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

Advancements in simulation-based nursing education: Insights from a bibliometric analysis of temporal trends

BACKGROUND

Simulations are used in nursing education to create realistic clinical practice environments. With rapid changes in educational demands and the growing importance of simulation in nursing, understanding the evolution of its application will provide critical insights into how educational strategies have undergone adaptive changes over time to meet the needs of nursing students and healthcare settings.

AIMS

This study aimed to identify temporal trends in simulation-based nursing education, map key research themes, and examine changes in the educational landscape over time.

DESIGN

This is a bibliometric study of simulation-based nursing education.

METHODS

The analysis was conducted using VOSviewer. A total of 12,083 publications retrieved from PubMed, the Excerpta Medica Database, and the Cumulative Index to Nursing and Allied Health Literature were analyzed. To identify temporal shifts in simulation-based nursing education, articles were categorized into four periods based on the progression of simulation usage and technological advancements. Co-occurrence analysis was performed for each period.

RESULTS

Our analysis revealed a substantial increase in research on simulation-based nursing education after 2014, with a surge following the COVID-19 pandemic. The results show an increasing adoption of advanced techniques, such as standardized patients, in-situ simulations, and virtual reality. Core keywords, such as CPR, critical thinking, and team training, highlight the diverse applications of simulations in technical and psychological training. Temporal trends highlight significant shifts in keywords driven by technological advancements and evolving pedagogical approaches. Integrating advanced technology and realistic scenarios provides learners with immersive experiences that can substantially enhance their nursing competencies.

CONCLUSIONS

This study revealed that simulation-based nursing education has evolved substantially, reflecting technological progress and changes in educational priorities. This underscores the need to integrate advanced technology with innovative simulation methods to prepare nursing students for real-world clinical challenges.

COVID-19 and psychiatric disorders among young people: a cross-sectional study

During the COVID-19 pandemic, a significant rise in mental health issues was observed. Particularly, children and adolescents have shown a higher risk of developing mental disorders than adults. This study aimed to describe the evolving features of the requests for psychiatric emergency interventions during the COVID-19 pandemic in young people. We conducted a cross-sectional study comparing the number, characteristics, and symptoms of people aged between 12 and 18 years old attending one Emergency Department (ED) for psychiatric issues, considering three different periods: T0 (8 March 2019-7 March 2020), T1 (8 March 2020-7 March 2021), and T2 (8 March 2021-7 March 2022). Total admissions were 220: 99 (45%) during T0, 40 (18.1%) for T1, and 81 (36.8%) for T2 ( P  < 0.001). A significant decrease in the mean age from T0 to T1 was found ( P  < 0.01). Admissions for psychomotor agitation decreased, while admission due to anxiety disorder and nonsuicidal self-injury raised significantly ( P  < 0.05), as for first psychiatric presentation ( P  < 0.01). Regarding substance use, a significant reduction was observed ( P  < 0.05). The rates of eating disorders ( P  < 0.001) and early insomnia ( P  < 0.01) increased from T0. These findings highlight the worsening of psychiatric symptoms in the young population during the COVID-19 pandemic.

Impact of change in insomnia on change in pandemic paranoia: a longitudinal moderated-mediation model in an international sample

The impact of mistrust of others during a pandemic is an important consideration for public health interventions. Pandemic paranoia is a particular form of persecutory thinking characterised by mistrust and suspicion towards other people specifically due to a pandemic. Pandemic paranoia is heightened among those with a persecutory thinking tendency. We examined the longitudinal relationship between insomnia and pandemic paranoia, with anxiety, depression, and worry as mediators and persecutory thinking as moderator. A longitudinal online survey design was utilized involving an international sample (N = 715) across two timepoints, 12 weeks apart. A moderated mediation model was tested, assessing the effect of change in insomnia on change in pandemic paranoia with changes in anxiety, depression and worry as mediators. The effect of persecutory thinking as a moderator was then tested on the above paths in relation to insomnia. Changes in insomnia predicted changes in pandemic paranoia. Change in anxiety was a significant mediator of insomnia's effects on pandemic paranoia: this indirect pathway was moderated by persecutory thinking. Changes in worry and depression were not significant mediators. Our findings indicate that insomnia influences pandemic paranoia, indirectly through anxiety; persecutory thinking plays a consequential role in these relationships. These findings suggest that special attention should be given to mitigation efforts during pandemics to promote sleep health in individuals with pre-existing vulnerabilities, such as persecutory thinking styles.

Over-the-counter products for insomnia in adults: A scoping review of randomised controlled trials

BACKGROUND

Insomnia is highly prevalent and poses significant personal and socio-economic challenges. While the National Institute for Health and Care Excellence (NICE) recommendations define possible medical approaches, over-the-counter products are commonly used to self-manage insomnia symptoms. This scoping review aims to determine the size and scope of the evidence-base regarding the effectiveness and safety of over-the-counter products for insomnia symptoms in adults.

METHODS

The electronic databases of CENTRAL, MEDLINE, EMBASE, PsycINFO, and AMED were searched from inception to December 19th, 2022, for all randomised controlled trials evaluating over-the-counter products compared to placebo, in adults aged 18-65 with insomnia symptoms. Results were synthesised descriptively.

RESULTS

51 randomised controlled trials were included, evaluating herbal products (n = 34), dietary supplements (n = 15), herbal-dietary combinations (n = 4), and over-the-counter medicines (n = 2). Sample sizes ranged between 10 and 405 participants. Eleven studies were conducted in participants with co-morbidities. Interventions were most frequently given as monotherapy and compared against placebo. Most studies (n = 41) demonstrated interventions' positive effects on insomnia symptoms. Among the most studied products, valerian and melatonin have substantial evidence to demonstrate their effectiveness and safety. Promising products demonstrating benefits compared with prescription medication alone included: valerian; lemon balm and fennel; and valerian, hops, and passionflower. Intervention-related side effects were mostly mild and transient. No serious adverse events were reported across all studies.

CONCLUSIONS

Over-the-counter products show promising, but inconclusive findings in alleviating insomnia symptoms in adults. Future research should focus on investigating products currently used in real life, consider economic evaluations, and be evaluated in populations with co-morbidities and ethnic minorities, to better guide clinical advice.

Long-COVID from the perspective of neurologists at the outpatient clinic: A cross-sectional field study

OBJECTIVES

Approximately 25% of individuals experience various symptoms months after the COVID-19 infection and are referred to as having Long-COVID syndrome. The primary objective of this study was to identify the pattern of neuropsychiatric symptoms and their influence on psychological health, sleep quality, and overall well-being.

METHODS

In this cross-sectional study, Long-COVID patients reported on their symptoms by using a predefined list. The symptom patterns were examined using cluster analysis. The clustering groups were compared based on psychological health, sleep, and well-being scores obtained from structured questionnaires.

RESULTS

There were 40 females and 13 males, with a mean age of 54.1 ± 12.2 years. The most frequently reported symptoms were fatigue (94.3%), followed by anxiety (79.2%), myalgias (75.5%), and concentration difficulties (71.7%). Clustering analysis revealed two clusters separated by the number of cognitive, psychiatric, general neurologic, and somatic symptoms (i.e. high and low number). Patients within the high number cluster reported significantly more symptoms of depression, anxiety and stress, and worse quality of sleep than the low number cluster. Overall, 32 patients (60.4%) were found to have poor well-being. Reporting more than 17 symptoms (58.6% of patients) predicted poor well-being with a sensitivity of 37.5% and specificity of 95.2% (p = 0.011).

DISCUSSION

In this study, Long-COVID patients presenting at the outpatient neurologic clinic were clustered based on the number of symptoms instead of the nature of these symptoms. A higher number of symptoms were associated with poorer psychological health, sleep quality, and overall well-being.

Status and risk factors for depression, anxiety, and insomnia symptoms among adolescents in the post-pandemic era

BACKGROUND

Owing to their vulnerability to public health crises, adolescents' mental health status, and related risk factors in the post-pandemic era in China require examination. This study aimed to lay a foundation for subsequent interventions and mental disorder prevention among adolescents.

METHODS

An anonymous online survey was conducted January 8-18, 2023. The survey comprised two parts. The first part collected personal information. The second part included the nine-item Patient Health Questionnaire, seven-item Generalized Anxiety Disorder Scale, and Pittsburgh Sleep Quality Index.

RESULTS

Of 50,666 adolescent participants, 46.8% displayed depressive symptoms, 31.5% showed anxiety symptoms, and 47.9% experienced difficulties initiating sleep within 30 min, while 4.9% manifested depressive, anxiety, and insomnia symptoms simultaneously. Chi-square tests revealed significant variations in the prevalence of these conditions according to age, sex, coronavirus disease-2019 (COVID-19) infection status, family infection status, and increased screen time (P < 0.001). Logistic regression analysis indicated heightened rates of depression, anxiety, and insomnia symptoms among rural adolescents, females, those aged 16-18 years, individuals with a history of COVID-19, those with a long COVID-19 illness, and those with increased screen time (all P < 0.001).

CONCLUSION

The mental health status of adolescents in the post-pandemic era should be taken seriously, particularly that of females, high school students, and adolescents with increased use of electronic screens. Among such efforts, school administrators should strengthen their connection with psychologists, as early identification and intervention in adolescents are important for preventing school crises.

Definitions and symptoms of the post-COVID syndrome: an updated systematic umbrella review

Post-COVID syndrome (PCS) describes a persistent complex of symptoms following a COVID-19 episode, lasting at least 4 to 12 weeks, depending on the specific criteria used for its definition. It is often associated with moderate to severe impairments of daily life and represents a major burden for many people worldwide. However, especially during the first two years of the COVID-19 pandemic, therapeutic and diagnostic uncertainties were prominent due to the novelty of the disease and non-specific definitions that overlooked functional deficits and lacked objective assessment. The present work comprehensively examines the status of PCS definitions as depicted in recent reviews and meta-analyses, alongside exploring associated symptoms and functional impairments. We searched the database Pubmed for reviews and meta-analysis evaluating PCS in the period between May 31, 2022, to December 31, 2023. Out of 95 studies, 33 were selected for inclusion in our analyses. Furthermore, we extended upon prior research by systematically recording the symptoms linked with PCS as identified in the studies. We found that fatigue, neurological complaints, and exercise intolerance were the most frequently reported symptoms. In conclusion, over the past eighteen months, there has been a notable increase in quantity and quality of research studies on PCS. However, there still remains a clear need for improvement, particularly with regard to the definition of the symptoms necessary for diagnosing this syndrome. Enhancing this aspect will render future research more comparable and precise, thereby advancing and understanding PCS.

Impact of COVID-19 on medical utilization for psychiatric conditions in Japan

BACKGROUND

During COVID-19, Japan experienced an increase in suicides, in contrast to many other countries. We sought to examine whether access to outpatient and inpatient care for psychiatric conditions was maintained in Japan during the pandemic.

METHODS

Difference-in-differences analysis with Poisson regression comparing psychiatric patient admissions during the pre-pandemic period (January 2015-December 2019) versus the pandemic period (January 2020-December 2020) was performed, using the data from 242 acute-care hospitals in Japan. The Japanese government's emergency declaration in April 2020 was considered an exogenous shock. Primary outcomes included the number of inpatient and outpatient admissions for schizophrenia, mood disorders, anxiety disorders, dementia, and alcohol-related disorders.

RESULTS

During the study period, 79,867 outpatient cases and 2600 hospitalizations were observed. The difference-in-differences analysis showed a decline in the number of outpatient and inpatient admissions except for anxiety disorders after April 2020: incidence-rate ratios (95% confidence intervals), 0·92 (0·83 - 1·02) and 0·71 (0·46 - 1·09) for outpatients and inpatients with schizophrenia, 0·92 (0·85 - 0·99) and 0·87 (0·50 - 1·49) for mood disorders, 1·02 (0·92 - 1·13) and 1·07 (0·69 - 1·65) for anxiety disorders, 0·88 (0·80 - 0·96) and 0·68 (0·38 - 1·22) for dementia, and 0·77 (0·54 - 1·11) and 0·63 (0·43 - 0·90) for alcohol-related disorders.

CONCLUSION

In Japan, psychiatric admissions decreased overall following the start of the COVID-19 pandemic, with the exception of anxiety disorder cases. The decrease in psychiatric care utilization contrasted with rising suicide rates in the nation, underscoring the need for enhanced psychiatric access during crises.

Pandemic policies and sleeping problems in older adults

Sleep quality is fundamental to physical and mental health. Recent research shows that the COVID-19 pandemic has affected individuals' sleep quality. This study aims to investigate whether the containment and health policies (Oxford Coronavirus Government Response Tracker indexes) adopted by European countries and Israel during the pandemic are related to sleep problems in people aged 50 and over. A cross-sectional study was conducted using a logistic regression analysis based on data from the Survey of Health, Ageing and Retirement in Europe, collected in 27 European countries and Israel, in 2021. The results show that containment and health policies affect older adults' sleep, once we neutralise the influence of the sociodemographic, economic, and health characteristics of the individuals and close contact with COVID-19. In fact, the more containment and health policies, the fewer chances of sleep problems. A possible explanation for this is that these policies give people over 50 a sense of safety and security in relation to COVID-19, which may reduce sleep problems.

Identification and validation of diagnostic genes IFI44 and IRF9 in insomnia-associated autoimmune uveitis

Objective

Insomnia is increasingly recognized as a significant factor in the development of various autoimmune diseases, including autoimmune uveitis (AU). We investigated insomnia-associated genes that may contribute to AU pathogenesis and sought to identify potential biomarkers for insomnia-associated AU.

Methods

Microarray data related to insomnia and AU were downloaded from the Gene Expression Omnibus (GEO) database and analyzed. The GEO2R tool was used to identify differentially expressed genes (DEGs) that were common between insomnia and AU. Weighted gene co-expression network analysis (WGCNA), protein-protein interaction (PPI), functional enrichment, and CMap analyses were then performed to identify pathogenic genes, underlying mechanisms, and potential therapeutic drugs for insomnia-associated AU. Least absolute shrinkage and selection operator regression was employed to screen for candidate biomarkers, and their diagnostic performance was evaluated using receiver operating characteristic (ROC) curves and quantitative polymerase chain reaction (qPCR). Finally, molecular docking was applied to verify binding activities.

Results

We identified 138 up-regulated and 85 down-regulated DEGs that were common to insomnia and AU. PPI network analysis highlighted 10 key genes, CMap analysis identified 30 compounds, and WGCNA revealed 54 key genes and 30 compounds. Intersection of the above-mentioned key genes and compounds identified six genes and five compounds. After verification by qPCR and ROC curve analysis, IFI44 and IRF9 were confirmed as hub genes. Finally, two compounds were selected based on docking scores of less than -7 kcal/mol.

Conclusion

Our study demonstrated involvement of the viral response in both insomnia and AU and identified the diagnostic significance of IFI44 and IRF9 in these conditions. These findings provide novel insights for future diagnostic and therapeutic strategies to treat insomnia-associated AU.

Characteristics and Associated Factors of Insomnia Among the General Population in the Post-Pandemic Era of COVID-19 in Zhejiang, China: A Cross-Sectional Study

Objective

This study aimed to analyze the changes in insomnia characteristics among the general population and explore associated factors during the COVID-19 pandemic and post-pandemic periods.

Methods

A cross-sectional study was conducted using an anonymous online survey. Questionnaires were administered at two-time points (T1: March 1-31, 2022; T2: March 1-31, 2023), which included an Insomnia Severity Index (ISI) and questions related to sleep risk factors, including the COVID-19 pandemic, familial influences, work and study conditions, social activities, physical health, use of electronic devices before sleep, sleep environment, food intake and exercise before sleep, etc. Insomnia characteristics were compared at two points, with logistic regression testing associations with sociodemographic covariates and risk factors. Six machine learning models were employed to develop a predictive model for insomnia, namely logistic regression, random forest, neural network, support vector machine, CatBoost, and gradient boosting decision tree.

Results

The study obtained 2769 and 1161 valid responses in T1 and T2, respectively. The prevalence of insomnia increased from 23.4% in T1 to 34.83% in T2. Univariate analyses indicated the factors of the COVID-19 pandemic, familial influences, social activity, physical health, food intake, and exercise before sleep significantly differed in T1 (p<0.05) between insomnia and non-insomnia groups. In T2, significant differences (p<0.05) were observed between the two groups, including the factors of the COVID-19 pandemic, family structure, work and study conditions, social activity, and physical health status. The random forest model had the highest prediction accuracy (90.92% correct and 86.59% correct in T1 and T2, respectively), while the pandemic was the most critical variable at both time points.

Conclusion

The prevalence and severity of insomnia have worsened in the post-pandemic period, highlighting an urgent need for effective interventions. Notably, the COVID-19 pandemic and physical health status were identified as significant risk factors for insomnia.

Ubiquitination and degradation of MHC-II by Tim-3 inhibits antiviral immunity

We previously reported that Tim-3, an immune checkpoint inhibitor, inhibits MHC-II expression, but the molecular mechanisms involved and the implications for antiviral immunity remain to be determined. Here, we found that during H1N1 infection, Tim-3 inhibits MHC-II expression in macrophages/microglia in vitro. Tim-3 interacts with MHC-II via its intracellular tail and induces proteasomal dependent degradation of MHC-II. In H1N1 infected macrophages/microglia, Tim-3 promotes the K48-linked ubiquitination of MHC-II via MARCH8, a ubiquitin E3 ligase that can be upregulated by Tim-3. In H1N1 infected mice, specific knockout of Tim-3 in macrophages leads to a decreased viral load, attenuates tissue damage and increases the survival rate. We have thus identified a novel mechanism by which Tim-3 mediates virus immune escape. Manipulating the Tim-3-MHC-II signaling pathway may provide a novel treatment for viral infections.

Exploring Health Promotion Behaviors, Occupational Burnout, and Sleep Disturbances in Traditional Industry Workers

Background: Sleep disturbances affect about 40% of the global population and are a common issue among patients seeking medical consultation. There is limited research on sleep disturbances in Taiwan's traditional industry workforce. Objective: This study aims to investigate the correlations between work patterns, health promotion behaviors, occupational burnout, and sleep disturbances among employees in traditional industries. Methods: A cross-sectional study was conducted to collect data on the work patterns, health promotion behaviors, occupational burnout, and sleep disturbances within a traditional industry. The study period was from May to June 2023. Data analysis was performed using chi-square tests, independent sample t-tests, and logistic regression. Result: Data from a total of 365 employees were collected, with 63.3% of the study subjects working in shifts and 47.9% experiencing sleep disturbances. Factors associated with sleep disturbances included personal burnout (OR = 1.07 (95% CI 1.06, 1.09); p < 0.001), shift work (OR = 2.67 (95% CI 1.53, 4.65); p < 0.001), health responsibility behavior (OR = 0.50 (95% CI 0.33, 0.77); p = 0.001), and life appreciation behavior (OR = 0.47 (95% CI 0.29, 0.76); p = 0.002). Conclusion: Occupational health nurses should regularly assess employees' sleep status and provide psychological counseling services and health promotion programs to help employees alleviate sleep disturbances.

Impact of COVID-19 Infection and Related Social Concerns on Depressive Symptoms: Mediating Effects of Negative Changes in Daily Life and Moderating Effects of Age and Gender

OBJECTIVE

This study examined the mediating effect of negative changes in daily life due to the coronavirus disease-2019 (COVID-19) pandemic on depressive symptoms, considering COVID-19 infection and related social concerns. Additionally, comparisons of path coefficients between the groups were conducted based on age and gender.

METHODS

A cross-sectional study design used data from the 2020 Korean Community Health Survey consisting of 229,269 individuals. This study used a self-reported questionnaire, including the Patient Health Questionnaire-9 and three items addressing social concerns related to COVID-19 infection. A single question assessed whether individuals had experienced COVID-19 infection within the last 3 months, and scores of negative changes in daily life due to the COVID-19 pandemic. Correlation analysis was performed on the variables. Structural equation model analysis was conducted to identify the mediating role of negative changes in daily life. Chi-square tests were also performed to compare the path coefficients based on age and gender.

RESULTS

The structural equation models revealed that COVID-19 infection and related social concerns had both significant direct effects on depressive symptoms and indirect effects through negative changes in daily life. When comparing the path coefficients by age and gender, the coefficients related to depressive symptoms were highest in those under 65 years and in females.

CONCLUSION

Negative changes in daily life due to the COVID-19 pandemic serve as a partial mediator of the impact of COVID-19 infection and related social concerns on depressive symptoms. Special attention should be paid to depressive symptoms in those under 65 years of age and in females.

Impact of the COVID-19 pandemic on participants in pragmatic clinical trials for chronic pain: implications for trial outcomes and beyond

OBJECTIVE

The COVID-19 pandemic had profound effects on society, including those living with chronic pain. This study sought to examine pandemic impacts on individuals enrolled in pragmatic clinical trials focused on nonpharmacological treatments for chronic pain.

METHODS

We evaluated responses to a questionnaire on COVID-19 impacts that had been administered to participants (n=2024) during study enrollment in 3 pragmatic clinical trials for chronic pain treatment. All trials were part of the National Institutes of Health (NIH)-Department of Veterans Affairs (VA)-Department of Defense (DOD) Pain Management Collaboratory. COVID-19-related impacts on access to health care, mental health, finances, ability to meet basic needs, and social support were assessed.

RESULTS

Pandemic impacts were found in all domains assessed, including access to health care, mental and emotional health, ability to meet basic needs, finances, and social support. Impacts varied by demographic and clinical characteristics. The participants most negatively impacted by the pandemic were younger, Black or Latino, female, more educated, and unemployed and had screened positive for depression. No impact differences were found with regard to alcohol use disorder screenings or a prior history of COVID-19. Higher levels of pain were associated with worse pandemic impacts, and negative impacts declined over time.

CONCLUSIONS

Negative impacts of the pandemic on individuals living with chronic pain cut across aspects of life that are also central to effective pain management, including access to health care, social support, and mental and emotional health, with differential impacts found across key demographic and clinical factors. These findings should yield consideration of pandemic impacts in clinical practice and as moderating effects of treatment outcomes in clinical trials conducted during the pandemic.

Sleep health, its intraindividuality, and perceived stress in college students during the COVID-19 pandemic

Objective: To describe the changes in sleep health domains and examine the associations between the repeated measures and intraindividual variability (IIV) of these domains and perceived stress. Participants: A diverse racial and ethnic group of first-year college students (N = 23, 78.3% female, aged 17-18) attending in-person classes during the COVID-19 pandemic. Methods: Sleep health domains were determined using 7-day wrist actigraph and daily sleep diaries, and perceived stress scale was completed at 1-month intervals across 3 months. Results: Sleep timing, regularity, and alertness during daytime demonstrated statistically significant changes between three timepoints. Greater stress was associated with more irregularity (B = 2.25 [.87-3.62], p < .001), more dissatisfaction in sleep (B = .04 [.02-.19], p < .01), alertness during daytime (B = .18 [.05-.31], p < .001), and greater IIV (ie, fluctuations) in sleep satisfaction (B = .083 [.02, .15], p < .01). Conclusion: These findings offer insights for future researchers to facilitate intervention development to promote mental and sleep health among college students.

Machine learning for anxiety and depression profiling and risk assessment in the aftermath of an emergency

BACKGROUND & OBJECTIVES

Mental health disorders pose an increasing public health challenge worsened by the COVID-19 pandemic. The pandemic highlighted gaps in preparedness, emphasizing the need for early identification of at-risk groups and targeted interventions. This study aims to develop a risk assessment tool for anxiety, depression, and self-perceived stress using machine learning (ML) and explainable AI to identify key risk factors and stratify the population into meaningful risk profiles.

METHODS

We utilized a cohort of 9291 individuals from Northern Spain, with extensive post-COVID-19 mental health surveys. ML classification algorithms predicted depression, anxiety, and self-reported stress in three classes: healthy, mild, and severe outcomes. A novel combination of SHAP (SHapley Additive exPlanations) and UMAP (Uniform Manifold Approximation and Projection) was employed to interpret model predictions and facilitate the identification of high-risk phenotypic clusters.

RESULTS

The mean macro-averaged one-vs-one AUROC was 0.77 (± 0.01) for depression, 0.72 (± 0.01) for anxiety, and 0.73 (± 0.02) for self-perceived stress. Key risk factors included poor self-reported health, chronic mental health conditions, and poor social support. High-risk profiles, such as women with reduced sleep hours, were identified for self-perceived stress. Binary classification of healthy vs. at-risk classes yielded F1-Scores over 0.70.

CONCLUSIONS

Combining SHAP with UMAP for risk profile stratification offers valuable insights for developing effective interventions and shaping public health policies. This data-driven approach to mental health preparedness, when validated in real-world scenarios, can significantly address the mental health impact of public health crises like COVID-19.

The effect of restricted and free-living conditions on light exposure and sleep in older adults

During the COVID-19 pandemic, studies reported that restricted living conditions were associated with worse subjective sleep quality. This effect might have been caused by reduced light exposure during lockdowns. We investigated light exposure levels, subjective and objective sleep and physical activity levels in older adults during restricted and free-living conditions after the pandemic. Ninety-one participants (62.7 ± 8.4 years) recruited from the community using social media with 44 participants (63.4 ± 8.9 years) completed follow-up during free-living conditions. Participants wore an actigraphy device and completed sleep diaries for 7 days during each condition. Light values were extracted in hourly bins across the 24-h period and objective and subjective sleep were compared between the conditions. There was an increase in mean 24-h light exposure during restricted-living (1103.7 ± 1024.8 lux) compared to free-living (803.0 ± 803.6 lux; p < 0.001). This was partially related to participants spending 18 min more in bright light conditions (>1,000 lux) during wakefulness in restricted living (2.6 ± 1.9 h) compared to free-living (2.3 ± 2.0 h; p = 0.036). Despite differences in light exposure, there were no significant differences in objective and subjective sleep parameters between the two conditions. More research is required to better understand behaviours related to light exposure and how this may impact on sleep.

Limited carry-over effects of socioemotional manipulations on subsequent unrelated memory tasks

Although age is typically associated with significant impairments in memory performance, several domains exist in which these impairments are reduced or even eliminated. These "pockets of preservation" in older adults' memory can be seen in tasks involving socioemotional processing and may be supported by distinct encoding or retrieval modes relative to neutral content. The current study examines whether engaging in socioemotional tasks prior to encoding or retrieval allows older adults to enter an encoding or retrieval mode that better supports memory performance. In two online studies, adults across the lifespan were asked to complete a memory task where they incidentally encoded and retrieved neutral (Experiment 1, N = 1621) or emotional (Experiment 2, N = 409) word-image pairs. Participants were randomly assigned to a control (i.e., no manipulation), pre-encoding, or pre-retrieval socioemotional manipulation condition. There were no main effects of manipulation condition, suggesting that such manipulations may not reliably enhance memory. However, future research is needed to follow up on exploratory analyses that highlighted particular conditions under which these manipulations may convey benefits. There were also no age-by-manipulation interactions. While these null effects may suggest that these manipulations are not better suited to older adults, this may also be a result of the unexpected age-related increases (Experiment 1) and age invariance (Experiment 2) in overall memory accuracy in the current study. Socioemotional manipulations should also be examined in older adults who underperform younger adults.

Assessment of sleep patterns in dementia and general population cohorts using passive in-home monitoring technologies

BACKGROUND

Nocturnal disturbances are a common symptom experienced by People Living with Dementia (PLWD), and these often present prior to diagnosis. Whilst sleep anomalies have been frequently reported, most studies have been conducted in lab environments, which are expensive, invasive and not natural sleeping environments. In this study, we investigate the use of in-home nocturnal monitoring technologies, which enable passive data collection, at low cost, in real-world environments, and without requiring a change in routine.

METHODS

Clustering analysis of passively collected sleep data in the natural sleep environment can help identify distinct sub-groups based on sleep patterns. The analysis uses sleep activity data from; (1) the Minder study, collecting in-home data from PLWD and (2) a general population dataset (combined n = 100, >9500 person-nights).

RESULTS

Unsupervised clustering and profiling analysis identifies three distinct clusters. One cluster is predominantly PLWD relative to the two other groups (72% ± 3.22, p = 6.4 × 10-7, p = 1.2 × 10-2) and has the highest mean age (77.96 ± 0.93, p = 6.8 × 10-4 and p = 6.4 × 10-7). This cluster is defined by increases in light and wake after sleep onset (p = 1.5 × 10-22, p = 1.4 × 10-7 and p = 1.7 × 10-22, p = 1.4 × 10-23) and decreases in rapid eye movement (p = 5.5 × 10-12, p = 5.9 × 10-7) and non-rapid eye movement sleep duration (p = 1.7 × 10-4, p = 3.8 × 10-11), in comparison to the general population.

CONCLUSIONS

In line with current clinical knowledge, these results suggest detectable dementia sleep phenotypes, highlighting the potential for using passive digital technologies in PLWD, and for  detecting architectural sleep changes more generally. This study indicates the feasibility of leveraging passive in-home technologies for disease monitoring.

Neuropsychiatric symptoms of patients two years after experiencing severe COVID-19: A mixed observational study

BACKGROUND

The impact of SARS-CoV-2 infection (COVID-19) on mental health has not been extensively studied in the medium and long term. This study assessed how clinical, biological, and social factors affect mental health in patients who recovered from severe COVID-19. The evaluation was done 90 days after hospital discharge and followed up at 12 and 24 months.

METHODS

A retrospective-prospective cohort mixed observational study was conducted on patients over 18 years of age who required hospitalization in Internal Medicine or ICU for severe COVID-19 pneumonia during 2020 and 2021. Demographic information, clinical variables, and data for the scales were obtained from electronic medical records and telephone interviews. For comparisons of the different variables in each clinical variable (insomnia, depression, anxiety), the Student's t-test for independent samples has been used (normal distribution); otherwise, the Mann-Whitney test will be used. All tests and intervals will be performed with a confidence level of 95. Fisher's exact or Pearson's Chi-square test has been used as appropriate for qualitative variables.

RESULTS

201 patients were recruited. 37.3% presented insomnia, 22.4% anxiety, and 21.4% depressive symptoms. A direct association was established between female sex and depressive symptoms. Psychotropic history, fatigue, and C-reactive protein levels (CRP) were correlated with depression. Anosmia and ageusia, CRP, cognitive symptoms, and dyspnea predicted insomnia. Sex, orotracheal intubation (OTI), pain, fatigue, mental health history, and academic level were independent predictors of anxiety. High percentages of depressive, anxiety, and insomnia symptoms were detected in the second month after discharge and persisted at 12 and 24 months. The fatigue variable maintained a significant relationship with depressive symptoms at 2, 12 and 24 months. A possible limitation could be recall bias in retrospective data collection.

CONCLUSIONS

This is a novel study to follow up on mental health for two years in patients with severe COVID-19. Clinical, biological, and psychosocial variables could be predictors of depressive symptoms, anxiety, and insomnia. The psychiatric symptoms persisted throughout the 2-year follow-up. These findings are critical for the follow-up of these patients and open the possibility of further studies in the medium and long term.

Longitudinal investigation of a single variant SARS-CoV-2-outbreak in the immunologically naïve population of Ulvik, Norway

PURPOSE

To perform an extensive investigation of the clinical features and long-term complications among the n = 134 adults and children with nucleic acid amplification test (NAAT) verified SARS-CoV-2-infection in the immunologically naïve population of Ulvik, Norway, during the single variant B.1.1.7 outbreak in late January through February 2021.

METHODS

Every infected person regardless of whether symptoms of COVID-19 were present was invited to answer a web-based questionnaire at two- and seven months after testing positive. The period from initial infection to the first questionnaire was assessed retrospectively, and the time points at two- and seven months were assessed prospectively.

RESULTS

A total of 87 of 134 (65%) NAAT-positive persons answered the first questionnaire, of which 35/87 (40%) were children, and 74 of 87 (85%) answered the second questionnaire. Children experienced symptoms less often than adults during the acute phase of infection (51% (18/35) versus 81% (42/52) (p = .004)). At two-months follow-up 88% (53/60) of participants with symptoms during the acute phase, including all children, reported no longer having symptoms. Among those with persisting symptoms at seven months, fatigue (18/25) and insomnia (16/24) were common.

CONCLUSION

In an immunologically naïve population infected with the SARS-CoV-2 B.1.1.7 variant, the clinical features of acute phase symptoms were similar to previous studies. Children underwent asymptomatic infection more often than adults, and adults more often experienced persisting symptoms. Insomnia and fatigue were common complaints among those with persisting symptoms seven months after infection.

A Longitudinal Examination between Chronotype and Insomnia in Youths: A Cross-Lagged Panel Analysis

Adolescence and young adulthood are transitional periods associated with significant changes and challenges, leading to a heightened vulnerability to sleep disturbances and mental health difficulties. This stage is often associated with an increased preference for eveningness, manifested as a later chronotype. The current study aimed to investigate the directionality of the association between chronotype, based on an individual's sleep-wake behaviour, and insomnia in young people using a two-wave panel design with a 12-month interval. A total of 370 participants aged 15-24 (mean age: 21.0 ± 2.0, 72.7% female) were recruited from local secondary schools and universities. Insomnia symptoms were assessed using the Insomnia Severity Index, while chronotype was measured using the Munich Chronotype Questionnaire. Temporal associations were analysed using a series of cross-lagged panel models. The best fitting and most parsimonious model indicated that a later chronotype at baseline predicts more severe insomnia symptoms at the 12-month follow-up after accounting for autoregressive effects. However, the opposite causal model, where baseline insomnia symptoms predicted the chronotype at the 12-month follow-up, was not supported. These findings suggest that a late chronotype may be a potential risk factor for the development of insomnia in young people, emphasising the importance of considering circadian factors in the prevention and treatment of sleep disturbances among this population.

Monoclonal Antibody Infusions for Outpatient Management of Mild-Moderate COVID-19

BACKGROUND

The COVID-19 pandemic has led to a rapid, exponential increase in hospitalizations and morbidity/mortality. In November 2020, the Food and Drug Administration (FDA) issued Emergency Use Authorizations (EUAs) permitting administration of the first monoclonal antibodies (mAb) for outpatient treatment of COVID-19. Early data showed a reduction in COVID-19-related hospitalizations with few adverse events. However, since these treatments are only authorized under an EUA, real-world data are minimal.

OBJECTIVE

To assess efficacy and safety of mAbs in a veteran population.

METHODS

This retrospective study analyzed veterans at the Ralph H. Johnson Veterans Affairs Health Care System with mild-moderate COVID-19 and screened for mAb eligibility between December 1, 2020, and October 31, 2021. The primary outcome was hospitalizations and/or emergency department (ED) visits within 30 days. Secondary outcomes included 30-day mortality and post-COVID-19 conditions. Adverse events were also evaluated. Outcomes were compared between mAb-treated patients and eligible veterans who were not treated.

RESULTS

There were 296 and 275 veterans in the mAb and control groups, respectively. No statistically significant difference was found for the primary outcome overall (25.7% vs 25.1%; P = 0.87), nor for COVID-19-related return visits or hospitalizations (13.9% v. 16%; P = 0.4). However, the mAb group had more return ED visits (P = 0.35), and the control group had significantly more hospitalizations (P = 0.02). Vaccinated veterans who received an mAb had fewer return visits and hospitalizations (P = 0.01). More mAb-treated veterans experienced post-COVID-19 conditions. No difference in mortality was found. Four nonsevere adverse events occurred after the mAb therapy.

CONCLUSION AND RELEVANCE

Overall, the mAbs appeared safe and effective. Sicker, higher-risk mAb-treated veterans faired similarly to less-sick, high-risk veterans not treated. Those who were vaccinated seemed to benefit the most from mAb therapy. Future prospective studies with more matched groups are needed to assess full benefits and risks of mAbs shown to neutralize the predominant variants.

Definition of the Post-COVID syndrome using a symptom-based Post-COVID score in a prospective, multi-center, cross-sectoral cohort of the German National Pandemic Cohort Network (NAPKON)

PURPOSE

The objective examination of the Post-COVID syndrome (PCS) remains difficult due to heterogeneous definitions and clinical phenotypes. The aim of the study was to verify the functionality and correlates of a recently developed PCS score.

METHODS

The PCS score was applied to the prospective, multi-center cross-sectoral cohort (in- and outpatients with SARS-CoV-2 infection) of the "National Pandemic Cohort Network (NAPKON, Germany)". Symptom assessment and patient-reported outcome measure questionnaires were analyzed at 3 and 12 months (3/12MFU) after diagnosis. Scores indicative of PCS severity were compared and correlated to demographic and clinical characteristics as well as quality of life (QoL, EQ-5D-5L).

RESULTS

Six hundred three patients (mean 54.0 years, 60.6% male, 82.0% hospitalized) were included. Among those, 35.7% (215) had no and 64.3% (388) had mild, moderate, or severe PCS. PCS severity groups differed considering sex and pre-existing respiratory diseases. 3MFU PCS worsened with clinical severity of acute infection (p = .011), and number of comorbidities (p = .004). PCS severity was associated with poor QoL at the 3MFU and 12MFU (p < .001).

CONCLUSION

The PCS score correlated with patients' QoL and demonstrated to be instructive for clinical characterization and stratification across health care settings. Further studies should critically address the high prevalence, clinical relevance, and the role of comorbidities.

TRAIL REGISTRATION NUMBER

The cohort is registered at www.

CLINICALTRIALS

gov under NCT04768998.

The Role of Sleep Effort as a Mediator Between Anxiety and Depression

Depression, anxiety, and insomnia are all conditions that share a complex bidirectional relationship. Sleep effort is a construct with cognitive and behavioral components that perpetuates insomnia. Although many studies have examined the associations between these three variables, no studies have yet examined sleep effort as a mediating variable between anxiety and depression and vice versa. Online versions of the Hospital Anxiety and Depression Scale and the Glasgow Sleep Effort Scale were administered to a sample of 1927 higher education students aged 18-40 years (75.9% women and 76% from 18 to 23 years old). As part of the survey, participants also completed a sociodemographic questionnaire. Mediation analysis indicated that sleep effort mediates the relationship between depression and anxiety, when the former was the predictor and the latter was the criterion. Moreover, sleep effort also mediated the relationship between anxiety and depression when the former was the predictor and the latter was the criterion, albeit in a lesser extent. Sleep effort appears to play a bidirectional mediational role between depression and anxiety, being a potential target for intervention.

Insomnia in teachers at the time of resumption of in-person instruction at schools amidst the COVID-19 pandemic: A cross-sectional study

BACKGROUND

The coronavirus (COVID-19) pandemic has affected people's economies, lifestyles, and physical, emotional, and sleep health. This research aimed to estimate the prevalence of insomnia and symptoms of stress, anxiety, and depression among teachers with the resumption of in-person instruction at schools following a hiatus after COVID-19 lockdowns in India. We also studied the association of teachers' insomnia with psychological symptoms and demographic variables.

METHODS

We conducted a cross-sectional survey between October -November 2021 after schools had reopened during the COVID-19 pandemic. Data was collected using standard questionnaires online among schoolteachers. We explored the association of insomnia with teachers' symptoms of stress, anxiety, depression, sex, school boards, and age groups.

RESULTS

Of 124 schoolteachers surveyed, the prevalence of insomnia was 37.9% (subthreshold in 25% and clinical in 12.9%). The prevalence of stress, depression, and anxiety was 20.2%, 30.6%, and 45.2%, respectively. There was a significant association (p<0.001) of insomnia with symptoms of anxiety, stress, and depression in univariate analysis. On multivariate analysis, we found that those feeling stressed had a 6.4 times higher risk of insomnia (95% CI: 1.5-28.3, p - 0.01). There was no association of insomnia with age, sex, school educational boards, and type of institution.

CONCLUSIONS

Over one-third (37.9%) of teachers reported having trouble sleeping when they returned to the school's typical face-to-face instruction modalities through COVID-19 times, and insomnia was more prevalent in those with stress.

Comparative insomnia prevalence between geriatrics lived in urban and rural areas: a multicenter nationwide study analysis

AIMS

Insomnia is a common complaint among older adults. However, the comparative prevalence between older adults living in urban versus rural areas remains under-researched. This study aims to validate the overall prevalence of insomnia among older adults in Indonesia and investigate the comparative prevalence between older adults living in urban and rural areas.

METHODS

The data were derived from the 2018 Indonesian Basic Health Research Study. We included a total of 93,830 older participants aged > 60 years old who completed the insomnia questions. The prevalence and regression models were analyzed using the SPSS software.

RESULTS

The insomnia group has a higher age compared to the non-insomnia group (P < 0.05). Insomnia is more prevalent in females compared to males (P < 0.05). When classified by age groups (60-64, 65-69, 70-74, and > 75 years old), the prevalence of insomnia was 20%, 21%, 23%, and 24%, respectively. The prevalence of insomnia among older individuals living in rural areas was higher compared to those living in urban areas. In addition, increasing age, being female, unemployed, having comorbidities, being less active, and drinking alcohol are associated with insomnia symptoms.

CONCLUSION

The findings of this study indicated that the prevalence of insomnia is high among older adults in Indonesia, with older adults living in rural areas exhibiting a higher prevalence compared to those living in urban areas. Our findings strengthen the importance of sleep management in clinical or community settings.

Cognitive Behavioral Therapy for Insomnia Self-Management Mobile Apps: A Review of Efficacy and Quality

Cognitive behavioral therapy for insomnia (CBT-I) is the recommended treatment for insomnia, yet multiple barriers limit utilization. Digital CBT-I may present a solution, though related reviews have focused on Internet-based delivery rather than app use. The high utilization of health apps and prevalence of sleep apps indicate the need to equip clinicians with app-specific research. Toward this end, we reviewed efficacy and quality data on self-management CBT-I smartphone apps, revealing efficacy research on eleven apps, five of which were publicly available. While preliminary, these efficacy studies showed consistent positive findings. When examining quantitative quality indicators for the five publicly available apps, two had consistent data. Overall, two apps, CBTi Coach and Insomnia Coach, had positive, empirical findings across all efficacy and quality assessment approaches. We provide recommendations to guide clinician decision making regarding CBT-I self-management apps based on the literature and publicly available methods of app evaluations.

Prevalence and Predictors of Fatigue among Thai Women after COVID-19 Infection

Background

Several people suffered from fatigue after recovering from coronavirus disease 2019 (COVID-19). However, limited studies focused on fatigue in women who recovered from COVID-19 infection. This study aimed to investigate the prevalence of fatigue among Thai women after COVID-19 infection and to identify predictive factors, including depression, anxiety, fear, and insomnia.

Materials and Methods

A cross-sectional research design using convenience sampling was conducted from October 2022 to January 2023. A total of 142 Thai women after COVID-19 infection were recruited from two urban communities located in the Bangkok Metropolitan area, Thailand. The participants completed self-reported questionnaires, including the demographic and illness-related data questionnaire, the Depress Anxiety Stress Scales, the Insomnia Severity Index, the Fear of Progression Questionnaire, and the Fatigue Severity Scale. Data were analyzed using mean, standard deviation, range, Pearson's product-moment correlations, and stepwise multiple regression.

Results

All (100%) participants returned the questionnaires. After recovering from COVID-19 infection for at least 1 month or longer, 39.40% of the participants reported fatigue. The multiple regression analysis revealed that fear, anxiety, and insomnia collectively contributed to 47% of the variance in the participants' fatigue (R2 = 0.47; p < 0.001).

Conclusions

Nearly two-quarters of Thai women after recovering from COVID-19 infection experienced fatigue. To prevent fatigue among Thai women after COVID-19 infection, it is necessary to help them overcome feelings of fear and anxiety. Furthermore, nursing interventions aiming to alleviate insomnia should be implemented.

Assessing the Short-Term Efficacy of Digital Cognitive Behavioral Therapy for Insomnia With Different Types of Coaching: Randomized Controlled Comparative Trial

BACKGROUND

Digital cognitive behavioral therapy for insomnia (dCBTi) is an effective intervention for treating insomnia. The findings regarding its efficacy compared to face-to-face cognitive behavioral therapy for insomnia are inconclusive but suggest that dCBTi might be inferior. The lack of human support and low treatment adherence are believed to be barriers to dCBTi achieving its optimal efficacy. However, there has yet to be a direct comparative trial of dCBTi with different types of coaching support.

OBJECTIVE

This study examines whether adding chatbot-based and human coaching would improve the treatment efficacy of, and adherence to, dCBTi.

METHODS

Overall, 129 participants (n=98, 76% women; age: mean 34.09, SD 12.05 y) whose scores on the Insomnia Severity Index [ISI] were greater than 9 were recruited. A randomized controlled comparative trial with 5 arms was conducted: dCBTi with chatbot-based coaching and therapist support (dCBTi-therapist), dCBTi with chatbot-based coaching and research assistant support, dCBTi with chatbot-based coaching only, dCBTi without any coaching, and digital sleep hygiene and self-monitoring control. Participants were blinded to the condition assignment and study hypotheses, and the outcomes were self-assessed using questionnaires administered on the web. The outcomes included measures of insomnia (the ISI and the Sleep Condition Indicator), mood disturbances, fatigue, daytime sleepiness, quality of life, dysfunctional beliefs about sleep, and sleep-related safety behaviors administered at baseline, after treatment, and at 4-week follow-up. Treatment adherence was measured by the completion of video sessions and sleep diaries. An intention-to-treat analysis was conducted.

RESULTS

Significant condition-by-time interaction effects showed that dCBTi recipients, regardless of having any coaching, had greater improvements in insomnia measured by the Sleep Condition Indicator (P=.003; d=0.45) but not the ISI (P=.86; d=-0.28), depressive symptoms (P<.001; d=-0.62), anxiety (P=.01; d=-0.40), fatigue (P=.02; d=-0.35), dysfunctional beliefs about sleep (P<.001; d=-0.53), and safety behaviors related to sleep (P=.001; d=-0.50) than those who received digital sleep hygiene and self-monitoring control. The addition of chatbot-based coaching and human support did not improve treatment efficacy. However, adding human support promoted greater reductions in fatigue (P=.03; d=-0.33) and sleep-related safety behaviors (P=.05; d=-0.30) than dCBTi with chatbot-based coaching only at 4-week follow-up. dCBTi-therapist had the highest video and diary completion rates compared to other conditions (video: 16/25, 60% in dCBTi-therapist vs <3/21, <25% in dCBTi without any coaching), indicating greater treatment adherence.

CONCLUSIONS

Our findings support the efficacy of dCBTi in treating insomnia, reducing thoughts and behaviors that perpetuate insomnia, reducing mood disturbances and fatigue, and improving quality of life. Adding chatbot-based coaching and human support did not significantly improve the efficacy of dCBTi after treatment. However, adding human support had incremental benefits on reducing fatigue and behaviors that could perpetuate insomnia, and hence may improve long-term efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05136638; https://www.clinicaltrials.gov/study/NCT05136638.

Identification of the risk factors for insomnia in nurses with long COVID-19

PURPOSE

To investigate the prevalence of insomnia among nurses with long COVID-19, analyze the potential risk factors and establish a nomogram model.

METHODS

Nurses in Ningbo, China, were recruited for this study. General demographic information and insomnia, burnout, and stress assessment scores were collected through a face-to face questionnaire survey administered at a single center from March to May 2023. We used LASSO regression to identify potential factors contributing to insomnia. Then, a nomogram was plotted based on the model chosen to visualize the results and evaluated by receiver operating characteristic curves and calibration curves.

RESULTS

A total of 437 nurses were recruited. 54% of the nurses had insomnia according to the Insomnia Severity Index (ISI) score. Eleven variables, including family structure, years of work experience, relaxation time, respiratory system sequelae, nervous system sequelae, others sequelae, attitudes toward COVID-19, sleep duration before infection, previous sleep problems, stress, and job burnout, were independently associated with insomnia. The R-squared value was 0.464, and the area under the curve was 0.866. The derived nomogram showed that neurological sequelae, stress, job burnout, sleep duration before infection, and previous sleep problems contributed the most to insomnia. The calibration curves showed significant agreement between the nomogram models and actual observations.

CONCLUSION

This study focused on insomnia among nurses with long COVID-19 and identified eleven risk factors related to nurses' insomnia. A nomogram model was established to illustrate and visualize these factors, which will be instrumental in future research for identifying nurses with insomnia amid pandemic normalization and may increase awareness of the health status of healthcare workers with long COVID-19.

Comparative short-term safety and efficacy of hypnotics: A quantitative risk-benefit analysis

Several professional societies have provided recommendations for prescribing medications for insomnia. None has provided an integrative analysis that concurrently quantifies safety and efficacy (e.g., risk-benefit ratios). This represents an important gap for informing clinician decision-making. Accordingly, the aim of the present review is to provide such an analysis for five classes of sleep-promoting medications. Adverse event data values were extracted from the most recent FDA-approved package inserts and converted to an integer before being placebo-adjusted and standardized as a rate per 1000 (AEr). Efficacy data, pre-to-post self-reported data for active and placebo conditions were acquired from pivotal trials identified in "white papers" and systematic reviews/meta-analyses. Weighted effect sizes were calculated for subjective sleep latency, wake time after sleep onset and total sleep time, and then were averaged by medication class for each sleep continuity variable. Overall efficacy was represented by a single variable, SWT (sleep latency + wake time after sleep onset + total sleep time). Risk-benefit was represented using a simple ratio value. For safety, it was found that melatonin receptor agonists had the lowest adverse event rate (AEr = 43.1), and non-benzodiazepine benzodiazepine receptor agonists had the highest rate (AEr = 255.0). For efficacy, it was found that the pre-to-post placebo adjusted effect sizes were largest for benzodiazepines (effect size = 1.94) and smallest for melatonin receptor agonists (effect size = 0.109). For risk-benefit, histamine antagonist had the most favourable profile (risk-benefit = 69.5), while melatonin receptor agonist had the least favourable profile (risk-benefit = 395.7). Overall, the combined metric for risk-benefit suggests that treatment with a histamine antagonist is optimal and potentially represents the best first-line therapy for the medical management of insomnia.

Bereavement scheduling policy for emergency medicine residents: A descriptive pilot study

Background

The Accreditation Council for Graduate Medical Education has tasked residency programs to prioritize resident wellness, reduce trainee stress, and prevent burnout. Grief and bereavement can significantly impact residents' wellness during difficult clinical training schedules. There are no best practices on how to support residents during this time.

Methods

In a split academic county emergency medicine (EM) residency, this pilot study documents a resident-driven change to scheduling practices for bereavement leave. An advisory group of residents, chief residents, and program directors informally polled peer institutions to develop bereavement leave guidelines. Considerations were made to balance resident wellness, education, and patient care in developing a bereavement scheduling policy.

Results

The bereavement policy was adopted in January 2023, aiming to "support the resident during a difficult time and reduce concerns around shift coverage" following the death of a family member without impacting sick call. The number of covered days depended on the relationship of the resident to the deceased. Residents covering bereavement days for their peers were financially compensated. During the first 7 months following implementation, five residents utilized the policy. These residents noted this to be the most positive impact on the residency during the past year. Based on resident feedback, the scope was expanded to include grave medical illness of a family member as an implementation criterion.

Conclusions

This article outlines the creation, implementation, and benefits of a bereavement scheduling policy within an EM residency. Describing this approach will provide guidance for other residencies to adopt similar wellness-focused strategies.

Restless legs symptoms increased during COVID-19 pandemic. International ICOSS-survey

BACKGROUND AND OBJECTIVES

Restless legs syndrome (RLS) has been associated with anxiety, depression, insomnia, lifestyle factors and infections. We aimed to study the prevalence of symptoms of RLS during the COVID-19 pandemic versus pre-pandemic. We hypothesized that pre-existing RLS symptoms worsened and pandemic-related factors may have triggered new symptoms of RLS.

METHODS

Adults (≥18 years) from fifteen countries across four continents participated in an online survey between May and August 2020. The harmonized questionnaire included a validated single question on RLS with response alternatives from 1 to 5 on a scale from never to every/almost every evening or night. Other measures were the Insomnia Severity Index (ISI), measures of symptoms of anxiety (GAD-2) and depression (PHQ-2), and questions on different pandemic-related factors.

RESULTS

Altogether, 17 846 subjects (63.8 % women) were included in the final analyses. The mean age was 41.4 years (SD 16.1). During the pandemic, symptoms of RLS (≥3 evenings/nights per week) were more common 9.1 % (95 % CI 8.7-10.1) compared to 5.4 % (95 % CI 4.9-6.0) before the pandemic (P < 0.0001). Alltogether 1.3 % (95 % CI 1.1-1.6) respondents had new-onset symptoms (≥3 evenings/nights per week). Moderate-severe insomnia was strongly associated with RLS symptoms. The occurrences of new-onset RLS symptoms were 5.6 % (95 % CI 0.9-13.0) for participants reporting COVID-19 and 1.1 % (95 % CI 0.7-1.5) for non-COVID-19 participants. In the fully adjusted logistic regression model, the occurrence of new-onset RLS symptoms was associated with younger age, social restrictions and insomnia severity. In a similar analysis, RLS symptoms (≥3 evenings/nights per week) were associated with lower education, financial hardship, sleep apnea symptoms, use of hypnotics, insomnia severity, symptoms of depression and possible post-traumatic stress disorder.

DISCUSSION

Our findings indicate that RLS symptoms were more common during the pandemic than before. Usually, the prevalence of RLS increases with age. However, during the pandemic, new-onset symptoms of RLS were more common in younger age groups. This may be due to the pandemic-related factors being more pronounced in the younger compared to the older. The association between insomnia, psychiatric symptoms and RLS warrants clinical attention.

Depression, anxiety, and insomnia symptoms among Chinese college students: A network analysis across pandemic stages

BACKGROUND

As the stages of the COVID-19 pandemic evolved, the symptoms of depression, anxiety, and insomnia have increasingly manifested among Chinese college students. The aim of this study is to investigate the relationships between these symptoms through network analysis among Chinese college students during COVID-19.

METHOD

A three-wave cross-sectional survey was conducted at 22 colleges in Guangdong Province, involving 381,152 students during three specific time intervals: T1 (baseline, February 3 to 10, 2020), T2 (19 months after baseline, June 10 to 18, 2021), and T3 (37 months after baseline, March 15 to April 22, 2023). Depression (PHQ-9), anxiety (GAD-7), and insomnia (YSIS) were used separately. We analyzed two key network indices: "Expected influence" and "Bridge expected influence". Network stability was assessed through a case-dropping bootstrap program.

RESULT

The effective sample sizes for the three periods were as follows: T1 - 164,101 (103,645 females, 63.2 %), T2 - 86,767 (52,146 females, 60.1 %), and T3 - 130,284 (76,720 females, 58.9 %). Across these three periods, the key central symptoms were "Fatigue" (PHQ4), "Restlessness" (GAD5), "Uncontrollable worrying" (GAD2), "Worry too much" (GAD3) and "Sleep insufficiency" (YSIS6). Notably, "Fatigue" (PHQ4), "Restlessness" (GAD5) and "Irritability" (GAD6) consistently served as bridge symptoms. In the T1 and T2 period, "Motor" (PHQ8) acted as a bridge symptom but weakened in T3.

CONCLUSION

Throughout the three periods, the mental health issues among Chinese college students displayed characteristics of somatization within the depression-anxiety-insomnia comorbidity network. Over time, anxiety symptoms appeared to become more prominent. Consequently, this study highlights the importance of accurately identifying and promptly intervening in these core symptoms of mental health among college students, as these symptoms may evolve across different stages of a pandemic.

More Adult Women than Men at High Cardiometabolic Risk Reported Worse Lifestyles and Self-Reported Health Status in the COVID-19 Lockdown

BACKGROUND

The COVID-19 lockdown represented an immense impact on human health, which was characterized by lifestyle and dietary changes, social distancing and isolation at home. Some evidence suggests that these consequences mainly affected women and altered relevant ongoing clinical trials. The aim of this study was to evaluate the status and changes in diet, physical activity (PA), sleep and self-reported health status (SRH) as perceived by older adult men and women with metabolic syndrome during the COVID-19 lockdown.

METHODS

We analyzed data from 4681 Spanish adults with metabolic syndrome. We carried out a telephone survey during May and June 2020 to collect information on demographics, dietary habits, PA, sleep, SRH and anthropometric data.

RESULTS

The mean age of participants was 64.9 years at recruitment, and 52% of participants were men. Most participants (64.1%) perceived a decrease in their PA during confinement. Regarding gender-specific differences, a higher proportion of women than men perceived a decrease in their PA (67.5% vs. 61.1%), Mediterranean diet adherence (20.9% vs. 16.8%), sleep hours (30.3% vs. 19.1%), sleep quality (31.6% vs. 18.2%) and SRH (25.9% vs. 11.9%) (all p < 0.001).

CONCLUSIONS

The COVID-19 lockdown affected women more negatively, particularly their self-reported diet, PA, sleep and health status.

The benefits of socioemotional learning strategies and video formats for older digital immigrants learning a novel smartphone application

The need to continually learn and adjust to new technology can be an arduous demand, particularly for older adults who did not grow up with digital technology ("older digital immigrants" or ODIs). This study tests the efficacy of socioemotional learning strategies (i.e., encoding information in a socially- or emotionally-meaningful way) for ODIs learning a new software application from an instructional video (Experiment 1) or a written manual (Experiment 2). An experiment-by-condition effect was identified, where memory was greatest for participants engaging socioemotional learning strategies while learning from a video, suggesting a synergistic effect of these manipulations. These findings serve as a first step toward identifying and implementing an optimal learning context for ODIs to learn new technologies in everyday life.

Diagnosing OSA and Insomnia at Home Based Only on an Actigraphy Total Sleep Time and RIP Belts an Algorithm "Nox Body Sleep™"

Purpose

The COVID-19 pandemic has influenced clinical sleep protocols with stricter hospital disinfection requirements. Facing these new rules, we tested if a new artificial intelligence (AI) algorithm: The Nox BodySleep™ (NBS) developed without airflow signals for the analysis of sleep might assess pertinently sleep in patients with Obstructive Sleep Apnea (OSA) and chronic insomnia (CI) as a control group, compared to polysomnography (PSG) manual scoring.

Patients-Methods

NBS is a recurrent neural network model that estimates Wake, NREM, and REM states, given features extracted from activity and respiratory inductance plethysmography (RIP) belt signals (Nox A1 PSG). Sleep states from 139 PSG studies (CI N = 72; OSA N = 67) were analyzed by NBS and compared to manually scored PSG using positive percentage agreement, negative percentage agreement, and overall agreement metrics. Similarly, we compared common sleep parameters and OSA severity using sleep states estimated by NBS for each recording and compared to manual scoring using Bland-Altman analysis and intra-class correlation coefficient.

Results

For 127,170 sleep epochs, an overall agreement of 83% was reached for Wake, NREM and REM states (92% for REM states in CI patients) between NBS and manually scored PSG. Overall agreement for estimating OSA severity was 100% for moderate-severe OSA and 91% for minimal OSA. The absolute errors of the apnea-hypopnea index (AHI) and total sleep time (TST) were significantly lower for the NBS compared to no scoring of sleep. The intra-class correlation was higher for AHI and significantly higher for TST using the NBS compared to no scoring of sleep.

Conclusion

NBS gives sleep states, parameters and AHI with a good positive and negative percentage agreement, compared with manually scored PSG.

The effect of social support and resource support on emotional exhaustion, insomnia, and suicidal ideation among allied health trainees and post-graduate year doctors in Taiwan

BACKGROUND

COVID-19-related stigmatization refers to COVID-19-related judgements by others that devalue the individual. Such stigmatization towards healthcare workers may cause psychological burden and negative consequences. Such stigmatization may have particularly overwhelmed allied health trainees (AHTs) and post-graduate year doctors (PGYDs) because they just started their medical career. Social support and resource support have been reported to benefit psychological health and reduce stigmatization. Therefore, the present study used a cross-sectional study design to investigate the association between perceived stigma, self-stigma, psychological distress, and negative outcomes (including emotional exhaustion, insomnia and suicidal ideation) among AHTs and PGYDs in Taiwan.

METHODS

An online survey distributed between July and December, 2022 received 522 responses. Variables were assessed using the 21-item Depression, Anxiety and Stress Scale, Insomnia Severity Index and a series of self-designed questions to assess social support, resource support, perceived stigma, self-stigma, emotional exhaustion, and suicidal ideation.

RESULTS

Structural equation modeling showed that perceived stigma was associated with self-stigma (standardized coefficient [β] = 0.428, p < 0.001), and self-stigma was associated with psychological distress (β = 0.197, p < 0.001), as well as being associated with emotional exhaustion, insomnia, and suicidal ideation (β = 0.349, 0.556 and 0.212, all p-values < 0.001). While social support and resource support were negatively associated with perceived stigma (β= - 0.175 and - 0.152, p < 0.01), additional associations were found between social support and emotional exhaustion (β= - 0.093, p < 0.001), as well as between resource support and insomnia (β= - 0.120, p < 0.001).

CONCLUSIONS

The results showed that COVID-19 related stigmatization was correlated to the detrimental consequences of emotional exhaustion, insomnia and suicidal ideation. Clear paths regarding the associations of social support and resource support with the three negative associations were found as the possible solutions. Strategies to reduce the stigmatization and these negative outcomes, or improve the psychological health will benefit AHTs and PGYDs in maintaining a healthy mental status.

Insomnia

Sleep significantly impacts health. Insomnia, characterized by difficulty with sleep onset, maintenance, and subsequent daytime symptoms, is increasingly prevalent and increases the risk of other medical comorbidities. The pathophysiology involves hyperarousal during non-REM sleep and altered sleep homeostasis. The 3P model explains the development and persistence of insomnia. Assessment is primarily clinical and based on appropriate history while distinguishing from other sleep disorders. "Somnomics" suggests a personalized approach to management. Cognitive behavioral therapy for insomnia is the first-line treatment in addition to other nonpharmacological strategies. Medications are a secondary option with weak supporting evidence.

Depressive Symptoms, Sleep Quality, and Pain Are Associated With Frailty in Nursing Home Residents During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has caused severe effects on older adults. Depressive symptoms, poor sleep quality, and pain are common in older adults with frailty. However, it is unknown the relationship between these symptoms and frailty in nursing home residents and the difference of importance between pain intensity and pain impact on frailty during the COVID-19 Pandemic. Therefore, this study aims to explore the associations between depressive symptoms, poor sleep quality, pain intensity, and pain impact with frailty in older adults living in nursing homes.

METHODS

In this cross-sectional population-based study, 172 older adults living in nursing homes from Changsha in China were included. We collected data on depressive symptoms, sleep quality, pain, and frailty using the Patient Health Questionnaire, the Pittsburgh Sleep Quality, the Brief Pain Inventory-short form, and the FRAIL-NH Scale. Generalized linear regression models were used to explore the interaction association between these symptoms with frailty.

RESULTS

Most older adults were between 80 and 90 years old. Approximately 11.6% of older adults experienced one of the following symptoms: depressive symptoms, poor sleep quality, pain intensity, or pain impact. Moreover, 76.7% of older adults experienced at least two of these symptoms. The most common overlapping symptoms were depressive symptoms and poor sleep quality (14.5%). Among nursing home residents, the most common sites of pain were the lower limbs, followed by the back. There was a strong correlation between depressive symptoms, sleep quality, pain intensity, pain impact, and frailty. After adjusting for covariates, the interaction term between any two or three symptoms of depressive symptoms, poor sleep quality, pain intensity, and pain impact was found to be associated with a higher likelihood of frailty in older adults residing in nursing homes (p< .05).

CONCLUSIONS

Depressive symptoms, poor sleep quality, pain intensity, and pain impact are common among nursing home residents. Furthermore, these symptoms interacted with each other. In future studies, multidisciplinary interventions aimed at releasing these symptoms and reducing the adverse outcome of frailty are needed.

Mental health symptoms and associated factors among primary healthcare workers in China during the post-pandemic era

Background

The impact of the COVID-19 pandemic on mental health among healthcare workers has been widely reported during the initial and ongoing phases of the COVID-19 pandemic. Yet, little remains known about the mental health status of primary healthcare workers in China during the post-pandemic era.

Methods

A cross-sectional study was conducted between March 1, 2023, and May 31, 2023 in Anhui China. A total of 13,530 primary healthcare workers were recruited. Multiple logistic regression was used to identify potential factors associated with the incidence of depression and anxiety among primary healthcare workers.

Results

The prevalence of depression and anxiety among primary healthcare workers was 50.7 and 26.4%, respectively. Multiple logistic regression revealed that female gender (OR = 1.345, 95%CI = 1.222-1.479), being divorced or widowed (OR = 1.432, 95%CI = 1.128-1.817), being a nurse (OR = 1.250, 95%CI = 1.126-1.388), and working more than 8 h per day (OR = 1.710, 95%CI = 1.583-1.846) were significantly associated with depression. A higher risk of anxiety among primary healthcare workers was associated with female gender (OR = 1.338, 95%CI = 1.198-1.494), being divorced or widowed (OR = 1.373, 95%CI = 1.056-1.770), being a nurse (OR = 1.139, 95%CI = 1.013-1.282), and working more than 8 h per day (OR = 1.638, 95%CI = 1.497-1.794). Better monthly income, more than 21 years of working experience and without experience of workplace violence were protective factors against depression and anxiety during the post-pandemic era.

Conclusion

Depressive symptoms are more common among primary healthcare workers in China during the post-pandemic era. Female gender, being divorced or widowed, being a nurse, working years, working seniority, monthly income, and experience of workplace violence were identified as associated factors. Targeted intervention is needed when developing strategies to reduce depression and improve primary healthcare workers' wellness and mental health.

How COVID-19 Affected Sleep Talking Episodes, Sleep and Dreams?

BACKGROUND

The COVID-19 pandemic increased symptoms of stress and anxiety and induced changes in sleep quality, dream activity, and parasomnia episodes. It has been shown that stressful factors and/or bad sleep habits can affect parasomnia behaviors. However, investigations on how COVID-19 has affected sleep, dreams, and episode frequency in parasomnias are rare. The current study focuses on the impact of the pandemic on a specific parasomnia characterized by speech production (sleep talking, ST).

METHODS

We selected 27 participants with frequent ST episodes (STs) during the pandemic and compared them with 27 participants with frequent STs from a previous study conducted during a pre-pandemic period. All participants performed home monitoring through sleep logs and recorded their nocturnal STs for one week.

RESULTS

We observed a higher frequency of STs in the pandemic group. Moreover, STs were related to the emotional intensity of dreams, independent of the pandemic condition. The pandemic was associated with lower bizarreness of dreams in the pandemic group. There were no differences in sleep variables between the two groups.

CONCLUSION

Overall, these results suggest a stressful effect of COVID-19 on the frequency of STs. Both the pandemic and the frequency of STs affect qualitative characteristics of dreams in this population.

Poor sleep hygiene practices are associated with a higher increase in sleep problems during the COVID-19 pandemic: A latent change score model

The Coronavirus 2019 (COVID-19) pandemic significantly influenced physical and mental health worldwide. The present study aimed to investigate changes in sleep problems across three waves of the COVID-19 pandemic, and to identify potential predictors of the inter-individual variability around these changes, with a particular focus on the role of detrimental sleep hygiene practices. A total of 352 participants completed an online survey of self-report questionnaires at three different waves of the COVID-19 pandemic: T1 (Spring 2020); T2 (Autumn-Winter 2020); and T3 (Spring 2021). The questionnaires collected information on socio-demographic and COVID-19-related variables, psychological distress (i.e. the Depression Anxiety Stress Scale-21), sleep hygiene (i.e. the Sleep Hygiene Index) and sleep problems (i.e. the Medical Outcomes Study-Sleep Scale). Latent change score modelling revealed an average increase in sleep problems between T1 and T2 with significant inter-individual variability. No substantial changes were observed on average between T2 and T3. Notably, poorer sleep hygiene practices were associated with a more pronounced increase in sleep problems between T1 and T2 (β = 0.191, p = 0.013), even after controlling for relevant confounders such as demographic factors, COVID-19-related information and psychological distress. These findings expand on previous research regarding the detrimental effects of the pandemic on mental health, suggesting that interventions targeting sleep hygiene practices may be beneficial for mitigating its negative impact on sleep disruptions.

A systematic review on the relationship between socioeconomic conditions and emotional disorder symptoms during Covid-19: unearthing the potential role of economic concerns and financial strain

BACKGROUND

Covid-19 has disrupted the lives of many and resulted in high prevalence rates of mental disorders. Despite a vast amount of research into the social determinants of mental health during Covid-19, little is known about whether the results are consistent with the social gradient in mental health. Here we report a systematic review of studies that investigated how socioeconomic condition (SEC)-a multifaceted construct that measures a person's socioeconomic standing in society, using indicators such as education and income, predicts emotional health (depression and anxiety) risk during the pandemic. Furthermore, we examined which classes of SEC indicators would best predict symptoms of emotional disorders.

METHODS

Following PRISMA guidelines, we conducted search over six databases, including Scopus, PubMed, etc., between November 4, 2021 and November 11, 2021 for studies that investigated how SEC indicators predict emotional health risks during Covid-19, after obtaining approval from PROSPERO (ID: CRD42021288508). Using Covidence as the platform, 362 articles (324 cross-sectional/repeated cross-sectional and 38 longitudinal) were included in this review according to the eligibility criteria. We categorized SEC indicators into 'actual versus perceived' and 'static versus fluid' classes to explore their differential effects on emotional health.

RESULTS

Out of the 1479 SEC indicators used in these 362 studies, our results showed that 43.68% of the SEC indicators showed 'expected' results (i.e., higher SEC predicting better emotional health outcomes); 51.86% reported non-significant results and 4.46% reported the reverse. Economic concerns (67.16% expected results) and financial strains (64.16%) emerged as the best predictors while education (26.85%) and living conditions (30.14%) were the worst.

CONCLUSIONS

This review summarizes how different SEC indicators influenced emotional health risks across 98 countries, with a total of 5,677,007 participants, ranging from high to low-income countries. Our findings showed that not all SEC indicators were strongly predictive of emotional health risks. In fact, over half of the SEC indicators studied showed a null effect. We found that perceived and fluid SEC indicators, particularly economic concerns and financial strain could best predict depressive and anxiety symptoms. These findings have implications for policymakers to further understand how different SEC classes affect mental health during a pandemic in order to tackle associated social issues effectively.

Impact of Home-Based Work during the COVID-19 Pandemic on Mental and Physical Health in a German Population-Based Sample

Background: The COVID-19 outbreak necessitated physical distancing, as part of secondary prevention, at a personal and professional level. Working from home (WFH) became increasingly important. In this study, the impact of the COVID-19 pandemic restrictions on physical and mental health is investigated, compared with pre-pandemic data, and with employees who WFH and are on-site. Methods: Data from the German Saxon longitudinal study population were used. Attitudes towards WFH as well as mental and physical health assessments during the COVID-19 pandemic were examined. Comparisons were made with corresponding pre-pandemic scores and between employees WFH and on-site in 2022. Results: In total, 319 participants with equal gender distribution were included. Of those, 86 worked from home stating better organizability of their work, more time for partnership, less stress, and greater work satisfaction. Compared to pre-pandemic data, the D-score, PHQ-4, G-Score, and PHQ-SSS-8 showed a significant increase. No difference in physical or mental health between employees WFH and on-site was observed. Conclusion: In general, COVID-19 restrictions had a negative impact on mental and physical health. Although WFH is well accepted, it did not show significant health benefits.

The Prevalence of Depression among the Global Public in the Context of the COVID-19 Epidemic: A Systematic Review and Meta-Analysis

Background

We aimed to analyze the prevalence of depression among the global public during COVID-19, identify its influencing factors in order to provide reference, and help safeguard public mental health.

Methods

A comprehensive literature on global public depression in various countries during the COVID-19 pandemic was obtained through electronic searches of PubMed, Web of Science, and other databases, combined with literature tracing from Dec 2019 to Mar 2023. Then a meta-analysis was conducted using the random effects model by Stata 16.0. The heterogeneity was evaluated by I2 . Subgroup analysis, sensitivity analysis, and meta-regression analysis were used to explore the sources of heterogeneity and the factors influencing public depression. Egger's test was used to test publication bias.

Results

Overall, 68 articles with 234,678 samples were included in the study. Analysis revealed that the overall prevalence of depression among the population during COVID-19 was 32.0% (95% CI: 29.0%-35.0%). Of these, marital status (OR=0.65, 95% CI: 0.47-0.87), presence of infected cases (OR=2.45, 95% CI: 1.82-3.30), and fear of being infected by the virus (OR=9.31, 95% CI: 6.03-14.37) were the main factors influencing people's depression and the main source of heterogeneity.

Conclusion

The prevalence of depression among the global public is at a high level during COVID-19. The prevalence of depression among people unmarried, divorced, or widowed, surrounded by infected cases, contact infection cases, and worried about being were higher than others.

Associations of Anxiety, Insomnia, and Physical Activity during the COVID-19 Pandemic

PURPOSE

Anxiety, insomnia, and physical activity (PA) are interrelated, but the bi-directional relationships between these three variables are not well understood. Less is known of these relationships in settings of disrupted daily activities and acute stress. This study aimed to characterize and examine relationships between insomnia, anxiety, and PA throughout the first year of the COVID-19 pandemic, when many lifestyle behaviors were disrupted.

METHODS

Participants comprised a convenience sample of 204 adults (55.4% female; 43.85 ± 15.85 years old) who completed the Generalized Anxiety Disorder Questionnaire (GAD-7), Insomnia Severity Index (ISI), and the International Physical Activity Questionnaire (IPAQ) at three time points through the first year of the COVID-19 pandemic. A cross-lagged panel model was used to evaluate these variables' concurrent, autoregressive, and cross-lagged relationships across time. Follow-up dynamic panel modeling using maximum likelihood and structural equation modeling was employed.

RESULTS

Approximately 64% of participants reported their work/occupation as affected by the pandemic. At baseline, associations between anxiety and insomnia were observed (β-coefficient: 15.87; p < 0.001). Insomnia was a positive future predictor of anxiety (ISI time point 2: 7.9 ± 5.6 points; GAD-7 at time point 3: 4.1 ± 4.2 points; β-coefficient: 0.16; p < 0.01). No associations were observed between PA and anxiety or insomnia (all p > 0.05).

CONCLUSIONS

Insomnia and anxiety were interrelated, and effects were cross-lagged. These data can inform future work focused on improving anxiety in settings of acute stress and disruptions to daily life, such as changes in occupational structure and stability. Specifically, targeting sleep parameters may be of interest to elicit downstream positive health behaviors.