key: cord-0793521-j7t3jlt6
authors: Goncalves, M.; Henriques, A.; Costa, A.R.; Correia, D.; Severo, M.; Lucas, R.; Barros, H.
title: Insomnia and nightmare profiles during the COVID-19 pandemic in Portugal: characterization and associated factors
date: 2022-01-10
journal: Sleep Med
DOI: 10.1016/j.sleep.2021.12.018
sha: 5e5cf0c8316387214d552ca5128e1ad1aae7e54c
doc_id: 793521
cord_uid: j7t3jlt6

OBJECTIVE/BACKGROUND: To describe and characterize insomnia symptoms and nightmare profiles in Portugal during the first six weeks of a national lockdown due to COVID-19. PATIENTS/METHODS: An open cohort study was conducted to collect information of the general population during the first wave of SARS-CoV-2/COVID-19 pandemic in Portugal. We analyzed data from 5011 participants (≥16 years) who answered a weekly questionnaire about their well-being. Two questions about the frequency of insomnia and nightmares about COVID-19 were consecutively applied during six weeks (March-May 2020). Latent class analysis was conducted and different insomnia and nightmare profiles were identified. Associations between individual characteristics and both profiles were estimated using odds ratios (ORs) and 95% confidence intervals (CI). RESULTS: Five insomnia (No insomnia, Stable-mild, Decreasing-moderate, Stable-severe, Increasing-severe) and three nightmares profiles (Stable-mild, Stable-moderate, Stable-severe) were identified, respectively. Being female, younger, perceiving their income as insufficient and feelings of fear towards COVID-19 were associated with higher odds of insomnia (Women: OR=6.98 95%CI:4.18-11.64; ≥60 years: OR=0.30 95%CI:0.18-0.53); Insufficient income: aOR=8.413 95%CI:3.93-16.84; Often presenting fear of being infected with SARS-CoV-2 infection: aOR=9.13 95%CI:6.36-13.11), and nightmares (Women: OR=2.60 95%CI:1.74-3.86; ≥60 years: OR=0.45 95%CI:0.28-0.74) Insufficient income: aOR=2.60 95%CI:1.20-5.20; Often/almost always presenting fear of being infected with SARS-CoV-2 infection: aOR=6.62 95%CI:5.01-8.74). Having a diagnosis of SARS-CoV-2 virus infection was associated with worse patterns of nightmares about the pandemic. CONCLUSIONS: Social and psychological individual factors are important characteristics to consider in the development of therapeutic strategies to support people with sleep problems during COVID-19 pandemic.

were "never/almost never", "occasionally", "often", "always/almost always". These questions 156 were applied weekly during six weeks. During the same weeks and using the same answer following question: "How do you consider your household income. The answer options were a) 165 insufficient, b) cautious with expenses, c) enough to make ends meet, and d) comfortable.

For this particular analysis, we considered information retrieved from 5011 participants 167 that provided information about insomnia symptoms and nightmares in three or more time points 168 throughout the six weeks and their characteristics are depicted in Table 1 . From the participants 169 who provided information during the six weeks of the study, 73.4% were women, 68.3% had less 170 than 50 years of age, 81.3% had a University degree, 82.3% were not living alone, and the 171 majority did not have any child (80.0%) or a person with a chronic disease (58.7%) in their 172 household. A quarter of this sample considered their household income as insufficient or reported 173 the need to be cautious with expenses. During the study period, 3% of the sample was diagnosed 174 with SARS-CoV-2 infection and 23.8% reported to often/almost always/always feel fear of 175 getting infected (Table 1) 

Insomnia symptoms' profiles were labelled as "No insomnia" (n=1100, 22.0%), "Stable-mild" 211 (n=1334, 26.6%), "Decreasing-moderate" (n=1207, 24.1%), "Stable-severe" (n=1146, 22.9%) 212 and "Increasing-severe" (n=224, 4.5%). The three profiles that emerged for nightmares were 213 named "Stable mild" (n=3613, 72.1%), "Stable moderate" (n=1153, 23.0%), and "Stable severe" 214 (n=245, 4.9%) (Figure 1 ).

The "No insomnia" profile included mainly individuals stating that they never/almost 216 never had difficulties to fall asleep or stay asleep throughout the study period, while half of the 217 participants in "Stable-mild" profile occasionally presented insomnia symptoms during the six 218 weeks. The profile entitled "Decreasing-moderate" included around a quarter of participants who 219 referred to often experiencing insomnia symptoms but with decreasing frequency over time. The 220 two profiles with the worst insomnia symptoms were "Stable-severe" and "Increasing-severe".

Most participants in both profiles reported to struggle to fall asleep or stay asleep recurrently with 222 the latter presenting a worsening of symptoms over time ( Figure 2 and Table S2 ). Regarding 223 nightmares, the three profiles had a stable trajectory over time, with "Stable-moderate" and 224 "Stable-severe" presenting a slight worsening of symptoms in the middle weeks. Most 225 participants in the "Stable-mild" profile never/almost never had nightmares about COVID-19 226 during the study period, while people in "Stable-moderate" and "Stable-severe" mostly referred 227 to have them occasionally and often, respectively (Figure 3 and Table S2 ).

In the crude analysis, being female, having less than 50 years of age, belonging to a but also before that period and highlights that sleep problems are a major public health concern. 279 According to our findings, five percent of the participants reported to have nightmares 280 about COVID-19 pandemic often, almost always or always. In a Brazilian study they observed 281 almost a 3-fold increase in the number of participants reporting nightmares "once a week or more" 282 comparing the periods before and after the pandemic and over two thirds of these participants 283 described nightmares with a pandemic content (21), which is considerably higher compared to Table 2 . Crude and multivariate-adjusted odds ratio for the association between individual characteristics and insomnia symptoms' profiles during the first wave of the COVID-19 pandemic 

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