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ORIGINAL ARTICLE
Year : 2022  |  Volume : 31  |  Issue : 2  |  Page : 262-266  Table of Contents     

A cross-sectional survey of sleep patterns and quality and its association with psychological symptoms among doctors working in a COVID-19 care facility


Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Submission18-Jun-2021
Date of Acceptance19-Oct-2021
Date of Web Publication08-Aug-2022

Correspondence Address:
Dr. Shankar Kumar
Department of Psychiatry, Bangalore Medical College and Research Institute¸ Bengaluru - 560 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipj.ipj_142_21

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   Abstract 


Context: The coronavirus disease 2019 (COVID-19) outbreak has led to several psychological symptoms among frontline doctors of which sleep disturbances are common. Stress due to isolation and disease-related factors are known to be associated with sleep disturbances. Aim: The aim of this study is to establish the prevalence of poor sleep and its association with psychological symptoms among doctors working in COVID-19 tertiary hospital. Settings and Design: A cross-sectional online survey was conducted among 150 doctors who were treating COVID-19 patients. Materials and Methods: The survey contained a semi-structured questionnaire including sociodemographic details, Depression Anxiety Stress Scale 21, and Pittsburgh Sleep Quality Index scale. Analysis was done using the SPSS v20. Results: Of 150 doctors, we found 67 (44.67%) and 83 (55.33%) doctors were poor sleepers and good sleepers, respectively. Those who were married (P = 0.001), had higher working hours per month (P = 0.001), the presence of family history of psychiatric illness (P = 0.008), and history of substance use (P = 0.007) were associated with poor sleep. Furthermore, poor sleep was associated with higher stress (P = 0.001), anxiety (P = 0.001), and depression (P = 0.001). A multiple logistic regression revealed that family history of psychiatric illness (odds ratio [OR]-5.44, P = 0.01) and the presence of substance use (OR-7.77, P = 0.01) predicted poor sleep. Conclusion: Sleep pattern abnormalities were present in 45% of the frontline COVID-19 doctors studied. Family history of psychiatric illness and substance use was associated with higher chances of having poor sleep. It is important to recognize and manage sleep abnormalities as these could be initial signs of a psychiatric disorder or manifestations of underlying stress, especially in the vulnerable population.

Keywords: Adaptation, coronavirus disease 2019, psychological, sleep, sleep-wake disorders, vulnerable population


How to cite this article:
Kota S, Kumar S, Gopal A, Rudra PN, Anvitha K. A cross-sectional survey of sleep patterns and quality and its association with psychological symptoms among doctors working in a COVID-19 care facility. Ind Psychiatry J 2022;31:262-6

How to cite this URL:
Kota S, Kumar S, Gopal A, Rudra PN, Anvitha K. A cross-sectional survey of sleep patterns and quality and its association with psychological symptoms among doctors working in a COVID-19 care facility. Ind Psychiatry J [serial online] 2022 [cited 2022 Dec 2];31:262-6. Available from: https://www.industrialpsychiatry.org/text.asp?2022/31/2/262/353550



The novel coronavirus disease 2019 (COVID-19) since its origin in December 2019 in the Hubei province of China, is spreading worldwide and was declared as pandemic in March 2020. The outbreak has caused severe respiratory and other medical health problems. In addition to this, it has also caused great impact on mental health among general population. Medical health professionals who have been participating in treating COVID patients have been affected with psychological distress.[1]

In a study on medical workers in Wuhan, it was reported that they faced enormous pressure associated with a high risk of infection and inadequate protection from contamination, discrimination, and isolation. In addition, a lack of contact with their families contributed to psychological stress.[2] Uncertainty and stigmatization were also prominent themes for both medical staff and patients.[3] In addition, it was also reported that many frontline medical staff who worked for more than 16 h a day on average reported poor sleep.[4] It is important to ensure good sleep equality to protect physicians from mental health problems for their long-term well-being.[5]

Sleep disturbances have been reported in 36%–75% of healthcare workers caring for patients with COVID-19. Sleep disturbances which have been described are difficulty falling asleep, maintaining sleep, as well as early awakening.[6] Higher odds of sleep disturbances in medical professionals have been described among doctors, those working in isolation units, having worries about being infected, perceived lack of support, and disease-associated uncertainty.[7] It has been hypothesized that stress among frontline workers is associated with sleep disturbances.[5]

It is important to assess and treat sleep disturbances as those with past history of psychiatric illness or medical morbidity can have an exacerbation or precipitation of psychiatric illness.[8] Sleep disturbances may be the initial manifestation of a broad range of psychiatric illnesses. In addition, these changes significantly impact the quality of life and functioning of health care staff, which thus need to be assessed and addressed.[9] Hence, the aims and objectives of the study were to assess sleep quality and patterns among doctors working in COVID-19 tertiary care center and to study the association of psychological symptoms, sociodemographic details with sleep patterns.


   Materials and Methods Top


Ethics

The Institutional Ethical Committee clearance with reference number BMCRI/PS/99/2020-21 was obtained on 29/07/2020 before initiating the study. Confidentiality of the participants was maintained in the study. Informed consent was obtained from all participants.

Study design

The study was conducted among healthcare professionals at dedicated COVID care center. It was a cross-sectional study. The project was conducted in the form of an online survey using self-administered semi-structured questionnaire. The total number of participants in the study was 150.

Inclusion Criteria

  1. Doctors who are involved in treating patients with COVID-19
  2. Participants willing to give consent.


Exclusion criteria

  1. Doctors who are not frontline healthcare workers.


The tools which were used in the study were:

  1. A semi-structured pro forma with sociodemographic data, past and family history of psychiatric illness, and medical illness
  2. Depression Anxiety Stress Scale (DASS 21): This scale contains 21 items which is used to assess the psychological symptoms. It is a screening tool which mainly assesses stress, anxiety, and depression[10]
  3. Pittsburgh Sleep Quality Index (PSQI): It contains nine questions that helps to assess sleeping habits of an individuals during the past 1 month.[11]


Both DASS-21 and PSQI are self-report tools. Both have good reliability and construct validity.[12],[13]

Participants fulfilling the inclusion criteria were enrolled into the study. The participants were informed about the objectives and potential benefits of the study and informed consent to participate in the study was obtained. A semi-structured questionnaire containing sociodemographic data, past and family history of psychiatric illness, and medical illness was filled up by each participant. Confidentiality of the participants was ensured. All questionnaires were sent through Google forms and strict confidentiality was maintained. For those individuals with difficulties, consultation with psychiatrist/clinical psychologist was suggested.

Statistical analysis

The data collected were analyzed using the SPSS v20 (SPSS Inc., IBM, Armonk city, New York, USA). We used Chi-square test for descriptive statistics, t-test for continuous variables, and Pearson correlation coefficient for correlations. A multiple logistic regression was done to predict poor sleepers using sociodemographic and clinical variables.


   Results Top


About 150 doctors were included in the study. Of 150, 53 (35.33%) were males and 97 (52.67%) were females. 58 (38.67%) doctors were married and 92 (61.33%) doctors were staying without family in our study. 14 (9.33%) doctors had medical comorbidities and 11 (7.33%) had psychiatric illness in the past. 15 (10%) gave history of substance use and 15 (10%) doctors had family history of psychiatric illness. Among the above participants, five were on psychotropics of which three were on regular use of SSRIs and two of them on short course of benzodiazepines.

Sleep quality of doctors who participated in the study was classified into poor sleepers and good sleepers. The doctors whose PQSI score were more than 5 they were considered poor sleepers. With this cutoff, we found 67 (44.67%) of the doctors were poor sleepers.

We found that most of the poor sleepers were married (n = 48) and had higher working hours per month [ref [Table 1]] and also most of the poor sleepers had history of substance use (n = 12) and family history of psychiatry illness (n = 13) [Table 2].
Table 1: Association of sleep with socio demographic variables

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Table 2: Association of sleep with underlying vulnerability variables

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Poor sleepers were associated with stress, anxiety, and depression (P = 0.001 each) [Table 3]. In our study, we found that all the subscales of sleep patterns were higher in poor sleepers than good sleepers (P = 0.001 each) as shown in [Table 4]. Poor sleep quality was found 5.4 times more in the individuals having family history of psychiatry illness and 7.7 times high among individuals with the use of substance which is shown in the [Table 5] (chi-square = 34.45, df = 5, P = 0.0000).
Table 3: Differences in psychological symptoms among good and poor sleepers

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Table 4: Subscale score differences in pittsburgh sleep quality index among poor/good sleepers

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Table 5: Multiple logistic regression to predict poor sleepers

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   Discussion Top


This was a cross-sectional study to assess sleep quality and patterns and its association with psychological symptoms among doctors caring for COVID-19 patients.

Association of sleep with sociodemographic details [Table 1]

We found that poor sleep was significantly higher among married doctors (82.76%). We also found that poor sleep was associated with higher working hours per month. A study by Zhang et al. in 2020 reported that insomnia was associated with worries of being infected in addition to other variables such as working in an isolation unit, perceived helplessness. This study also found insomnia to be higher among married than single individuals which has been replicated in our study.[6],[7] Many of the doctors who were married were returning back to their families everyday which could have contributed to worries of infecting family members and poor sleep quality among these doctors. Previous research has also found that the length of time in isolation predicted anger and avoidance behaviors, and those in longer isolation (longer duration of work) would find more negative outcomes which could be associated with poor sleep.[14]

Association of sleep with vulnerability variables [Table 2]

In our study, the presence of family history of psychiatric illness (P = 0.008) and the presence of substance use (P = 0.007) were associated with poor sleep. Multiple logistic regression also demonstrated these two variables to predict poor sleep in the study population [Table 5]. This may represent a population with predisposition to poor sleep which may be exacerbated in the presence of current stress.[15] Thus, in this pandemic, sleep problems may be more common in those with the above vulnerabilities which probably predisposes them to higher stress, anxiety, or depression.

Differences in psychological symptoms among good and poor sleepers [Table 3]

The present study showed that stress, anxiety symptoms, and depressive symptoms were significantly higher in poor sleepers. Studies have also shown that stress, anxiety symptoms, and depressive symptoms were associated with poor sleepers.[7] A study by Jiang et al. has reported poor sleep quality among medical staff was predicted by higher stress, anxiety, and depression levels, in addition to poor social support and higher negative coping, and lesser degree of positive coping.[16] The findings of the present study are also in concordance with the above study.

An analysis of subscale score (sleep patterns) differences among poor and good sleepers [Table 4]

It was seen that all the 7 subscale scores (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency score, sleep disturbances, use of sleep medications, and daytime dysfunction scores) were significantly higher among poor sleepers than good sleepers (P = 0.001). Studies have demonstrated that sleep pattern disturbances such as difficulty falling asleep, early awakening occur among healthcare professionals which could be associated with isolation and stress.[6] However, we have been able to demonstrate a variety of sleep pattern abnormalities which is important to recognize in this vulnerable population for early intervention.

Factors associated with poor sleep

When a multiple logistic regression was performed to predict the factors associated with poor sleep, we found that those with a family history of psychiatric illness (5.4 times) and the presence of substance use (7.7 times) had a higher odds of having poor sleep than those without.

Strengths and limitations of the study

We have used a tool to measure sleep quality and patterns unlike other studies which have assessed only insomnia. We have also included questions on disease vulnerability which can independently be associated with sleep.

It was a cross-sectional study. Although confidentiality was ensured, underreporting of symptoms is possible. Although we enquired about the presence of axis 1 psychiatric illness including substance use, we did not use a tool to assess the presence and severity of the same. Few of the study participants (n = 5) were on psychotropics which could have independently affected sleep and could be a confounding factor.


   Conclusion Top


Sleep pattern abnormalities were present in almost half of the frontline COVID-19 doctors studied. In this pandemic, in the current study, we found those with a family history of psychiatric illness, having higher working hours per month, having a past history of psychiatric illness, and substance use had higher sleep problems which could probably be explained by higher levels of stress, anxiety, and depressive symptoms in this population. These factors need to be screened among frontline doctors which could indicate the presence or predisposition to sleep problems.

It is important to recognize and manage sleep pattern abnormalities as these could also be initial signs of a psychiatric disorder or manifestations of underlying stress or poor coping, especially in the vulnerable population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Dalal PK, Roy D, Choudhary P, Kar SK, Tripathi A. Emerging mental health issues during the COVID-19 pandemic: An Indian perspective. Indian J Psychiatry 2020;62:S354-64.  Back to cited text no. 1
    
2.
Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry 2020;7:e14.  Back to cited text no. 2
    
3.
Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003;168:1245-51.  Back to cited text no. 3
    
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Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey. Psychiatry Res 2020;288:112954.  Back to cited text no. 4
    
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Abdulah DM, Musa DH. Insomnia and stress of physicians during COVID-19 outbreak. Sleep Med X 2020;2:100017.  Back to cited text no. 5
    
6.
Xue Z, Lin L, Zhang S. Sleep problems and medical isolation during the SARS-CoV-2 outbreak. Sleep Med 2020;70:112-5.  Back to cited text no. 6
    
7.
Zhang C, Yang L, Liu S, Ma S, Wang Y, Cai Z, et al. Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. Front Psychiatry 2020;11:306.  Back to cited text no. 7
    
8.
Su TP, Lien TC, Yang CY, Su YL, Wang JH, Tsai SL, et al. Prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured SARS caring unit during outbreak: A prospective and periodic assessment study in Taiwan. J Psychiatr Res 2007;41:119-30.  Back to cited text no. 8
    
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Suryavanshi N, Kadam A, Dhumal G, Nimkar S, Mave V, Gupta A, et al. Mental health and quality of life among healthcare professionals during the COVID-19 pandemic in India. Brain Behav 2020;10:e01837.  Back to cited text no. 9
    
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González-Rivera JA, Pagán-Torres OM, Pérez-Torres EM. Depression, anxiety and stress scales (DASS-21): Construct validity problem in hispanics. Eur J Investig Health Psychol Educ 2020;10:375-89.  Back to cited text no. 10
    
11.
Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193-213.  Back to cited text no. 11
    
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Manzar MD, Moiz JA, Zannat W, Spence DW, Pandi-Perumal SR, BaHammam AS, et al. Validity of the Pittsburgh sleep quality index in Indian university students. Oman Med J 2015;30:193-202.  Back to cited text no. 12
    
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Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP. Psychometric properties of the 42-item and 21-item versions of the depression anxiety stress scales in clinical groups and a community sample. Psychol Assess 1998;10:176-81.  Back to cited text no. 13
    
14.
Marjanovic Z, Greenglass ER, Coffey S. The relevance of psychosocial variables and working conditions in predicting nurses' coping strategies during the SARS crisis: An online questionnaire survey. Int J Nurs Stud 2007;44:991-8.  Back to cited text no. 14
    
15.
Tyssen R. Work and mental health in doctors: A short review of Norwegian studies. Porto Biomed J 2019;4:e50.  Back to cited text no. 15
    
16.
Jiang F, Xiao Y, Dong H, Liu S, Guo F, Gong Z, et al. Sleep quality in medical staffs during the outbreak of coronavirus disease 2019 in China: A web-based cross-sectional study. Front Psychiatry 2021;12:630330.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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