How Has the COVID-19 Pandemic Affected Sleep Quality?

Editor's note: Find the latest long COVID news and guidance in Medscape's Long COVID Resource Center.

How have you been sleeping? And what about your patients? The COVID-19 pandemic affected people's sleep in various ways, leading to several reports of negative changes as well as some positive experiences. These effects are associated with physiological aspects (ie, those resulting from the direct action of the viral infection) and with the social isolation imposed by the health crisis and subsequent changes in routine. But what are the physiological mechanisms of these changes, and how do we mitigate them? These and other questions were discussed at the World Sleep Congress 2023 in Rio de Janeiro.

In 2020 and 2021, the International COVID‑19 Sleep Study (ICOSS) assessed the impact of the COVID‑19 pandemic on sleep, circadian rhythm, and various sleep disorders. Fourteen countries in Europe, Asia, North America, and South America participated in the international study, including more than 22,000 participants in total.

According to Bjørn Bjorvatn, MD, PhD, professor of global public health and primary care at the University of Bergen in Norway, the ICOSS results showed that of the countries evaluated, Canada had the highest increase in sleep disorder cases during the pandemic (33.1%). Brazil was second with 18.3%, followed by the United States (14.3%), Italy (10.9%), Norway (8.4%), and China (7.3%).

Claudia Moreno, MD, PhD, head of public health at the University of São Paulo in Brazil, pointed out that the COVID‑19 pandemic also affected demographic groups in Brazil in different ways. Adolescents, for example, began going to sleep and waking up later because online classes began later than in‑person classes during this period. In contrast, studies conducted in healthcare professionals showed that sleep quality worsened for most interviewees, with increasing episodes of insomnia and other sleep disorders during the COVID-19 pandemic.

Sleep and Recovery

In recent years, several studies have shown that not sleeping enough increases the risk of some infectious diseases, such as the flu. But what about COVID‑19?

According to Michael Irwin, MD, professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles, recent studies assessing the relationship between insomnia and SARS‑CoV‑2 infection have shown that although insomnia is not associated with a higher probability of testing positive for COVID‑19, it seems to increase the risk of experiencing more severe forms of the disease and symptoms that last longer. That is, insomnia seems to delay the recovery of patients with COVID‑19.

Insomnia has also been associated with long COVID. According to Bjorvatn, ICOSS data show that this sleep disorder is among the symptoms that persist for more than 3 months after SARS‑CoV‑2 infection. Another problem that appears on this list is excessive daytime sleepiness.

Moreover, an ICOSS substudy conducted in 2311 patients with COVID‑19 revealed that individuals with a history of insomnia before the pandemic were at greater risk for long COVID, compared with those without a history of insomnia. Also, patients with long COVID seem to be at greater risk of insomnia, compared with those who quickly recovered from COVID‑19. The data will be published soon in Sleep Medicine.

Sleep and Vaccination

Sleep disorders also seem to affect SARS‑CoV‑2 vaccine response. Irwin showed data from a meta‑analysis that suggest insufficient sleep duration substantially decreases the response to antiviral vaccination. He explained, however, that the findings are limited, and the results did not reach statistical significance in women. Nevertheless, Irwin emphasized that the data indicate "it is imperative to know whether the person was already experiencing sleep disturbances when they received the vaccine, as this condition seems to be associated with lower antibody titers."

Bjorvatn also pointed out that the ICOSS substudies assessed the association between vaccination, long COVID, and sleep. According to Bjorvatn, studies showed that among the individuals who received two doses of the COVID‑19 mRNA vaccine, those who slept less than 6 hours per night had reduced protection against the risk for long‑lasting COVID‑19 symptoms.

Clinical Practice

Matthew Maas, MD, a neurocritical care specialist at Northwestern Medicine in Chicago, presented data from the Researching COVID to Enhance Recovery initiative, which was created by the National Institutes of Health to better understand the effects of long COVID. The study also seeks to improve treatment and prevent postacute sequelae of SARS‑CoV‑2 infection.

The researcher addressed hypersomnia and sleep disorders related to postacute sequelae of COVID‑19, which were both studied as part of the project.

Maas stated that a Phase 2, double-blind, placebo-controlled clinical study of hypersomnia is ongoing. Researchers are evaluating the effects of modafinil or solriamfetol versus placebo for 10 weeks.

In the case of sleep disorders related to postacute sequelae of SARS‑CoV‑2 infection, ongoing research is analyzing the effects of behavioral therapy and strategies that modify the circadian rhythm. One group of participants is taking melatonin and the other is taking a placebo.

Moreno, who presided over the session with Phyllis Zee, MD, PhD, sleep medicine specialist at Northwestern University, emphasized that despite the large number of studies, there is still work to be done to fully understand the relationship between COVID‑19 and sleep. "Everyone knows what COVID-19 did to us, but at the same time, we don't know the full extent," she said.

This article was translated from the Medscape Portuguese edition.

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