed the 36-item COVID Stress Scales (CSS) to measure these features, as they pertain to COVID-19. The CSS were developed to better understand and assess COVID-19-related distress. The scales were intentionally designed so they could be readily adapted for future pandemics. The CSS were developed and initially validated in population-representative samples from Canada (N = 3479) and the United States (N = 3375). A stable 5-factor solution was identified, corresponding to scales assessing COVID-related stress and anxiety symptoms: (1) Danger and contamination fears, (2) fears about economic consequences, (3) xenophobia, (4) compulsive checking and reassurance seeking, and (5) traumatic stress symptoms about COVID-19. The scales performed well on various indices of reliability and validity. The scales were intercorrelated, providing evidence of a COVID Stress Syndrome. The scales offer promise as tools for better understanding the distress associated with COVID-19 and for identifying people in need of mental health services.     

Psychological correlates of poor sleep quality among U.S. young adults during the COVID-19 pandemic

ObjectiveUncertainty due to the COVID-19 pandemic may result in problematic sleep that can lead to negative effects on overall health. This unprecedented and stressful time can be even more detrimental for young adults with pre-existing mental health conditions. The purpose of this study is to investigate potential risk factors (i.e., current mental health symptoms, and COVID-19-related grief and worry) on sleep quality of U.S. young adults during the initial months of the global pandemic.MethodThis cross-sectional study examined 908 young adults in the weeks following the declaration of the coronavirus pandemic as a national emergency by the United States. A series of hierarchical multiple regression analyses examined depression, anxiety, and PTSD, as well as COVID-19-related grief and worry as predictors of young adults’ sleep quality.ResultsYoung adults experienced high rates of sleep problems during the first two months (April to May 2020) of the pandemic. Depressive and anxiety symptoms appear to be predictors of sleep quality regardless of any pre-existing diagnosis. Furthermore, high levels of PTSD symptoms and COVID-19-related worry were associated with young adults’ poor sleep.ConclusionsOur findings point to possible psychological factors that uniquely explain young adults’ poor sleep quality during the COVID-19 pandemic in the U.S. This study shed new light on how the COVID-19 pandemic might affect the sleep behaviors of young adults without a pre-existing mental health diagnosis. Implications for supporting young adults sleep and well-being during the pandemic are addressed.     

Intolerance of uncertainty,anxiety sensitivity,and health anxiety during the COVID-19 pandemic: Exploring temporal relationships using cross-lag analysis

Intolerance of uncertainty (IU) and anxiety sensitivity (AS) have been widely discussed and explored as factors that may contribute to health anxiety. We propose that IU and AS are salient issues for many during the COVID-19 pandemic, and may play a role in the development or exacerbation of health anxiety during the pandemic. Studies have examined links between IU and AS with health anxiety during the pandemic, but these relationships have not been tested together using a longitudinal study design. In the present study, measures of IU, AS, and health anxiety were collected from 301 adults at two time points 6 months apart during (early stages of) the COVID-19 pandemic using an online survey platform. Cross-lagged analysis was utilized to simultaneously estimate cross-sectional and longitudinal associations between these three variables. Robust cross-sectional associations were observed, and IU prospectively predicted changes in both health anxiety and AS. No other statistically significant prospective associations emerged. Present findings support the putative role of IU in health anxiety, suggesting that some observed links between AS and health anxiety could be driven by shared variance with IU. IU may be an important factor to monitor and target in health anxiety interventions during the pandemic.     

Worry,avoidance, and coping during the COVID-19 pandemic: A comprehensive network analysis

BackgroundMany psychological factors play a role in the COVID-19 pandemic, including various forms of worry, avoidance, and coping. Adding to the complexity, some people believe the threat of COVID-19 is exaggerated. We used network analysis to investigate how these diverse elements are interrelated.MethodsA population-representative sample of 3075 American and Canadian adults completed an online survey, including measures of COVID-19-related worry, avoidance, self-protective behaviors, and other variables.ResultsThe network contained three major hubs, replicated across gender and age groups. The most important hub centered around worries about the dangerousness of COVID-19, and formed the core of the previously identified COVID Stress Syndrome. The second most important hub, which was negatively correlated with the first hub, centered around the belief that the COVID-19 threat is exaggerated, and was associated with disregard for social distancing, poor hand hygiene, and anti-vaccination attitudes. The third most important hub, which was linked to the first hub, centered around COVID-19-related compulsive checking and reassurance-seeking, including self-protective behaviors such as panic buying and use of personal protective equipment.ConclusionNetwork analysis showed how various forms of worry, avoidance, coping, and other variables are interrelated. Implications for managing disease and distress are discussed.     

A national survey on the impact of the COVID-19 pandemic upon burnout and career satisfaction among neurosurgery residents

The coronavirus disease 2019 (COVID-19) pandemic has posed significant changes to resident education and workflow. However, the impact of the pandemic on U.S. neurosurgery residents has not been well characterized. We investigated the impact of the COVID-19 pandemic on U.S. neurosurgery resident workflow, burnout, and career satisfaction. In 2020, a survey evaluating factors related to career satisfaction and burnout was emailed to 1,374 American Association of Neurological Surgeons (AANS) residents. Bivariate and multivariate (logistic) analyses were performed to characterize predictors of burnout and career satisfaction. 167 survey responses were received, with a response rate (12.2%) comparable to that of similar studies. Exclusion of incomplete responses yielded 111 complete responses. Most respondents were male (65.8%) and White (75.7%). Residents reported fewer work hours (67.6%) and concern that COVID-19 would impair their achievement of surgical milestones (65.8%). Burnout was identified in 29 (26.1%) respondents and career satisfaction in 82 (73.9%) respondents. In multivariate analysis, burnout was significantly associated with alterations in elective rotation/vacation schedules (p = .013) and the decision to not pursue neurosurgery again if given the choice (p < .001). Higher post-graduate year was associated with less burnout (p = .011). Residents displayed greater career satisfaction when focusing their clinical work upon neurosurgical care (p = .065). Factors related to COVID-19 have contributed to workflow changes among U.S. neurosurgery residents. We report a moderate burnout rate and a paradoxically high career satisfaction rate among neurosurgery residents. Understanding modifiable stressors during the COVID-19 pandemic may help to formulate interventions to mitigate burnout and improve career satisfaction among residents.     

Sleep quality during the COVID-19 pandemic: not one size fits all

BackgroundThe COVID-19 pandemic imposes a long period of stress on people worldwide and has been shown to significantly affect sleep duration across different populations. However, decreases in sleep quality rather than duration are associated with adverse mental health effects. Additionally, the one third of the general population suffering from poor sleep quality was underrepresented in previous studies. The current study aimed to elucidate effects of the COVID -19 pandemic on sleep quality across different levels of pre-pandemic sleep complaints and as a function of affect and worry.MethodParticipants (n = 667) of the Netherlands Sleep Registry (NSR) were invited for weekly online assessment of the subjective severity of major stressors, insomnia, sleep times, distress, depression, and anxiety using validated scales.AnalysisTo investigate the overall impact of the COVID-19 pandemic on the sleep quality of people with and without a history of insomnia, we performed a mixed model analysis using pre-pandemic insomnia severity, negative affect, and worry as predictors.ResultsThe effect of COVID -19 on sleep quality differs critically across participants, and depends on the pre-pandemic sleep quality. Interestingly, a quarter of people with pre-pandemic (clinical) insomnia experienced a meaningful improvement in sleep quality, whereas 20% of pre-pandemic good sleepers experienced worse sleep during the lockdown measures. Additionally, changes in sleep quality throughout the pandemic were associated with negative affect and worry.ConclusionOur data suggests that there is no uniform effect of the lockdown on sleep quality. COVID-19 lockdown measures more often worsened sleep complaints in pre-pandemic good sleepers, whereas a subset of people with pre-pandemic severe insomnia symptoms underwent a clinically meaningful alleviation of symptoms in our sample.     

Effect of COVID-19 on mental health among the young population in Lebanon

BackgroundCOVID-19 is a global pandemic that has raised worldwide public health concerns. The wide spread of the virus has led to unprecedented disturbance to regular life for people around the globe and impacted their mental health.AimsThe aims of the current study were to investigate the prevalence of psychiatric symptoms related to insomnia, depression, and anxiety, and identify risk factors contributing to psychological stress in Lebanese young population during COVID-19 pandemic.MethodA cross-sectional study was done on the Lebanese young population. Participants were 4397 males and females aged 18 to 35 years who filled a self-administered online questionnaire. Three validated scales were used to measure the mental health status of the participants during the COVID-19 pandemic: 7-item Insomnia Severity Index for insomnia, the Patient Health Questionnaire 9-item depression module for depression, and the 7-item Generalized Anxiety Disorder scale for anxiety.ResultsThe median interquartile range scores for anxiety, insomnia, and depression, were 8 (4–13), 10 (5–14), and 9 (5–12) respectively. Higher anxiety scores were reported with female gender (P < 0.001) and alcohol usage (P = 0.04). Moderate to severe insomnia was associated with single (P = 0.02) and divorced marital status (P = 0.003), university education (P < 0.001), consumption of caffeinated beverages (P = 0.02) and energy drinks (P = 0.03). Higher depression scores were associated with status of being the only person working at home (P = 0.01), family income more than 500 USD (P = 0.008), multiple insurance plans (P = 0.01), and contact with a confirmed COVID-19 case (P = 0.01).ConclusionsThe findings of this study demonstrate the considerable impact of COVID-19 pandemic and lockdown on Lebanese young population's mental status such as anxiety, depression and insomnia. Further follow-up studies are warranted to assess the long-term mental effects that can be imposed by the pandemic.     

Relapse insomnia increases greater risk of anxiety and depression: evidence from a population-based 4-year cohort study

ObjectiveWe investigated the longitudinal impacts of insomnia on the subsequent developments of anxiety and depression during a four-year follow-up. We further categorized individuals with insomnia into different insomnia subgroups to examine whether the risk of anxiety and depression varies by subtype.MethodsParticipants were identified from National Health Insurance enrollees in Taiwan during 2002–2009. The study included 19,273 subjects with insomnia and 38,546 matched subjects without insomnia. All subjects did not have previous diagnosis of insomnia, sleep apnea, anxiety, or depression.ResultsCompared with non-insomniacs, insomniacs had a higher risk of developing anxiety only [adjusted hazard ratio (HR) = 8.83, 95% CI = 7.59–10.27], depression only (adjusted HR = 8.48, 95% CI = 6.92–10.39), and both anxiety and depression (adjusted HR = 17.98, 95% CI = 12.65–25.56). When breaking down the insomnia subgroups, individuals with a relapse of insomnia (adjusted HR = 10.42–26.80) had the highest risk of anxiety only, depression only, and both anxiety and depression, followed by persistent insomnia (adjusted HR = 9.82–18.98), then remitted insomnia (adjusted HR = 4.50–8.27). All three insomnia subgroups had a greater four-year cumulative incidence rate than the non-insomnia group for anxiety only, depression only, and both anxiety and depression (p < 0.0001).ConclusionOur findings reinforce the clinical predictor role of insomnia in the future onset of anxiety or/and depression. Awareness of insomnia and treatment of insomnia should be recommended at clinics, and patterns of insomnia should be monitored to help treatment and control of subsequent psychiatric disorders. Future research with comprehensive data collection is needed to identify factors that contribute to different insomnia subtypes.     

新冠肺炎疫情下失眠人群心理特征及失眠的相关因素

目的 调查新冠肺炎疫情下失眠人群的心理特征及失眠的相关因素,为改善失眠人群心理健康状况提供参考。方法 采用阿森斯失眠量表（AIS）于2020年1月-3月对某市居民进行测评,AIS评分>6分者为失眠组（n=216）,AIS评分<4分者为非失眠组（n=105）,采用症状自评量表（SCL-90）对两组居民进行评定,并收集其社会人口学资料。结果 失眠组SCL-90的躯体化、人际关系敏感、敌对、恐怖及精神病性因子评分均高于非失眠组（Z=2.035~2.323,P均<0.05）。Spearman相关分析显示,失眠组AIS总评分与SCL-90的强迫症状、人际关系敏感及偏执因子评分均呈正相关（r=0.153、0.140、0.159,P均<0.05）。结论 新冠肺炎疫情下,失眠人群存在躯体化、人际关系敏感、敌对、恐怖及精神病性等心理问题,其失眠的严重程度与强迫、人际关系敏感及偏执等相关。     

A longitudinal study on the mental health of general population during the COVID-19 epidemic in China

In addition to being a public physical health emergency, Coronavirus disease 2019 (COVID-19) affected global mental health, as evidenced by panic-buying worldwide as cases soared. Little is known about changes in levels of psychological impact, stress, anxiety and depression during this pandemic. This longitudinal study surveyed the general population twice - during the initial outbreak, and the epidemic's peak four weeks later, surveying demographics, symptoms, knowledge, concerns, and precautionary measures against COVID-19. There were 1738 respondents from 190 Chinese cities (1210 first-survey respondents, 861 s-survey respondents; 333 respondents participated in both). Psychological impact and mental health status were assessed by the Impact of Event Scale-Revised (IES-R) and the Depression, Anxiety and Stress Scale (DASS-21), respectively. IES-R measures PTSD symptoms in survivorship after an event. DASS -21 is based on tripartite model of psychopathology that comprise a general distress construct with distinct characteristics. This study found that there was a statistically significant longitudinal reduction in mean IES-R scores (from 32.98 to 30.76, p < 0.01) after 4 weeks. Nevertheless, the mean IES-R score of the first- and second-survey respondents were above the cut-off scores (>24) for PTSD symptoms, suggesting that the reduction in scores was not clinically significant. During the initial evaluation, moderate-to-severe stress, anxiety and depression were noted in 8.1%, 28.8% and 16.5%, respectively and there were no significant longitudinal changes in stress, anxiety and depression levels (p > 0.05). Protective factors included high level of confidence in doctors, perceived survival likelihood and low risk of contracting COVID-19, satisfaction with health information, personal precautionary measures. As countries around the world brace for an escalation in cases, Governments should focus on effective methods of disseminating unbiased COVID-19 knowledge, teaching correct containment methods, ensuring availability of essential services/commodities, and providing sufficient financial support.     

Prevalence of sleep disturbances during COVID-19 outbreak in an urban Chinese population: a cross-sectional study

ObjectiveThe COVID-19 pandemic is a large-scale public health emergency that likely precipitated sleep disturbances in the community. This study aimed to investigate the prevalence and correlates of sleep disturbances during the early phase of COVID-19 pandemic.MethodsThis web-based cross-sectional study recruited 1138 Hong Kong adults using convenience sampling over a two-week period from 6th April 2020. The survey collected data on sleep disturbances, mood, stress, stock of infection control supplies, perceived risk of being infected by COVID-19, and sources for acquiring COVID-19 information. The participants were asked to compare their recent sleep and sleep before the outbreak. The Insomnia Severity Index (ISI) was used to assess their current insomnia severity. Prevalence was weighted according to 2016 population census.ResultsThe weighted prevalence of worsened sleep quality, difficulty in sleep initiation, and shortened sleep duration since the outbreak were 38.3%, 29.8%, and 29.1%, respectively. The prevalence of current insomnia (ISI score of ≥10) was 29.9%. Insufficient stock of masks was significantly associated with worsened sleep quality, impaired sleep initiation, shortened sleep duration, and current insomnia in multivariate logistic regression (adjusted OR = 1.57, 1.72, 1.99, and 1.96 respectively, all p < 0.05).ConclusionA high proportion of people in Hong Kong felt that their sleep had worsened since the COVID-19 outbreak. Insufficient stock of masks was one of the risk factors that were associated with sleep disturbances. Adequate and stable supply of masks may play an important role to maintain the sleep health in the Hong Kong general population during a pandemic outbreak.