key: cord-0842486-1ojmyvhp
authors: Brown, Lily A.; Hamlett, Gabriella E.; Zhu, Yiqin; Wiley, Joshua F.; Moore, Tyler M.; DiDomenico, Grace E.; Visoki, Elina; Greenberg, David M.; Gur, Ruben C.; Gur, Raquel E.; Barzilay, Ran
title: Worry about COVID‐19 as a predictor of future insomnia
date: 2022-02-14
journal: J Sleep Res
DOI: 10.1111/jsr.13564
sha: 5d2f49fe9591af0c8610ed48c33cf47f2dfe6424
doc_id: 842486
cord_uid: 1ojmyvhp

The coronavirus disease 2019 (COVID‐19) pandemic resulted in significant increases in insomnia, with up to 60% of people reporting increased insomnia. However, it is unclear whether exposure to risk factors for the virus or worries about COVID‐19 are more strongly associated with insomnia. Using a three‐part survey over the course of the first 6 months of the pandemic, we evaluated associations between COVID‐19 exposures, COVID‐19 worries, and insomnia. We hypothesised that COVID‐19‐related worries and exposure to risk of COVID‐19 would predict increases in insomnia. Participants (N = 3,560) completed a survey at three time‐points indicating their exposures to COVID‐19 risk factors, COVID‐19‐related worries, and insomnia. COVID‐19 worry variables were consistently associated with greater insomnia severity, whereas COVID‐19 exposure variables were not. COVID‐19 worries decreased significantly over time, and there were significant interactions between change in COVID‐19 worries and change in insomnia severity over time. Individuals who experienced increases in COVID‐19 worries also experienced increases in insomnia severity. Changes in worry during the COVID‐19 pandemic were associated with changes in insomnia; worries about COVID‐19 were a more consistent predictor of insomnia than COVID‐19 exposures. Evidence‐based treatments targeting virus‐related worries may improve insomnia during this and future calamities.

aspects of the pandemic are associated with insomnia symptoms.

Identifying the key drivers of insomnia can inform appropriate interventions to reduce insomnia symptoms during the COVID-19 pandemic and future calamities.

The tendency to worry before and in bed is associated with sleep interference and other adverse mental health outcomes (Bajaj, Blair, Schwartz, Dobbertin, & Blair, 2020; Harvey, 2002) . Worries about COVID-19 in particular may exacerbate symptoms of insomnia during the pandemic, as demonstrated by cross-sectional data from India (Bajaj et al., 2020) , China (Huang et al., 2020; Zhan et al., 2020; Zhang et al., 2020) , Greece (Voitsidis et al., 2020) , and France (Kokou-Kpolou, Megalakaki, Laimou, & Kousouri, 2020) . In addition, the association between worry during the pandemic and subsequent depression is mediated by insomnia (Bajaj et al., 2020) , which is independently associated with other negative health outcomes (Balikji et al., 2018; Grandner, Jackson, Pak, & Gehrman, 2012) .

Emerging evidence also suggests that exposure to COVID-19 risk factors, such as knowing someone who tested positive for the virus, may account for increases in insomnia. For instance, healthcare workers who were directly exposed to patients who tested positive for COVID-19 were at higher risk of insomnia Zhan et al., 2020) . However, it is not clear whether actual exposure to risk factors for COVID-19 or worries about the virus are more strongly associated with insomnia symptoms. One study found that individuals who were uncertain about whether their family had contracted the virus experienced more severe insomnia than individuals who knew that their family had contracted the virus (Voitsidis et al., 2020) . This finding suggests that worries about the virus may be more predictive of insomnia symptoms than exposure to the virus itself, but more research is needed to understand the relative importance of worries about COVID-19 versus exposure to risk factors when predicting insomnia. This research could inform which individuals would benefit the most from intervention: those at highest risk of exposure to or those with greater worries about the virus regardless of exposure risk. In addition, research is needed to evaluate longitudinal associations between exposure to risk factors, worry, and insomnia over time.

This study aimed to investigate the associations among COVID-19-related exposures, worries about COVID-19, and changes in insomnia symptoms. We disseminated a survey at three time-points throughout a 6-month period between April and August 2020 using an interactive crowdsourcing research website to measure insomnia symptoms (www.covid 19res ilien ce.org). We assessed COVID-19related worries (e.g., worries about contracting COVID-19, dying of COVID-19, family contracting COVID-19, unknowingly infecting others, having COVID-19, and finances); exposures related to COVID-19 (e.g., getting tested for COVID-19, having symptoms of COVID-19, knowing someone who tested positive for COVID-19, knowing someone who died from COVID-19, and job loss during the pandemic), and insomnia symptoms using the Insomnia Severity Index (ISI). We hypothesised that COVID-19-related worries and exposures both would predict increases in insomnia.

Participants were recruited to complete a survey offered in English or Hebrew through a crowdsourcing website (Barzilay et al., 2020) .

The study was advertised through: (1) the researchers' social networks, including emails to colleagues around the world; (2) social media; (3) the University of Pennsylvania and Children's Hospital of Philadelphia internal notifications and websites; and (4) organisational mailing lists. As described in Table 1 , participants (N = 3,560) had a mean (range) age of 40 (13-90) years and were mostly women.

The majority identified as White participants, and the majority reported being located in the United States. While recruitment was open across the lifespan, only 80 participants were aged <18 years during completion of the first survey. In addition to information reported in Table 1 , participants endorsed self-reported history of diagnoses of the following: attention-deficit hyperactivity disorder (304 participants), anorexia (96), autism spectrum disorder (21), bipolar disorder (112), intellectual disability (42), language delay (seven), obsessive compulsive disorder (134), personality disorder (28), schizophrenia (four), and PTSD (86). On a single item assessing physical health ("Compared to others your age, how would you rate your physical health?") about half of the sample (43%) reported good health, one-quarter (24%) reported excellent health, one-quarter (24%) reported average health, and the remainder reported below average health or preferred not to specify.

The ISI is a seven-item assessment of insomnia symptoms over the prior 2 weeks, with items rated on a scale ranging from 0 ("no problems") to 4 ("very severe") (Bastien, Vallières, & Morin, 2001) . The ISI is a reliable and valid instrument to determine perceived insomnia severity (Bastien et al., 2001) . Total scores are categorised as not clinically significant (0-7), subthreshold insomnia (8-14), moderate insomnia (15-21), or severe insomnia (22-28).

Participants were asked to indicate to what degree they were worried about a variety of COVID-19-related outcomes on a 0 ("not at all") to 4 ("a great deal") point Likert scale that was developed for this survey. Worries included: (1) Contracting COVID-19; (2) Dying from COVID-19; (3) Family members contracting (4) Unknowingly infecting others with COVID-19; (5) Currently having and (6) Having significant financial burden because of the COVID-19 pandemic.

Participants were asked to rate whether they had experienced the following: (1) Being tested for COVID-19; (2) Having experienced symptoms that they feel may be related to  (3) Knowing anyone who tested positive for COVID-19; (4) Knowing someone who died from COVID-19; and (5) Job loss/reduced pay since the start of the COVID-19 pandemic. These variables were scored as "Yes" = 1 (experienced) or "No" = 0 (not experienced).

Participants were asked whether they had received a diagnosis of MDD or GAD prior to the COVID-19 pandemic.

The study was approved by the Institutional Review Board of the University of Pennsylvania. After completion of online informed consent, the survey followed and provided personalised feedback on participants' responses. The feedback aimed to enhance wellbeing and was offered as an incentive to participate and complete follow-up surveys, which were delivered to those who provided their email address and consent for future contact. The Time 1 (T1) survey occurred from April 6 to May 5, 2020; Time 2 (T2) occurred between May 12 and June 21; Time 3 (T3) occurred between August 25 and September 27, 2020.

The present analysis was conducted on data from participants who provided their email at T1 (N = 3,560) and consented for future contact, from which 1,282 provided data at T2, and 944 provided data at T3. A total of 672 participants had data at all three time-points.

Participants who completed T2 (p < 0.001) were significantly older at T1 than participants who did not, but there were no differences in age at T1 based on participants who were missing at T3. Male and White participants were significantly more likely to not complete the T2 and T3 assessments (all p < 0.001), as were participants with a self-reported diagnosis of GAD (p < 0.05) or MDD (only at T2, p < 0.01). Participants in Israel were less likely to complete the observations at T2 and T3 (all p < 0.01). Therefore, these variables were included as covariates in sensitivity analyses throughout.

Table S1 provides comparisons between participants who provided longitudinal data and those who were lost to follow-up.

Cross-sectional multiple logistic regression analyses were run to establish the relative influence of COVID-19-related exposures variables and COVID-19-related worries variables (independent variables) in predicting ISI score (insomnia severity, the dependent variable) at each time-point. These analyses were repeated after controlling for age, gender, race (White participants, Other race), country (United the cross-sectional analyses (e.g., COVID-19-related worries) were extracted to allow for an examination of interactions between these key variables and change over time in ISI severity.

Given that there was some evidence for bidirectionality in the multilevel models (described below), we followed these analyses with a cross-lagged panel analysis to directly test directionality between Worry (calculated as a total score, a sum of all Worry variables to reduce the number of analyses) and ISI severity. We followed established procedures for this evaluation (Brown et al., 2015 (Brown et al., , 2018 (Brown et al., , 2019 Martens & Haase, 2006) 3). Model fit was evaluated, and chi-square difference tests compared the fit of the models. After determining optimal model fit, a follow-up "constrained analysis" was conducted to compare model fit wherein cross-lagged path coefficients were constrained to be equal versus freely estimated. In other words, this model constrained the path from sleep at baseline -> worry at 1 month to be equal to the path from worry at baseline -> sleep at 1 month. Then, model fit was compared between the constrained versus freely estimated model, allowing for a determination of whether constraining the paths to be equal worsened model fit (an indication that one direction is stronger than the other, providing evidence for unidirectionality as opposed to bidirectionality). As we discuss elsewhere (Brown et al., 2015) , the correlation matrix must be imported for this constrained analysis, which was calculated using full-information maximum likelihood to account for missing data using corFiml in the "psych" package in R (Revelle, 2013) . The results of this constrained analyses must be interpreted with caution, although the comparison between the constrained and unconstrained model can provide useful information about strength of directionality. 

Given that worry variables were consistently associated with ISI severity in multivariable cross-sectional analyses, whereas exposure variables were less consistently associated with ISI severity, longitudinal models were run to evaluate the change in worry variables as predictors of the change in ISI severity. There were significant reductions in all worry variables over time (Table 3) . Across all participants, a multilevel model with observations nested within participants and a random intercept and slope revealed that there was not a significant change in ISI over time (p = 0.522). However, there were significant interactions between Time and the Slope of all Worry variables (Table 4, 

Both Model 2 (ISI -> Worry Total Score, Figure 2b , chi-squared

(2) = 13.59, p < 0.01) and Model 3 (Worry Total Score -> ISI, Figure 2a ). Model 4, which contained bidirectional paths between ISI and Worry Total Score, significantly improved model fit above and beyond Model 2 (chi-squared (2) = 16.70, p < 0.001) and

3 (chi-squared (2) = 12.38, p < 0.01; column 6, Table 6, Figure 2d ).

However, the constrained model had significantly worsened fit relative to the model with freely estimated paths (chi-squared

(2) = 25.90, p < 0.001; column 7, Table 6 ). Examination of parameter estimates from Model 4 revealed that the strength of the association from ISI -> Worry was larger than from Worry -> ISI.

However, the only significant cross-lagged paths were earlier in the longitudinal model (from baseline to one-month, and not from oneto four-months). -19) was also observed but was not as consistent as the prediction from worries to insomnia. These findings suggest that the interpretation of risk about COVID-19, rather than exposure to risk factors for COVID-19 itself, influenced insomnia severity over time and there was some evidence to support unidirectionality for this association.

The findings from this study are consistent with prior crosssectional studies. Specifically, in a Greek sample, worries about COVID-19 were associated with elevations in insomnia severity (Voitsidis et al., 2020) . In this prior study, participants who reported "not knowing" whether they or their loved ones contracted COVID-19 had more severe insomnia than individuals who were certain that they or their loved ones had contracted the virus (Voitsidis et al., 2020) . This is notable in that it provides further evidence that worries about the virus (or uncertainty in contemporary research, which may lead to worries) may account for more variance in sleep disruptions than exposure to the risk of the virus per se. Similarly, in

China, COVID-related stress was associated with worsened insomnia symptoms during the pandemic (Yun et al., 2020; Zhang et al., 2020) , as was increased non-specific (i.e., generalised) worry (Huang et al., 2020) . France also had cross-sectional research demonstrating an association between COVID-19-related worries and insomnia (Zhao et al., 2020) . The present study replicates these findings in a sample of individuals primarily from the United States and Israel, adding a key longitudinal perspective on the dynamics of worries and sleep over time during a chronic global stressor.

Consistent with at least one prior study (Huang et al., 2020) , insomnia symptoms did not significantly change over time in this study over the entire sample. Some other studies have found evidence for increased insomnia and anxiety during the pandemic Gao & Scullin, 2020) . Our study potentially explains this discrepancy.

Specifically, individuals with heightened COVID-19-related worries F I G U R E 1 (a) Change in Insomnia Severity Index (ISI) by change in worries about getting COVID-19. Lines indicate participants who were at the mean in change in worries about getting COVID-19 over time ("Mean Worries-Getting"), 1 standard deviation (SD) below the mean in changes in worries about getting COVID-19 over time ("−1 SD Worries-Getting"), or 1 SD above the mean in changes in worries about getting COVID-19 over time ("+1 SD Worries-Getting"). (b) Change in ISI by change in worries about Family contracting COVID-19. The lines indicate participants who were at the mean in change in worries about family getting COVID-19 over time ("Mean Worries-Family"), 1 SD below the mean in changes in worries about family getting COVID-19 over time ("−1 SD Worries-Family"), or 1 SD above the mean in changes in worries about family getting COVID-19 over time ("+1 SD Worries-Family") experienced worsened insomnia, whereas individuals without these worries were protected from sleep disruption. However, prior studies did not measure changes in COVID-19-related worries over time,

nor the impact of changes in COVID-19-related worries on insomnia.

Our study adds to the literature in this regard.

In contrast to some prior studies (Sofi et al., 2014) , being tested for COVID-19 did not emerge as an important predictor of insomnia symptoms. One prior study reported that being infected with COVID-19 was associated with an increased risk of clinically significant insomnia, but the odds ratio reported in their study actually indicated a decreased risk of insomnia (Kokou-Kpolou et al., 2020) .

In the present study, some exposure variables were associated with insomnia severity at a given time-point, which suggests that under certain circumstances these risk factors may be important to consider. In particular, knowing someone who died from COVID-19 was consistently associated with increased severity of insomnia at all time-points. However, this variable did not remain significant in all multivariable models. In contrast, all worry variables were associated with insomnia severity at all time-points regardless of covariate inclusion. In multivariable models, worry variables remained consistently associated with ISI severity over and above the influence of exposure variables.

Clinically, these findings suggest that it might be worthwhile to help individuals manage their COVID-19-related worries, although more research is needed. Existing research suggests that healthcare workers who are directly exposed to COVID-19 patients are at higher risk of insomnia Zhan et al., 2020) . However, the present study suggests that increased risk of insomnia may be attributable to worries about COVID-19 as opposed to direct exposure to risk. This series of findings has implications for cognitive behavioural therapy, an evidence-based treatment for chronic worry (Covin, Ouimet, Seeds, & Dozois, 2008) that also results in significant improvements in insomnia symptoms (Harvey & Tang, 2003 (Cheng et al., 2022) and it will be important to study the effect of worry on insomnia among Black participants during the COVID-19 pandemic.

Second, as is to be expected by a study that did not pay partici- 

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