key: cord-0941030-14njy0us
authors: Duran, Songül; Geyiktepe, Özüm Erkin
title: Psychologic distress and sleep quality among adults in Turkey during the COVID-19 pandemic
date: 2021-01-22
journal: Prog Neuropsychopharmacol Biol Psychiatry
DOI: 10.1016/j.pnpbp.2021.110254
sha: e5e0589b6b46018a11b33ab87969c61d1d163d40
doc_id: 941030
cord_uid: 14njy0us

OBJECTIVE: The sudden novel coronavirus disease 2019 (COVID-19) pandemic has created a negative effect on the mental health of the public. In this study, in relation to the pandemic, psychological distress, sleep quality and affecting factors in adults were examined. METHODS: Using the convenience sampling method, the Pittsburgh Sleep Quality Index and questionnaires to determine psychological distress levels and sociodemographic characteristics were distributed online to 405 participants. RESULTS: The mean psychological distress score of the participants was 34.55 ± 8.07, while their mean sleep quality score was 6.39 ± 3.31. The prevalence of poor sleep quality was 55.1%. The psychological distress scores were higher among the men than the women, married participants than single ones, those with children than those without children and those who were employed than those who were not. The sleep quality of the single participants and the participants with low education levels was poorer. The sleep quality of those who left work in the pandemic period was poorer than those who were working from home/office and those who were already not employed before the pandemic. The sleep quality of those not working in the field of health was better than healthcare professionals and those not working at all. The scores for psychological distress were positively correlated with gender and negatively correlated with sleep quality levels. CONCLUSION: Our findings showed that the COVID-19 pandemic had a negative effect on the psychological distress and sleep quality of adults. It is recommended for healthcare professionals to take the necessary psychosocial precautions.

Coronaviruses (CoV) are a large virus family which causes various conditions from the common cold to more severe diseases such as the Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV) (Sadati et al., 2020) . In the world, by 6 November 2020, 48,534,508 individuals had been infected with COVID-19, while 1,231,017 had died (https://covid19.who.int/,2020). The restriction precautions for the COVID-19 pandemic have focused on determining, treating and isolating infected individuals, contact tracing, quarantining and encouraging precautionary behaviors in the general population (Qian et al., 2020) . Moreover, these precautions have interrupted the lives and work of people a lot, and thus, these restrictions may have significant effects on the health and prosperity of individuals (Arënliu, 2020; S. X. .

It is important to understand that COVID-19 infection may lead to cognitive distress, anxiety and fear in the society (Shah et al., 2020) . In the literature, it was reported that, in relation to the disease, a large proportion of the society would experience intense emotional adaptation reactions including contagion fear, long-term quarantine effects and death of relatives (Inchausti et al., 2020) . Experiences gained from previously experienced pandemics have shown that, while the pandemic is going on, depressive symptoms, various degrees of anxiety disorders, posttraumatic stress disorders (Rajkumar, 2020) and different levels of psychological problems such as aggression, anxiety, sleep problems and attention deficit (H. may develop among the general public. The COVID-19 pandemic creates concern among people especially in affected countries, and the media has great effects in increasing psychological distress (Fardin, 2020) . Qiu et al. (Qiu et al., 2020) determined psychological distress in 35% of the participants in their study. Psychological distress is defined as a broader manifestation of mental health-related problems that is characterized by depression and anxiety symptoms and known to continue to show severity with stress-related concerns (Liang et al., 2020) . In the study by Wang et al. (2020a) , 53.8% of survey participants assessed the psychological effect of the pandemic to be moderate or severe.

As COVID-19 is a disease that directly threatens life, concerns of getting infected and sleep disorders (like insomnia) were reported in the general population (Lin et al., 2020) .

Additionally, being confined at home increases the probability of uncomfortable sleep and insomnia through stress (Gupta et al., 2018) . Sleep quality is an important indicator of health (Xiao et al., 2020) . Therefore, it is important to determine the sleep quality of individuals.

Studies have reported that, due to the pressure by COVID-19, insomnia and psychological J o u r n a l P r e -p r o o f Journal Pre-proof distress levels in the general population are high (Huang & Zhao, 2020; Lin et al., 2020) .

Determining the factors that affect psychological distress and insomnia in the pandemic process is important in terms of making a status determination and taking precautions. This study was conducted to determine psychological distress and sleep quality among adults in Turkey during the COVID-19 pandemic.

This is a cross-sectional and descriptive study. To minimize face-to-face interactions with the participants and reduce the spread of the disease, the data were collected through Google Forms on online platforms (e.g., Facebook, WhatsApp (Buysse et al., 1989) and adapted into Turkish by Agargün et al. (1996) . PSQI is a 19-item self-report scale that assesses sleep quality and disorders in the last one month. It consists of 24 questions including 19 self-report questions and 5 

The data were analyzed in the computer environment by using the SPSS (Statistical Package for the Social Sciences) package software. The demographic data were analyzed using frequency and percentage. Psychological distress and PSQI were analyzed using mean, standard deviation (SD). Correlations between psychological distress and PSQI were analyzed using multivariate regression model. The differences in the psychological distress and sleep J o u r n a l P r e -p r o o f Journal Pre-proof quality levels based on sociodemographic characteristics were analyzed using two-way ANOVA and student t test.

A consent form was signed by all participants before they started the questionnaire. The study was approved by the Ethics Committee of İzmir Democracy University.

In this study, 70.9% of the participants were female, 29.1% were male. While 6.7% of the participants were single, 82.2% had undergraduate or higher degrees. 48.4% were continuing to work from their workplace, 15.1% were continuing to work from home, and 36.5% were not working at a job. 69.4% did not have children. 65.7% were living in the city center.

Among the participants, 71.9% were non-smokers, and 67.9% did not exercise. 17.5% had chronic diseases, while the relatives of 39.3% had been infected with COVID-19. Table 2 shows whether there were differences in the psychological distress and sleep quality levels based on sociodemographic characteristics. In this study, the psychological distress scores were higher among the men than the women, those who were married than those who were single and those who had children than those who did not have children. Considering working status, the psychological distress levels of those who were already not working before the pandemic were significantly lower than those who were working from their workplaces and those working from their homes. In other words, the psychological distress levels were higher in those who were working than those who were not. Considering the psychological distress levels based on occupation, these levels were higher in the participants who were healthcare personnel and those working at other professions in comparison to those who were not working. Considering factors affecting sleep quality, the sleep quality levels were poorer in the single participants than the married ones and in those with an educational J o u r n a l P r e -p r o o f level of high school or lower than those with undergraduate or higher degrees. The sleep quality of the participants who left work in the pandemic period was poorer in comparison to those working from home/office and those who were already not working before the pandemic. Considering sleep quality based on occupation, the sleep quality of those working outside the field of health was better in comparison to the healthcare professionals and those not working at all.

The results of the regression analysis explaining the factors affecting the participants' psychological distress levels are presented in Table 3 . The potential influencing factors

showing statistically significant association with the t-test, ANOVA or correlation test were selected in the multivariate regression analyses. The predictive power of the regression model calculated using the Enter method was 28%. The scores for psychological distress were positively correlated with gender and negatively correlated with sleep quality levels.

In this study, psychological distress in the COVID-19 pandemic period was found to of the participants was poor, and the participants' mean PSQI score was found as 6.39±3.31.

In the study by Targa et al. (Targa et al., 2020) which compared the mean PSQI scores of adults before COVID-19 and in the pandemic period reported that sleep quality worsened (5.45±3.14 to 6.18 ± 3.03). Xiao et al. (2020) showed that the reduction in the sleep quality of individuals in central China who were confined at home for 14 days was related to an increase in anxiety and stress (Xiao et al., 2020a) . A study in Nepal reported that insomnia substantially increased in the pandemic period (Chandra et al., 2020) . In the study conducted in China by Huang and Zhao (Huang & Zhao, 2020) , the sleep quality of 18.2% of adults was reported as poor. The findings of our study were like those in the literature, where the psychological distress levels of the adults were found to be high, and their sleep quality was found to be low. It is believed that it may be useful to provide psychosocial support by approaching especially individuals with high psychological distress scores.

The psychological distress scores were found to be higher among the male participants than the female participants. Additionally, gender was included among the factors predicting psychological distress in the regression analysis. Liang (Liang et al., 2020) similarly determined that gender played a moderate role between psychological distress and posttraumatic stress disorders, and the psychological distress rate among men was higher.

Tönbül (Tönbül, 2020) determined the psychological resilience of women to be higher. In some studies, as opposed to this finding, higher levels of stress were found in women than men in the COVID-19 period (Al-Rabiaah et al., 2020; Conversano et al., 2020; . In addition to this, it was reported that men may experience job loss and economic distress in relation to being compulsorily confined at home, and this may lead to an increase in psychological distress (Liang et al., 2020) . It may be recommended to conduct comprehensive and in-depth studies to assess stress to be experienced based on gender differences.

According to the findings in this study, those who were married experienced more intense stress than those who were single. A study conducted in Wuhan determined that being In the study, the psychological distress scores of those who had children were found to be higher than those who did not have children. In a study in Turkey, it was similarly found that the anxiety scores of those experiencing difficulty in looking after their children were higher (Hacimusalar et al., 2020) . In addition to the stress caused by the pandemic, the parentchild relationship and the relationship between the parents also affect the mental health of the parents in such a difficult period, and a vicious cycle may be created by the mental health of the parents affecting the mental and bodily health of the children even more .

It is thought that the factor of increased stress in parents with the closure of schools in the pandemic period may have increased psychological distress.

In this study, the psychological distress levels of the working participants were found to be higher than those of the non-working participants. Considering the relationship between occupation and psychological distress, the psychological distress levels of the healthcare professional and those in other professions were higher than those who were not working.

Studies conducted with healthcare personnel reported that stress, depression and anxiety increased in the pandemic process (Huang & Zhao, 2020; Xiao et al., 2020b) . In the period when this study was conducted, the system of working from home was left to the initiative of the workplace, and there have been individuals who had to go to work. The psychological distress of those having to go to work may have increased with their concerns of getting the disease. Additionally, those who had to work from home may have had trouble in adapting to this unfamiliar process. It is believed that all these factors may have increased psychological distress, and it may be useful to develop online social support programs for under-risk groups in this process.

The single participants in this study had poorer sleep quality than the married participants. Deo et al. (2020) also determined sleep quality to be poorer in single individuals than married individuals. It is considered that the single participants may have felt social isolation more deeply, and this may have negatively affected their sleep quality.

The sleep quality levels were lower among the participants in this study who had low education levels. This result was compatible with a study in China on insomnia in the general population finding low educational levels to be associated with the probability of insomnia (Xiang et al., 2008) . determined insomnia on higher levels in those with a lower educational level among healthcare personnel. In similarity to our finding, Nathiy et al.

(2020) observed that low educational levels were associated with insomnia (Nathiy et al., 2020). Education level was positively associated with higher awareness and compliance with prevention and management of the COVID-19 pandemic (Fu et al., 2020) . For this reason, during the fight against the COVID-19 pandemic, the individuals with high educational levels might have turned towards healthy lifestyle behaviors such as sleep, nutrition, and exercise.

Considering the relationship between working status and sleep quality, the sleep quality of those who left work in the pandemic period was poorer in comparison to those working from home/office and those who were already not working before the pandemic. In a review examining sleep problems in the pandemic period, it was reported that some employment-related factors affected sleep quality (Tasnim et al., 2020) . For example, it was found that low-income individuals had a higher risk of sleep disorders in comparison to their high-income colleagues (Fu et al., 2020) . While a study reported that leaving work in the J o u r n a l P r e -p r o o f Journal Pre-proof pandemic period created a high risk for mental problems (Rodríguez-rey et al., 2020) , the concern of individuals about their source of income and the negative effect on their income were associated with sleep disorders (Gaur et al., 2020) .

It was found that the participants who were not working and those who were working as healthcare personnel had poorer sleep quality. There are studies in the literature showing that sleep quality is poor among healthcare personnel working in the frontlines in the diagnosis, treatment and monitoring of COVID-19 patients (Qi et al., 2020; . Additionally, in this study, a significant relationship was found between sleep quality (including subjective sleep quality, sleep duration, sleep latency, sleep disturbances and general self-assessed sleep quality) and psychological distress. There was no significant relationship between the habitual sleep efficiency and sleep quality of the adult participants.

The negative effect of poor sleep quality on mental status has been proven in several studies conducted on the general population and risk groups such as healthcare specialists and students (Gupta et al., 2018; Xiao et al., 2020) . Thus, it may be stated that, as psychological distress levels increase, sleep problems such as difficulty in falling asleep or frequent awakening will be experienced more frequently.

This study had some limitations. As the study was carried out with the method of online questionnaire, the psychological distress and sleep quality levels of though who could not access the questionnaire could not be assessed. The data obtained in the study are limited to the statements in the scales that were used in the study and the self-reports of the participants. As the results of the study are limited to the sample, they may not be generalized to the entire society.

This study examined the psychological distress levels and sleep quality levels of adults in a Turkish population during the COVID-19 pandemic period and influential factors. The findings of this study provide a scientific foundation in psychological interventions aimed at reminding researchers, healthcare providers and government officials to take precautions.  During the COVID-19 period, the psychological distress level was found to be high in adults and the sleep quality was found to be at a poor level.

 Risk factors for psychological distress include being a man, being married, having a child, and being employed.

 Being single, low education level, losing job during the epidemic period, working in the health sector / not being employed at any job were among the risk factors for sleep quality.

The scores for psychological distress were positively correlated with gender and negatively correlated with sleep quality levels.

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