Stress and the hypothalamic-pituitary-adrenal axis: How can the COVID-19 pandemic inform our understanding and treatment of acute insomnia?

Sleep quality among solid organ transplant recipients during the COVID-19 reopening period in China: the interplay of SARS-CoV-2 infection, mental distress, and physical activity

OBJECTIVES

Given immunosuppression and comorbidities, solid organ transplant (SOT) recipients are more prone to infections during the COVID-19 pandemic. However, little is known about the relationship between SARS-CoV-2 infection and sleep quality in this population. This study aimed to investigate the association between SARS-CoV-2 infection and sleep quality among SOT recipients, examine the moderating roles of anxiety and depression, and explore whether the moderating effects vary with physical activity levels.

METHODS

1121 participants were recruited online in Changsha, China, from February to March 2023. Measurements included sociodemographic and infection-related questionnaire, Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, and International Physical Activity Questionnaire Short Form.

RESULTS

83.0% of participants were infected during China's reopening period, and the average sleep quality score was 7.88 (SD = 3.59), indicating mild sleep disturbance. Anxiety and depression significantly moderated and strengthened the negative relationship between SARS-CoV-2 infection and sleep quality. Additionally, the moderating effects were significant at moderate-high levels of physical activity but not at low-moderate levels.

CONCLUSIONS

Promoting interventions to alleviate anxiety and depressive symptoms, as well as facilitating a gradual return to general physical activity, is encouraged to mitigate the negative association between SARS-CoV-2 infection and sleep quality among SOT recipients.

Sleep disturbances in generalized anxiety Disorder: The central role of insomnia

Generalized anxiety disorder (GAD) is a chronic and disabling mental health condition characterized by excessive, uncontrollable worry and persistent psychological and somatic tension. Affecting approximately 3-6 % of the global population, GAD significantly impairs daily functioning and often coexists with other psychiatric conditions. Among its many symptoms, sleep disturbances-particularly insomnia-are among the most frequently reported and debilitating. Individuals with GAD commonly experience difficulties with sleep initiation, maintenance, and restorative rest, making insomnia one of the most pervasive features of the disorder. Emerging research highlights a bidirectional relationship between GAD and insomnia: while anxiety contributes to cognitive and physiological arousal that interferes with sleep, insomnia in turn exacerbates emotional dysregulation, amplifies worry, and may even precede the development of anxiety disorders. Neurobiological and neuroimaging studies support this reciprocal link, showing shared dysfunctions such as heightened hypothalamic-pituitary-adrenal (HPA) axis activity, increased amygdala reactivity, reduced prefrontal cortical control, and GABAergic deficits. These overlapping mechanisms underscore a common pathophysiological substrate that reinforces both conditions. Recognizing and addressing this interplay is critical, as untreated insomnia may perpetuate or intensify GAD symptoms. Notably, cognitive behavioral therapy for insomnia (CBT-I) has been effective in improving sleep and reducing anxiety severity-even without directly targeting anxiety-supporting a shift toward integrating sleep-focused interventions in the treatment of GAD. This review aimed to elucidate clinical and neurobiological evidence on the bidirectional link between insomnia and GAD, emphasizing shared mechanisms and treatment implications.

Brain Health in Sleep Disorders

Sleep is a critical determinant of brain health, influencing cognitive, emotional, and physiologic functions. The complex bidirectional relationship between sleep and brain health underscores the importance of sleep in maintaining cognitive function, regulating brain homeostasis, and facilitating the clearance of metabolic waste through the glymphatic system. Chronic sleep deprivation and sleep disorders such as insomnia and obstructive sleep apnea have been shown to negatively impact brain structures and functions. This review discusses the impact of sleep disorders on brain health. It also explores the implications of impaired sleep on cardiovascular health, immune function, and neuroplasticity.

An online behavioral self-help intervention rapidly improves acute insomnia severity and subjective mood during the coronavirus disease-2019 pandemic: a stratified randomized controlled trial

STUDY OBJECTIVES

Stressful life events, such as the coronavirus disease-2019 (COVID-19) pandemic, can cause acute insomnia. Cognitive behavioral therapy for acute insomnia is effective but is both time and resource-intensive. This study investigated if an online behavioral self-help intervention, which has been successfully used alongside sleep restriction for acute insomnia, reduced insomnia severity and improved mood in acute insomnia. This study also assessed good sleepers to explore if a "sleep vaccination" approach was feasible.

METHODS

In this online stratified randomized controlled trial, 344 participants (103 good sleepers and 241 participants with DSM-5 acute insomnia) were randomized to receive the intervention/no intervention (good sleepers) or intervention/intervention after 28 days (poor sleepers). Insomnia severity was assessed using the ISI (primary outcome), and anxiety and depression using the GAD-7/PHQ-9 (secondary outcomes) at baseline, 1 week, 1 month, and 3-month follow-up.

RESULTS

In people with acute insomnia, relative to baseline, there were significant reductions in ISI (dz = 1.17), GAD-7 (dz = 0.70), and PHQ-9 (dz = 0.60) scores at 1-week follow-up. ISI, GAD-7, and PHQ-9 scores were significantly lower at all follow-up time points, relative to baseline. Subjective diary-derived sleep continuity was unaffected. No beneficial effects on sleep or mood were observed in good sleepers.

CONCLUSIONS

An online behavioral self-help intervention rapidly reduces acute insomnia severity (within 1 week), and benefits mood in people with acute insomnia. These beneficial effects are maintained up to 3 months later. Although the use of the intervention is feasible in good sleepers, their subjective sleep was unaffected.

CLINICAL TRIAL REGISTRATION

Testing an early online intervention for the treatment of disturbed sleep during the COVID-19 pandemic; prospectively registered at ISRCTN on 8 April 2020 (identifier: ISRCTN43900695).

Mental health problems of front-line medical staff in the early stage of public health emergencies

In the face of the unprecedented public health crisis caused by the novel coronavirus pneumonia epidemic, front-line health workers are under enormous mental pressure. This paper aims to explore the mental health challenges faced by front-line health workers in the early stages of a public health emergency, such as stress, anxiety, and depression. At the same time, the factors that increase their mental stress are analyzed, and practical measures are put forward to prevent and manage mental health problems, aiming at improving the quality of medical treatment during public health emergencies. This paper has some reference value for people engaged in mental health prevention.

Insomnia among coronavirus disease 2019 survivors: A single-center cross-sectional study

Since the coronavirus disease 2019 (COVID-19) epidemic, insomnia has become one of the longer COVID-19 symptoms. This study aimed to investigate insomnia among COVID-19 survivors and explore the occurrence and influencing factors of insomnia. A cross-sectional study was performed from December 2022 to February 2023 through an online questionnaire star survey with 8 questions. The insomnia severity index scale (ISI) was used to assess the severity of insomnia. Univariate analysis was used to analyze the factors related to COVID-19 infection. A total of 564 participants (183 males and 381 females) were surveyed in the present study. The prevalence of insomnia was 63.12%. Among these insomnia patients, there were 202 (35.82%) with sub-threshold symptoms, 116 (20.57%) with moderate symptoms, and 38 (6.74%) with severe symptoms. Univariate analysis indicated that there were statistically significant differences in the prevalence of insomnia among COVID-19 survivors of different ages, occupations, and educational levels (P < .05). Of the 356 insomnia patients, 185 (51.97%) did not take any measures against insomnia, while those who took drugs only, physical exercise only, drugs and physical exercise, and other measures were 90 (25.28%), 42 (11.80%), 17 (4.78%), and 22 (6.18%), respectively. Additionally, of the 107 insomnia patients with drug therapy, 17 (15.89%) took estazolam, 16 (14.95%) took alprazolam, 39 (36.45%) took zopiclone, and 35 (32.71%) took other drugs to improve insomnia symptoms. The prevalence of insomnia symptoms remains high among COVID-19 survivors in China. Education level and occupation may be the influencing factors. Unfortunately, most patients with insomnia do not take corresponding treatment measures.

COVID-19 and Adrenal Insufficiency: Unmasking the Link

We describe a case of a 28-year-old male who presented with general malaise, fatigue, anorexia, occasional epigastric pain, and vomiting a few days after a mild severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Clinical evolution led to weight loss (6 kg in six months) and craving for salty foods. Physical examination revealed dehydration, hypotension, and hyperpigmentation of the skin and mucosal surfaces. Laboratory tests demonstrated normocytic normochromic anemia, acute kidney injury, hyperkalemia, hyponatremia, and compensated metabolic acidosis. Adrenal workup allowed us to establish a diagnosis of adrenal insufficiency (AI) due to autoimmune adrenalitis, considering findings of a low cortisol and positive 21-hydroxylase antibodies (21OH-Abs), as well as high serum renin and adrenocorticotropic hormone (ACTH). Atypical presentations and comorbidities may appear regarding coronavirus disease 2019 (COVID-19), such as the association between COVID-19 and the hypothalamic-pituitary-adrenal (HPA) axis, which may be affected in any patient with SARS-CoV-2 infection, thus making adrenal insufficiency a diagnosis to consider.