Sleep disorders common during COVID-19 pandemic

A recent study published on the preprint server medRxiv* in October 2020 reveals the significant prevalence of sleep abnormalities among the population in areas affected by COVID-19. This is likely to cause a heavy toll on mental and physical health if sustained over the long run.

The COVID-19 pandemic has caused millions of infections and hundreds of thousands of deaths worldwide within ten months of its onset. Public health authorities have focused on reducing the degree of spread of the virus via non-pharmaceutical interventions (NPIs) such as lockdowns and social distancing.

Another significant consequence of this pandemic period is the emotional and mental stress caused by the continuing and high levels of anxiety, panic, depression, and sleeplessness, as in other situations characterized by quarantine. Fears about the future, economic hardship, lockdown fatigue, uncertainty about the real situation concerning the disease and the measures taken to control its spread, stigmatization of COVID-19 patients, as well as the steep drop in social interactions and loss of social support, may react with the altered lifestyle to trigger sleep disorders.

The Importance of Sleep

Sleep is established to be crucial to maintaining physical and mental health at a reasonable level of quality. Disruptions of the normal sleep cycle can cause the total amount of sleep to reduce, with sustained alertness. This, in turn, can precipitate sleepless episodes, mood instability in the daytime, bad dreams, and tiredness.

Some common triggers for lousy sleep habits include the overuse of technology, severe stress, anxiety, trauma, poverty, city life, and the increased use of social media. Poor sleep habits are, therefore, not only quite common, being found in up to 25% of the population, but also are linked to a range of poor health conditions such as obesity, diabetes, hypertension, stroke, cancer, sepsis, and metabolic syndrome.

Risk Factors for Sleep Disorders During the Pandemic

The current study evaluates the presence and causes of sleep disorder and the current interventions intended to correct it. The researchers found 78 studies, mostly set in the US or China. The prevalence of sleep disorder varied from study to study, from as low as ~2% to ~77%. In many studies, younger people reported pandemic-related sleep disturbances, but there was a lack of contextual data that hindered the exploration of such associations.

Education at both higher and lower levels was found to have a significant impact on sleep. The former may be because of academic and professional stresses operating on the former, while the latter may be due to lack of financial stability. Other variables included living alone or in isolation and having poor family or social support.

The most specific factors for sleep disorder associated with the pandemic included fear of infection, anxiety about the illness itself, lack of trust in the countermeasures, and being unsure of the efficacy of both preventive and treatment measures in this condition.

Mental Ill-Health and Sleep Disorders

People who also had other physical or mental illnesses were at a higher risk of sleeping poorly during this period, as expected given the “bidirectional relationship between anxiety, depression and insomnia” already reported in other studies.

This was especially true of healthcare workers, and even more so among those working on the front line of the pandemic. The risk factors for sleep disorder in this group included a high workload, working in shifts, and fear of infection with SARS-CoV-2, all of which are linked to burnout due to high psychological and social stress. Such sleep disorders may even hinder their professional and social functioning, as seen in the earlier SARS and MERS outbreaks, and therefore warrant early recognition and intervention.

Other Risk Factors

Again, an enforced lack of physical activity, fear of losing income, and idleness for want of paid employment, were factors that tended to cause a higher incidence of sleep disorders. Females were at higher risk, as consistent with earlier studies showing their higher susceptibility to anxiety and depression.

Low Level of Intervention

The researchers found only two interventions directed at this specific area, one of which was a traditional Chinese mind-body exercise called Baduanjin, and the other progressive muscular reaction. Either seemed to be preferable to doing nothing in terms of improved sleep after the intervention, as assessed by the sleep score.

Compared with earlier reviews, the prevalence of insomnia and related symptoms were higher during the pandemic period, as has been earlier reported to occur after events like stroke and chronic injuries, that engender stress.

While older people are known to have more problems with insomnia, the current study showed that younger people also experience such sleep disorders, perhaps due to the pressure of higher academic and job-related stress and uncertainty during this period. Many students were faced with the difficulty of gaining access to online classes, poverty in the household, and even nutritional deprivation, after the pandemic-response lockdown.              

Implications and Future Directions

Despite the limitations of the review, mainly in its failure to provide a pre-pandemic control group and the use of studies limited mostly to two countries, it demonstrated associations between numerous physical and mental risk factors and the occurrence of sleep disorder. It is possible that people in poorer settings may have an even higher prevalence of sleep disorder and mental abnormality, say the researchers.

The researchers say these findings may serve as the basis of future studies on sleep disorders, focusing on separate areas, and using appropriate methods. Longitudinal studies would be ideal to understand how these change over time.

Moreover, standardized scales must be developed to arrive at a uniform reporting of these conditions and their risk factors or correlates. This will in turn, require the analysis of numerous factors to identify the most relevant and valuable among them.

A better understanding of mental health and sleep disorders could help shape policies in this area, helping to intervene at the optimal time and avoid such outcomes in future pandemics.

The study also indicates the poor reach of pharmacological and psychosocial treatments for this disorder. It is notable that despite the high prevalence of sleep abnormalities, only two interventions were identified, both among hospitalized COVID-19 patients.

It is necessary that more studies be conducted to explore the efficacy of available therapies such as cognitive behavioral therapy for insomnia (CBT-I), dietary changes, and the incorporation of exercise into the daily routine. It is also essential to identify more interventions directed at the specific social and mental risk factors associated with sleep disorders.

The authors conclude, “The findings of this review emphasizes the need for early detection and effective treatment all the symptoms of insomnia, including the mild ones before they evolve to more complex and evokes enduring psychological responses.”

Some suggested measures include the screening of all patients at out-patient centers for insomnia and referral for further investigation and treatment if found necessary. Healthcare workers should be specifically targeted as they have a higher prevalence.

*Important Notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Journal reference:
Dr. Liji Thomas

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.

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