A study recently published on the preprint server medRxiv * in October 2020 shows the significant prevalence of sleep disorders in the population in areas affected by COVID-19. This is likely to have a major impact on mental and physical health if sustained over the long term.
The COVID-19 pandemic has caused millions of infections and hundreds of thousands of deaths worldwide within ten months of its outbreak. Health officials have focused on reducing the rate of spread of the virus through non-pharmaceutical interventions (NPIs) like lockdowns and social distancing.
Another significant consequence of this pandemic is the emotional and mental stress caused by persistent and high levels of anxiety, panic, depression, and insomnia, as in other situations marked by quarantine. Fears about the future, economic difficulties, lockdown fatigue, uncertainty about the real situation regarding the disease and the measures taken to control its spread, stigmatization of COVID-19 patients, as well as the sharp decline in social interactions and loss of social support. can react with lifestyle changes to trigger sleep disorders.
The importance of sleep
Sleep is critical to maintaining physical and mental health at an adequate quality level. Disruptions to the normal sleep cycle can cause the total amount of sleep to decrease with continued vigilance. This, in turn, can trigger sleepless episodes, daytime mood instability, bad dreams, and fatigue.
Some common triggers for poor sleep habits include overuse of technology, severe stress, anxiety, trauma, poverty, city life, and increased use of social media. As a result, poor sleep habits are not only widespread in up to 25% of the population, but are also related to a number of poor health conditions such as obesity, diabetes, high blood pressure, stroke, cancer, sepsis and metabolic syndrome.
Risk factors for sleep disorders during the pandemic
The current study evaluates the presence and causes of insomnia and the current measures to remedy this disorder. The researchers found 78 studies, mostly conducted in the United States or China. The prevalence of sleep disorders varied from study to study from only ~ 2% to ~ 77%. In many studies, younger people reported pandemic-related sleep disorders, but there was a lack of contextual data that hampered exploration of such associations.
Education at higher and lower levels has been found to have a significant impact on sleep. The former may be due to academic and professional pressures, while the latter may be due to a lack of financial stability. Other variables were living alone or in isolation and having poor family or social support.
The most specific factors of sleep disturbance related to the pandemic included fear of infection, fear of the disease itself, lack of confidence in countermeasures, and uncertainty about the effectiveness of prevention and treatment measures for the condition.
Mental illness and sleep disorders
People who also had other physical or mental illnesses were at a higher risk of poor sleep during this time, as expected, as other studies have already reported the “two-way relationship between anxiety, depression and insomnia”.
This is especially true for healthcare workers and especially those working on the front lines of the pandemic. Risk factors for sleep disorders in this group included high workload, shift work, and fear of being infected with SARS-CoV-2, all of which are linked to burnout due to high psychological and social stress. Such sleep disorders can even affect their professional and social functioning, as has happened in previous SARS and MERS outbreaks, and therefore require early detection and intervention.
Other risk factors
Again, a forced lack of physical activity, fear of loss of income, and idleness from lack of paid employment were factors that tended to lead to a higher incidence of sleep disorders. Women were at higher risk, which is in line with previous studies that showed their higher susceptibility to anxiety and depression.
The researchers found only two interventions targeting this particular area, one of which was a traditional Chinese mind-body exercise called baduanjin and the other was progressive muscle response. Both seemed to prefer not to do anything after the intervention to improve sleep as judged by the sleep score.
Compared to previous reviews, the prevalence of insomnia and related symptoms was higher during the pandemic, as previously reported to occur after events such as stroke and chronic injuries that cause stress.
While the elderly are known to have more problems with insomnia, the current study has shown that younger people also suffer from such sleep disorders, possibly due to the pressures of higher academic and work-related stress and insecurity during this time. Many students have faced difficulty accessing online courses, household poverty and even nutritional deprivation after the pandemic response lockdown.
Implications and Future Directions
Despite the review’s limitations, largely due to the failure to provide a pre-pandemic control group and the use of studies that were mainly limited to two countries, associations have been shown between numerous physical and psychological risk factors and the occurrence of sleep disorders. It is possible that people in poorer backgrounds have an even higher prevalence of sleep disorders and mental abnormalities, say the researchers.
The researchers say these results could serve as a basis for future studies on sleep disorders that focus on specific areas and use appropriate methods. Longitudinal studies would be ideal for understanding how these change over time.
In addition, standardized scales need to be developed to provide consistent reporting of these conditions and their risk factors or correlates. This in turn requires the analysis of numerous factors in order to identify the most relevant and valuable among them.
A better understanding of mental health and sleep disorders could help shape policy in this area, intervene at the optimal time and avoid such outcomes in future pandemics.
The study also shows the poor reach of pharmacological and psychosocial treatments for this disorder. It is noteworthy that, despite the high prevalence of sleep disorders, only two interventions have been identified, both in hospitalized COVID-19 patients.
More studies need to be done to assess the effectiveness of available therapies such as cognitive behavioral therapy for insomnia (CBT-I), diet changes, and the incorporation of exercise into the daily routine. It is also important to identify more interventions that target the specific social and mental risk factors associated with sleep disorders.
The authors conclude: “The results of this review underscore the need for early detection and effective treatment of all symptoms of insomnia, including the mild ones, before they develop into more complex and persistent psychological responses.”
Some suggested actions include screening all patients in outpatient centers for insomnia and referring them for further evaluation and treatment if deemed necessary. Healthcare workers should be targeted as they have a higher prevalence.
* Important NOTE
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be considered conclusive, guide clinical practice / health-related behavior, or be treated as established information.