The role of sleep and dreams in long-COVID

Life After COVID-19: Alterations Related to Sleep and Circadian Rhythms

World Health Organization (WHO) estimates reveal that over 777 million people were reportedly infected by SARS-CoV-2, with approximately 7 million deaths and 770 million surviving the disease up to April 2025. Beyond the immediate social and economic impact, an additional challenge arises as a large percentage of COVID-19 survivors report a wide range of symptoms after the acute phase, including fatigue, shortness of breath, cognitive difficulties, joint and muscle pain, chest pain, heart palpitations, loss of taste or smell, headaches, depression, anxiety, and sleep and circadian alterations. In this chapter, we will specifically address the sleep- and circadian rhythm-related alterations within this context. First, we will focus on sleep-related changes following the acute phase of the disease, detailing their manifestations, prevalence, and associated factors. We will then discuss the potential impact of these sleep-related aspects on the risk of SARS-CoV-2 infection, the severity of COVID-19, and the presence of post-COVID-19 conditions. A similar approach will be applied to address the circadian-related alterations. Finally, we will provide a comprehensive discussion on the overall limitations of available knowledge and its applicability, highlighting the relevance of these findings for the present and future.

Effects of sleep quality on the risk of various long COVID symptoms among older adults following infection: an observational study

BACKGROUND

The long-term sequelae of coronavirus disease 2019 (COVID-19) and its recovery have becoming significant public health concerns. Therefore, this study aimed to enhance the limited evidence regarding the relationship between sleep quality on long COVID among the older population aged 60 years or old.

METHODS

Our study included 4,781 COVID-19 patients enrolled from April to May 2023, based on the Peking University Health Cohort. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) scale. Long COVID was evaluated by well-trained health professionals through patients' self-reported symptoms. Binary logistic regression models were employed to calculate odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

The prevalence of long COVID among older adults was 57.4% (2,743/4,781). Specifically, the prevalence of general symptoms, cardiovascular symptoms, respiratory symptoms, gastrointestinal symptoms, and neurological and psychiatric symptoms was 47.7% (2,282/4,781), 3.4% (163/4,781), 35.2% (1683/4,781), 8.7% (416/4,781) and 5.8% (279/4,781), respectively. For each one-point increase in PSQI scores, the risk of long COVID, general symptoms, cardiovascular symptoms, gastrointestinal symptoms, and neurological and psychiatric symptoms increased by 3% (95% CI: 1.01, 1.06), 3% (95% CI: 1.01, 1.06), 7% (95% CI: 1.01, 1.13), 11% (95% CI: 1.07, 1.15), and 20% (95% CI: 1.15, 1.25), respectively. In multivariate models, compared with good sleepers, COVID-19 patients with poor sleep quality exhibited an increased risk of general symptoms (aOR = 1.17; 95% CI: 1.03, 1.33), cardiovascular symptoms (aOR = 1.50; 95% CI: 1.06, 2.14), gastrointestinal symptoms (aOR = 2.03; 95% CI: 1.61, 2.54), and neurological and psychiatric symptoms (aOR = 2.57; 95% CI = 1.96, 3.37).

CONCLUSIONS

Our findings indicate that poor sleep quality is related to various manifestations of long COVID in older populations. A comprehensive assessment and multidisciplinary management of sleep health and long COVID may be essential to ensure healthy aging in the future.

Pathophysiological, Neuropsychological, and Psychosocial Influences on Neurological and Neuropsychiatric Symptoms of Post-Acute COVID-19 Syndrome: Impacts on Recovery and Symptom Persistence

Although the impact of post-acute COVID-19 syndrome (PACS) on patients and public health is undeniably significant, its etiology remains largely unclear. Much research has been conducted on the pathophysiology, shedding light on various aspects; however, due to the multitude of symptoms and clinical conditions that directly or indirectly define PACS, it is challenging to establish definitive causations. In this exploration, through systematically reviewing the latest pathophysiological findings related to the neurological symptoms of the syndrome, we aim to examine how psychosocial and neuropsychological symptoms may overlap with neurological ones, and how they may not only serve as risk factors but also contribute to the persistence of some primary symptoms of the disorder. Findings from our synthesis suggest that psychological and psychosocial factors, such as anxiety, depression, and loneliness, may interact with neurological symptoms in a self-reinforcing feedback loop. This cycle seems to be affecting both physical and psychological distress, potentially increasing the persistence and severity of PACS symptoms. By pointing out this interaction, in this review study, we attempt to offer a new perspective on the interconnected nature of psychological, psychosocial, and neurological factors, emphasizing the importance of integrated treatment approaches to disrupt this cycle and improve outcomes when possible.

Spa Therapy Efficacy in Mental Health and Sleep Quality Disorders in Patients with a History of COVID-19: A Comparative Study

The COVID-19 pandemic has left behind mental health issues like anxiety, depression, and sleep disorders among survivors. This study assessed the efficacy of spa therapy in enhancing psychological well-being and sleep quality in individuals with chronic arthro-rheumatic, respiratory, and otorhinolaryngological diseases, including COVID-19 recoverees. Our prospective observational study included 144 Caucasian subjects from three Italian spas who underwent a 2-week spa therapy cycle, involving balneotherapy and/or inhalation treatments. Symptoms were assessed with the Visual Analogue Scale (VAS), psychological well-being with Depression Anxiety Stress Scales-21 items (DASS-21), and sleep quality with the Insomnia Severity Index (ISI). Significant reductions in VAS scores for arthro-rheumatic, respiratory, and otorhinolaryngological symptoms were observed after spa therapy, as well as for DASS-21 and ISI scores for sleep quality, transitioning to less severe insomnia categories. Females had more pronounced improvements in DASS-21 scores and sleep quality. Subjects with and without prior SARS-CoV-2 infection experienced significant reductions in anxiety, depression, and stress, with more pronounced improvements in those without prior infection. COVID-19 survivors also showed significant ISI score improvements. Spa therapy is a promising complementary treatment for improving mental health and sleep quality in chronic disease patients, including COVID-19 survivors.

Dreaming for two: A systematic review of mental sleep activity during pregnancy

Changes in sleep and dreams are often observed during pregnancy. Dreaming may represent privileged access to the inner world of individuals, providing relevant information about their well-being. For this reason, a growing but heterogeneous literature has investigated dream experiences of pregnant women. The present paper aimed to systematically review the available evidence on the relationship between pregnancy and oneric activity, focusing on dream and nightmare frequency, dream contents, and emotional features. Moreover, dream changes between pre-partum and post-partum periods and the impact of previous pregnancy-related adverse events on dreaming have been summarized. Overall, 17 studies have been examined. The reviewed evidence suggests that women tend to have an abundant production of dreams and nightmares during pregnancy, and some results support the view that a high rate of dream recall is associated with poor sleep quality. Most studies have shown a high presence of pregnancy-related dream content, likely reflecting waking experiences and concerns. Additionally, dreaming may promote psychological preparation and activation of functional coping strategies to face life changes after childbirth.

Effect of long COVID-19 syndrome on health-related quality of life: a cross-sectional study

Purpose

This study aimed to assess the association of anxiety, headache, and insomnia on the QoL of patients with long COVID-19.

Methods

We conducted a cross-sectional survey between August 2020 and March 2023. A total of 200 participants were eligible, 53 were excluded and 147 patients with long COVID were included. QoL was evaluated across eight domains using the 36-Item Short Form Health Survey (SF-36). Standardized protocols including the Beck Anxiety Inventory (BAI) (n = 103), Pittsburgh Sleep Quality Index (PSQI) (n = 73), and Migraine Disability Assessment (MIDAS) (n = 67) were also used.

Results

Participants with sleep disorders had significantly lower Vitality (p < 0.001). Participants with anxiety disorders had significantly lower Vitality (p = 0.001), poorer Mental Health (p = 0.008), and more severe Bodily Pain (p = 0.008). Participants with headache had significantly lower Vitality (p = 0.032), poorer Mental Health (p = 0.036), and poorer Physical Functioning (p = 0.016). Participants with both headache and anxiety had significantly lower Vitality (p = 0.005) and Mental Health (p = 0.043) domain scores. Correlation analysis revealed that higher scores for anxiety, sleep disorder, and headache were independently correlated with poorer QoL across various domains. The presence of sleep disorder was associated with a fourfold increase in risk of experiencing diminished Vitality (odds ratio [OR]4.47; 95% CI 1.01-19.69; p = 0.048).

Conclusion

Participants with anxiety, sleep, and headache disorders tended to have a worse QoL. The Vitality and Mental Health domains were the most adversely affected in patients with long COVID. Sleep disorders were associated with a fourfold increase in the risk of poor Vitality.

Habitual short sleepers with pre-existing medical conditions are at higher risk of Long COVID

STUDY OBJECTIVES

Preliminary evidence suggests that the risk of Long COVID is higher among people with pre-existing medical conditions. Based on its proven adjuvant role in immunity, habitual sleep duration may alter the risk of developing Long COVID. The objective of this study was to determine whether the odds of Long COVID are higher among those with pre-existing medical conditions, and whether the strength of this association varies by habitual sleep duration.

METHODS

Using data from 13,461 respondents from 16 countries who participated in the 2021 survey-based International COVID Sleep Study II (ICOSS II), we studied the associations between habitual sleep duration, pre-existing medical conditions, and Long COVID.

RESULTS

Of 2,508 individuals who had COVID-19, 61% reported at least 1 Long COVID symptom. Multivariable logistic regression analysis showed that the risk of having Long COVID was 1.8-fold higher for average-length sleepers (6-9 h/night) with pre-existing medical conditions compared with those without pre-existing medical conditions (adjusted odds ratio [aOR] 1.84 [1.18-2.90]; P = .008). The risk of Long COVID was 3-fold higher for short sleepers with pre-existing medical conditions (aOR 2.95 [1.04-8.4]; P = .043) and not significantly higher for long sleepers with pre-existing conditions (aOR 2.11 [0.93-4.77]; P = .073) compared with average-length sleepers without pre-existing conditions.

CONCLUSIONS

Habitual short nighttime sleep duration exacerbated the risk of Long COVID in individuals with pre-existing conditions. Restoring nighttime sleep to average duration represents a potentially modifiable behavioral factor to lower the odds of Long COVID for at-risk patients.

CITATION

Berezin L, Waseem R, Merikanto I, et al. Habitual short sleepers with pre-existing medical conditions are at higher risk of long COVID. J Clin Sleep Med. 2024;20(1):111-119.

Mechanisms of long COVID: An updated review

The coronavirus disease 2019 (COVID-19) pandemic has been ongoing for more than 3 years, with an enormous impact on global health and economies. In some patients, symptoms and signs may remain after recovery from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which cannot be explained by an alternate diagnosis; this condition has been defined as long COVID. Long COVID may exist in patients with both mild and severe disease and is prevalent after infection with different SARS-CoV-2 variants. The most common symptoms include fatigue, dyspnea, and other symptoms involving multiple organs. Vaccination results in lower rates of long COVID. To date, the mechanisms of long COVID remain unclear. In this narrative review, we summarized the clinical presentations and current evidence regarding the pathogenesis of long COVID.

Online multimodal rehabilitation programme to improve symptoms and quality of life for adults diagnosed with long COVID-19: a Randomised Clinical Trial protocol

Background

Long COVID is a multisystemic condition which affects quality of life and implies a multidisciplinary treatment approach. There is still limited evidence on management techniques for this syndrome. "Telerehabilitation" could be an important tool when addressing the symptoms of this patients with the aim of increasing their quality of life. The purpose of this trial is to analyse the effectiveness of an online multimodal rehabilitation programme to improve the symptomatology of people with long COVID and their quality of life.

Methods

A pragmatic randomised controlled trial will be performed with two parallel groups: (1) usual treatment by the primary care practitioner (Treatment as usual, TAU; control group) and (2) TAU plus the use of an online multimodal rehabilitation programme, including videoconferences and content published on a Moodle platform (intervention group). The data will be collected before and after the intervention. A follow-up will take place 3 months later.

Discussion

There is still a lack of knowledge regarding the management of the symptoms of long COVID. This creates the need to add scientific evidence about the care of this disease, considering that multidisciplinary social and health teams can offer the necessary care so that these patients can recover their previous quality of life.Clinical trial registration: The protocol for this study was registered with the ISRCTN Registry [registration number: ISRCTN15414370] on 28 December 2022.

Short Sleep Duration is Associated with Prolonged Virus Shedding in SARS-CoV-2 Omicron-Infected Patients

Purpose

Sleep disturbance has been implicated in poor prognosis of coronavirus disease 2019 (COVID-19), but less is known about the influence of short sleep duration on COVID-19 outcomes. We aim to investigate whether short sleep duration is associated with prolonged virus shedding duration in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron-infected patients.

Patients and Methods

A total of 270 patients with a laboratory confirmed COVID-19 diagnosis during SARS-CoV-2 Omicron-predominant period were recruited. Self-reported sleep duration of the patients was collected. The two-way analysis of variance (ANOVA) was used to determine the interactions between sleep duration and variables, and multivariate logistic regression analysis was used to analyze the effect of independent variables on longer virus shedding duration.

Results

The two-way ANOVA revealed a significant sleep duration × snoring interaction effect for virus shedding duration, and a sleep duration × sex interaction effect for virus shedding duration. Multivariate logistic regression model illustrated that patients sleeping <6 h were at greater risk of prolonged virus shedding duration compared to those sleeping ≥6 hours (OR = 1.80, 95% CI = 1.01-3.26), independent of age, sex, co-existing diseases, vaccination condition, and antiviral treatment.

Conclusion

Short sleep duration (<6 h) was associated with increased virus shedding in SARS-CoV-2 Omicron-infected patients.

Association between hypersomnolence and the COVID-19 pandemic: The International COVID-19 Sleep Study (ICOSS)

BACKGROUND

The COVID-19 pandemic and related restriction measures have affected our daily life, sleep, and circadian rhythms worldwide. Their effects on hypersomnolence and fatigue remain unclear.

METHODS

The International COVID-19 Sleep Study questionnaire which included items on hypersomnolence such as excessive daytime sleepiness (EDS), and excessive quantity of sleep (EQS), as well as sociodemographic factors, sleep patterns, psychological symptoms, and quality of life was distributed in 15 countries across the world from May to September in 2020.

RESULTS

Altogether responses from 18,785 survey participants (65% women, median age 39 years) were available for analysis. Only 2.8% reported having had COVID-19. Compared to before the pandemic, the prevalence of EDS, EQS, and fatigue increased from 17.9% to 25.5%, 1.6%-4.9%, and 19.4%-28.3% amid the pandemic, respectively. In univariate logistic regression models, reports of having a COVID-19 were associated with EQS (OR 5.3; 95%-CI 3.6-8.0), EDS (2.6; 2.0-3.4), and fatigue (2.8; 2.1-3.6). In adjusted multivariate logistic regression, sleep duration shorter than desired (3.9; 3.2-4.7), depressive symptoms (3.1; 2.7-3.5), use of hypnotics (2.3; 1.9-2.8), and having reported COVID-19 (1.9; 1.3-2.6) remained strong predictors of EDS. Similar associations emerged for fatigue. In the multivariate model, depressive symptoms (4.1; 3.6-4.6) and reports of having COVID-19 (2.0; 1.4-2.8) remained associated with EQS.

CONCLUSIONS

A large increase in EDS, EQS, and fatigue occurred due to the COVID-19 pandemic, and especially in self-reported cases of COVID-19. These findings warrant a thorough understanding of their pathophysiology to target prevention and treatment strategies for long COVID condition.

Psychological changes in athletes infected with Omicron after return to training: fatigue, sleep, and mood

Background

This study aims to analyze the changes of approximately 1 month in fatigue, sleep, and mood in athletes after returning to training following infection with the COVID-19 Omicron strain and provide recommendations for returning to training after infection.

Methods

Two hundred and thirty professional athletes who had returned to training after being infected with COVID-19 in December 2022 were recruited to participate in three tests conducted from early January 2023. The second test was completed approximately 1 week after the first, and the third was completed about 2 weeks after the second. Each test consisted of completing scales and the exercise-induced fatigue measure. The scales included a visual analog scale, the Athens Insomnia Scale for non-clinical application, and the Depression-Anxiety-Stress scale. The exercise task was a six-minute stair climb test, and athletes evaluated subjective fatigue levels before and after exercise using another Visual Analog Scale and the Karolinska Sleepiness Scale.

Results

After returning to training, athletes' physical fatigue decreased initially but increased as training progressed. Cognitive fatigue did not change significantly. The exercise task led to elevated levels of physical fatigue after a longer duration of training. Sleep quality problems decreased rapidly after the start of training but remained stable with prolonged training. Depression levels continued to decline, while anxiety levels only reduced after a longer duration of training. Stress levels decreased rapidly after the start of training but did not change with prolonged training.

Conclusion

Athletes who return to training after recovering from COVID-19 experience positive effects on their fatigue, sleep, and mood. It is important to prioritize anxiety assessment and interventions during the short period after returning and to continue monitoring fatigue levels and implementing recovery interventions over a longer period of time.

Longitudinal Findings on the Oneiric Activity Changes Across the Pandemic

PURPOSE

COVID-19 pandemic waves have strongly influenced individuals' behaviors and mental health. Here, we analyzed longitudinal data collected in the Spring 2020 and 2021 from a large Italian sample with the aim of assessing changes in dream features between the first and third wave. Specifically, we evaluated the modifications of pandemic dream activity as a function of the general distress variations over time. Also, we detected the best explanatory variables of nightmare frequency and distress.

MATERIALS AND METHODS

Participants previously involved in the web survey during the first wave of the pandemic were asked to complete a new online survey on sleep and dream features available in Spring 2021 (N=728). Subjects decreasing their level of psychological general distress in the third (T3) vs the first (T1) pandemic wave were defined as "Improved" (N=330). In contrast, participants with an unchanged or increased level of general distress were defined as "Not Improved" (N=398).

RESULTS

Statistical comparisons revealed that dream recall frequency, nightmare frequency, lucid dream frequency, and emotional intensity show a reduction in T3 than T1. Moreover, the Improved group is characterized by lower nightmare rate and nightmare distress than Not Improved people. Our findings confirmed that beyond the trait-like variables (ie, age, sex), specific sleep-related measures are related to nightmare features. In particular, poor sleep hygiene was one of the best determinants of nightmare distress among Not Improved subjects.

CONCLUSION

Our findings revealed that people experienced an adaptation to the pandemic during the third wave. We also strengthen the notion that nightmares and their variations over time are strongly related to human well-being, suggesting that specific trait-like and sleep-related factors could modulate the relationship between mental health and nightmare features.

The long wave of COVID-19: a case report using Imagery Rehearsal Therapy for COVID-19-related nightmares after admission to intensive care unit

Introduction

The COVID-19 pandemic caused several psychological consequences for the general population. In particular, long-term and persistent psychopathological detriments were observed in those who were infected by acute forms of the virus and need specialistic care in the Intensive Care Unit (ICU). Imagery rehearsal therapy (IRT) has shown promising results in managing nightmares of patients with different traumas, but it has never been used with patients admitted to ICUs for severe COVID-19 despite this experience being considered traumatic in the literature.

Methods

The purpose of this case study is to describe the application of a four-session IRT for the treatment of COVID-related nightmares in a female patient after admission to the ICU. A 42-year-old Caucasian woman who recovered from a pulmonary rehabilitation program reported shortness of breath, dyspnea, and everyday life difficulties triggered by the long-COVID syndrome. She showed COVID-related nightmares and signs of post-traumatic symptoms (i.e., hyperarousal, nightmares, and avoidance of triggers associated with the traumatic situation). Psychological changes in the aftermath of a trauma, presence, and intensity of daytime sleepiness, dream activity, sleep disturbances, aspects of sleep and dreams, and symptoms of common mental health status are assessed as outcomes at the baseline (during the admission to pneumology rehabilitation) at 1-month (T1) and 3-month follow-up (T2). Follow-up data were collected through an online survey.

Results

By using IRT principles and techniques, the patient reported a decrease in the intensity and frequency of bad nightmares, an increase in the quality of sleep, and post-traumatic growth, developing a positive post-discharge.

Conclusion

Imagery rehearsal therapy may be effective for COVID-19-related nightmares and in increasing the quality of sleep among patients admitted to the ICU for the treatment of COVID-19. Furthermore, IRT could be useful for its brevity in hospital settings.

Sleep Deprivation and Insomnia in Adolescence: Implications for Mental Health

Sleep changes significantly throughout the human lifespan. Physiological modifications in sleep regulation, in common with many mammals (especially in the circadian rhythms), predispose adolescents to sleep loss until early adulthood. Adolescents are one-sixth of all human beings and are at high risk for mental diseases (particularly mood disorders) and self-injury. This has been attributed to the incredible number of changes occurring in a limited time window that encompasses rapid biological and psychosocial modifications, which predispose teens to at-risk behaviors. Adolescents' sleep patterns have been investigated as a biunivocal cause for potential damaging conditions, in which insufficient sleep may be both a cause and a consequence of mental health problems. The recent COVID-19 pandemic in particular has made a detrimental contribution to many adolescents' mental health and sleep quality. In this review, we aim to summarize the knowledge in the field and to explore implications for adolescents' (and future adults') mental and physical health, as well as to outline potential strategies of prevention.