Struggling to sleep following a COVID-19 infection? You’re not alone, experts say

Authors: Olivia WillisABC Health & Wellbeing  23 Mar 2022 Posted July 2022

When Jen Martin tested positive for COVID-19 in early February, she was surprised by just how unwell she felt.

“I didn’t have a fever but I had very serious aches and pains, crazy lethargy, and a hacking cough,” she says.

“I certainly felt worse than I had expected to, having heard all of the stories about it being mild.”

Six weeks later, the Melbourne-based academic still feels pretty average, dealing with regular headaches, daily fatigue, and disrupted sleep.

“In the early days, the cause [of my sleep problems] was obvious — I couldn’t stop coughing,” she says.

“But even since I’ve stopped coughing, I’ve noticed this very, very interrupted sleep pattern.”

Jen says she’s able to fall asleep reasonably quickly, but often finds herself awake two hours later.

She struggles to get back to sleep and stay asleep for more than an hour, before abruptly waking again — a cycle that repeats itself throughout the night.

“I try strategies to get back to sleep, knowing that I’ve got work the next day and I’m feeling really tired … but I just really struggle, it’s very frustrating.”

Early mornings, which used to be the most productive part of her day, are now noticeably slower, on account of feeling “dozy”.

“I feel very grateful that I have a job that I can largely do from home,” Jen says.

“But there’s just this little voice in the back of my head that’s like, ‘Jeez, it would be nice to get a solid sleep one of these days’.”

Sleep disturbances seen in post-COVID patients

While most people with a mild or moderate case of COVID-19 recover within about two weeks, others experience lingering symptoms, such as fatigue and shortness of breath.

Sleep disturbances are a well-documented symptom of long COVID, which is generally regarded as the persistence (or emergence) of symptoms at least three months after a SARS-CoV-2 infection.

But respiratory and sleep physician Megan Rees says people can also experience sleep problems during the acute phase of a COVID-19 infection and in the weeks and months that follow.

“At least a third to half of our patients say [their sleep] is worse than it was before they got COVID-19,” says Dr Rees, who is head of the Royal Melbourne Hospital’s Sleep and Respiratory unit.

“There certainly appears to be an increase in sleep disorders in patients both during the early recovery — just a few weeks after they’ve had COVID — and also in those who have more persistent symptoms long-term.”

When it comes to sleep disturbances, Dr Rees says people recently recovering from COVID-19 — and those diagnosed with long COVID — experience “a mixture of problems”.

“There seems to be a bit of insomnia, so difficulty being able to sleep at the time that you want, but also feeling tired and wanting to sleep during the daytime,” she says.

“In addition to that, there is what we call ‘phase delay’ or a disruption to your natural circadian rhythm.

“People aren’t always finding it easy to be awake at the time they usually like to be awake, and have difficulty being asleep at the time they want to be asleep.”

What triggers sleep problems following COVID-19?

The cause is likely to be “multifactorial”, Dr Rees says, meaning there’s usually several factors involved.

“There’s likely to be, to some extent, a direct viral effect — so viruses cause a lot of inflammation in the body, and those inflammatory chemicals as they circulate can disrupt sleep,” she says.

“Predominantly, they make you more fatigued or wanting to sleep at different times, but they can also upset your natural rhythms.”

Earlier this year, Australian researchers found that people with long COVID — even those whose initial infection was mild — had a sustained inflammatory response for at least eight months after their infection.

Dr Rees says more research is needed to understand the impacts of this ongoing inflammation, but that “it’s not surprising that an inflammatory illness like COVID-19 could disrupt sleep”.

“Sleep is a really complex process that actually takes a lot of coordination between various aspects of your brain to achieve,” she says.

The persistence of physical symptoms, particularly chest pain and breathlessness — “two of the most common symptoms seen in people as they recover” — can also cause disruptions to sleep.

“Those symptoms can be quite frightening and people can be concerned that something more serious, like a heart attack, is occurring,” she says.

“If you wake up with chest pain, it’s pretty hard to go back to sleep.”

Even for people whose physical symptoms have resolved, they may still feel afraid to fall asleep weeks or months later, worried they will struggle to breath.

In addition to the illness itself, Dr Rees says changes to regular routines during the isolation and recovery periods can also put people’s sleep routines out of whack.

“Often you do have a disruption to your normal rhythms of life, so people might be sleeping in, watching screens a little more in the evenings, or having afternoon naps,” she says.

“They might also not be able to do as many of their usual activities that help them have a normal sleep cycle so that they’re alert in the mornings and tired in the evenings.

“That natural cycle, where we follow the sun rising and the sun setting, is often a bit disrupted.”

Anxiety and ongoing stress a key factor

According to respiratory physician Anthony Byrne, the anxiety that’s often triggered when people become unwell may also play a part in disturbing sleep.

“Being unwell with a severe virus, whether or not you’re in hospital, would cause most people to have some level of anxiety about their own health and how they’re going to go in the short term as well as in the long term,” says Dr Byrne, who treats both acute and long COVID patients at St Vincent’s Hospital in Sydney.

“There’s a lot of worry and concern: will I have these symptoms forever? When will these symptoms go away? Am I going to get long COVID?”

Anxiety and ongoing stress a key factor

According to respiratory physician Anthony Byrne, the anxiety that’s often triggered when people become unwell may also play a part in disturbing sleep.

“Being unwell with a severe virus, whether or not you’re in hospital, would cause most people to have some level of anxiety about their own health and how they’re going to go in the short term as well as in the long term,” says Dr Byrne, who treats both acute and long COVID patients at St Vincent’s Hospital in Sydney.

“There’s a lot of worry and concern: will I have these symptoms forever? When will these symptoms go away? Am I going to get long COVID?”

Dr Byrne says research suggests people who had been infected with COVID-19 experienced increased levels of anxiety, and that there is a clear link between anxiety and poor sleep.

“The circadian rhythm is a natural rhythm inbuilt in us that means we have a certain amount of circulating melatonin and other factors in the blood that allow us to sleep at night,” he says.

“When you have anxiety and other neurotransmitters that are overactive in the brain, you get an inability to relax … you’re sort of in a fight/flight response, and so it’s hard to settle down.

“Then you can have this delayed sleep onset or difficulty getting to sleep … and that’s one of the things that has been found in patients post-COVID.”

Anxiety is also closely linked with insomnia, which can sometimes begin during times of increased stress, and continue even once the stress has gone away.

Dr Byrne says the psychological impacts of a severe COVID infection can sometimes be seen months after infection.

“One example is a young healthy guy that developed long COVID symptoms after he was admitted to hospital with COVID pneumonia,” Dr Byrne says.

“One reason that he was waking up at night was because he was getting flashbacks to when he was really breathless and on oxygen at the hospital.

“Even though he recovered from that, it was almost like post-traumatic stress.”

COVID-19 may expose existing sleep problems

While Dr Bryne acknowledges that sleep disturbances post-COVID are “a big, important problem”, he says it’s important to note that some sleep issues may have existed prior to infection.

“Obstructive sleep apnoea, for example, is a risk factor for severe COVID and is often undiagnosed [prior to COVID infection],” he says.

“It’s a very well-researched disorder that affects sleep quality and the ability to feel refreshed.

“So you can get this overlap of disorders, which are not causing long COVID, but they’re there, and they’re potentially modifiable and treatable.”

When investigating the cause of sleep problems following COVID-19, Dr Byrne says it’s important to do a comprehensive assessment of existing health problems and sleep habits before “laying blame solely on the shoulders of COVID”.

“When you go to see a GP or sleep physician, one of the first things that will be asked is: what’s your sleep routine?” he says.

“How’s your sleep hygiene? Are you going to bed at a reasonable hour? Are you avoiding caffeine and cutting out all the usual things?

“Good sleep hygiene is important … and often that’s not happening.”

A lot of people are also already experiencing heightened anxiety because of the pandemic, which may well be exacerbated if they get infected and become unwell, he adds.

“If you’ve got a background anxiety disorder and then you’ve got COVID on top of that, it’s going to make things worse — including sleep problems.”

Do these COVID-related sleep problems usually go away?

The good news, according to Dr Rees, is that most post and long COVID patients, in her experience, improve with time.

“We certainly understand a lot more about [persistent symptoms] now, and we are seeing a slow, steady recovery for the vast majority of people,” she says.

For those in the community struggling with sleep problems following a COVID infection, Dr Rees says there are a few things worth trying to improve sleep quality.

“I guess the first thing to say is that you’re not crazy: you’ve had a serious infection and this unfortunately can be a part of that illness, but it should get better over time,” she says.

The first thing she recommends to improve sleep is to ensure you follow a regular sleep-wake cycle.

“I recommend light exercise outside in the mornings, ideally walking without sunglasses,” Dr Rees says.

“Then towards the end of the day, have some relaxing, wind-down time in the evening, ideally without screens.”

In addition to avoiding the blue light that’s emitted from electronic devices, she recommends limiting alcohol intake and cigarettes.

“Although you will doze off more easily if you have a few drinks, alcohol prevents you from going into those deeper, restorative phases of sleep.”

Dr Bryne adds that melatonin tablets, over-the-counter or via prescription, may also help to alleviate sleep issues.

Finally, Dr Rees says if people haven’t yet received their COVID-19 booster vaccine, persistent COVID symptoms weren’t a reason to delay it.

“People were a little worried that getting vaccinated might worsen their long COVID symptoms, but actually the reverse is true,” she says.

“We’ve found that people who’ve already been suffering from long COVID can have their symptoms reduced if they get a booster dose.”

Lifestyle risk behaviors among adolescents: a two-year longitudinal study of the impact of the COVID-19 pandemic

Authors: Anne Gardner1, Jennifer Debenham1, Nicola Clare Newton1, Cath Chapman Fiona Elizabeth Wylie2, Bridie Osman1, Maree Teesson, Katrina Elizabeth Champion The British Medical Journal


Objective To examine changes in the prevalence of six key chronic disease risk factors (the “Big 6”), from before (2019) to during (2021) the COVID-19 pandemic, among a large and geographically diverse sample of adolescents, and whether differences over time are associated with lockdown status and gender.

Design Prospective cohort study.

Setting Three Australian states (New South Wales, Queensland and Western Australia) spanning over 3000 km.

Participants 983 adolescents (baseline Mage=12.6, SD=0.5, 54.8% girl) drawn from the control group of the Health4Life Study.

Primary outcomes The prevalence of physical inactivity, poor diet (insufficient fruit and vegetable intake, high sugar-sweetened beverage intake, high discretionary food intake), poor sleep, excessive recreational screen time, alcohol use and tobacco use.

Results The prevalence of excessive recreational screen time (prevalence ratios (PR)=1.06, 95% CI=1.03 to 1.11), insufficient fruit intake (PR=1.50, 95% CI=1.26 to 1.79), and alcohol (PR=4.34, 95% CI=2.82 to 6.67) and tobacco use (PR=4.05 95% CI=1.86 to 8.84) increased over the 2-year period, with alcohol use increasing more among girls (PR=2.34, 95% CI=1.19 to 4.62). The prevalence of insufficient sleep declined across the full sample (PR=0.74, 95% CI=0.68 to 0.81); however, increased among girls (PR=1.24, 95% CI=1.10 to 1.41). The prevalence of high sugar-sweetened beverage (PR=0.61, 95% CI=0.64 to 0.83) and discretionary food consumption (PR=0.73, 95% CI=0.64 to 0.83) reduced among those subjected to stay-at-home orders, compared with those not in lockdown.

Conclusion Lifestyle risk behaviors, particularly excessive recreational screen time, poor diet, physical inactivity and poor sleep, are prevalent among adolescents. Young people must be supported to find ways to improve or maintain their health, regardless of the course of the pandemic. Targeted approaches to support groups that may be disproportionately impacted, such as adolescent girls, are needed.

Trial registration number Australian New Zealand Clinical Trials Registry (ACTRN12619000431123)

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial.

Strengths and limitations of this study

  • A prospective cohort design was used to explore changes in a comprehensive set of health indicators among adolescents, from before (2019) to during (2021) the COVID-19 pandemic, and whether changes varied by gender and lockdown status.
  • The study included a large (n=983) and geographically diverse sample of adolescents across three Australian states (New South Wales, Queensland and Western Australia) spanning over 3000 km.
  • Limitations of the research include the reliance on self-report measures, and while the sample was diverse, it is not representative of the Australian population.

The global spread of COVID-19 and subsequent lockdown measures have presented challenges worldwide. While disease severity, hospital admissions and deaths have typically been lower among adolescents, compared with adults,1 government responses, such as movement restrictions and school closures, present further potential health ramifications due to the related changes in lifestyle behaviours. Critically, despite some studies demonstrating the significant physical and mental health consequences of lockdown measures on adolescents,2–4 research has typically focused on a few select behaviours, rather than a comprehensive set of health indicators. Given the unique presentation of COVID-19 across countries and differing government responses, there is a need to examine health-related changes from a variety of contexts to develop a better understanding of global health.

According to the Oxford COVID-19 Government Response Tracker,5 the strictness of lockdown restrictions since the first confirmed cases in January 2020 to October 2021 was similar in Australia, the USA and the UK, with average stringency indexes of 60/100, 59/100 and 61/100, respectively, despite much lower incidence and mortality rates in Australia.6 However, there can be substantial variation within countries.7 8 In Australia, for example, stringency index values varied between states and territories by as much as 68 during 2020.8 The strictest and most extensive lockdown restrictions have been implemented in Victoria and New South Wales (NSW), two of the most populous states that saw heightened case numbers during the January 2020 to October 2021 period, while other Australian states, such as Queensland (QLD) and Western Australia (WA), experienced far fewer cases and restrictions.9 10 The Australian context may therefore serve as a case study for understanding the impact of various levels of restrictions on adolescent health behaviours.

Previous research has highlighted the importance of six key lifestyle behaviours, including diet, physical activity, sleep, sedentary behaviour (including recreational screen time), alcohol use and smoking—collectively referred to as the ‘Big 6’—for the short-term and long-term health of adolescents.11–14 These behaviours are common among youth worldwide, with more than 80% of adolescents insufficiently physically active15 and screen time rapidly increasing.14 16 The Big 6 contribute significantly to global disease burden and are known predictors of chronic diseases, including cancer, cardiovascular disease and mental disorders.13 17

Research suggests that COVID-19 has impacted the Big 6, and in turn, the health of adolescents. For example, youth in Europe and Palestine have gained weight during the pandemic,18 19 which may be the result of increased consumption of discretionary food and sugar-sweetened beverages (SSB) during lockdown periods.18 20 However, some studies report improvements in dietary behaviours, including less SSB consumption among Colombian adolescents, higher fruit intake among Italian youth and higher vegetable intake among adolescents from Spain, Brazil and Chile.20 21 Among the few existing Australian studies, Munasinghe et al 3 found physical distancing measures implemented in the initial lockdown period (March–April 2020) were associated with a decline in fast food consumption among adolescents, but there were no changes in fruit and vegetable consumption. However, it is unknown whether these changes have been sustained, or whether other dietary behaviours changed.

The pandemic presents particular challenges for movement behaviours, including physical activity, sedentary behaviour and sleep. Typically, lockdowns are associated with lower levels of adolescent physical activity4 18 20 22 23 and increased screen time, both for remote learning and recreation, resulting in sedentary lifestyles.3 4 23 24 However, some research in Australia25 and Germany26 suggests physical activity increased.26 International studies also report an increase in adolescent sleep duration during lockdown periods,18 20 but higher prevalence of sleep problems, particularly among girls.27 Similarly, Australian adolescents perceived an increase in sleep difficulties and had increased sleep disturbance during the first lockdown.25 One study28 reported increased sleep duration among Australian adolescents who were engaged in remote learning; however, another3 found no changes.

Studies investigating the impact of the pandemic on adolescent alcohol and tobacco use have produced mixed findings. For example, alcohol use is reported to have increased among Canadian adolescents,29 reduced among Spanish adolescents,30 while there was no change in alcohol or tobacco use among adolescents from the USA.31 Further, European research suggests a reduction in adolescent tobacco use during the pandemic period,30 32 yet there has been an increase in Uganda.33 To date, changes in alcohol and tobacco use among Australian adolescents have not been examined.

Evidence suggests that the prevalence of the Big 6 varies by gender. For example, adolescent girls are more likely to be physically inactive, whereas adolescent boys are more likely to engage in high levels of recreational screen time, have a poor diet, and use alcohol and tobacco.15 34–38 However, less is known about whether changes in lifestyle behaviours over the pandemic period vary by gender.

To address these gaps in the literature, this study aims to examine changes in the prevalence of the Big 6 among a large, geographically diverse sample of adolescents, from before to during the COVID-19 pandemic, and explore whether differences over time are associated with gender and lockdown status.


Participants and procedure

The sample comprised participants from three Australian states (NSW, QLD and WA), spanning over 3000 km, who were randomly allocated to the control group of the Health4Life Study.39 Participants who provided written consent and had parental consent (passive, active written or active verbal, depending on approved procedures for the school type and region) completed self-report assessments in a supervised classroom setting. Only students who provided data prior to the beginning of the pandemic (between July and November 2019) and during the pandemic (approximately 24 months after baseline, between July and 10 October 2021) were included in this study. During the 2021 data collection period, Australia had strict border policies, restricting international travel and mandating hotel quarantine, while state-level and territory-level border policies for domestic travel varied.40 Greater Sydney, including the Central Coast, Shellharbour and Wollongong were subjected to lockdown restrictions under the NSW stay-at-home Public Health Order41; the most stringent of which included not being permitted to leave the home unless essential (eg, one person per household to shop for food or 1 hour of exercise per day), movement restricted to a 5 km radius of the home, closure of all non-essential retail (eg, hairdressers), home-based work and schooling requirements, curfews, and mandatory mask wearing, with a high police presence and large fines enforced for non-adherence. QLD, WA and areas outside of Greater Sydney were not subjected to extended stay-at-home lockdown restrictions.

Patient and public involvement

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.


Sociodemographic characteristics

Participants self-reported their age and gender (male, female, non-binary/gender fluid, missing). A binary ‘lockdown’ variable was created reflecting participants who attended schools in the Greater Sydney region that were subjected to the stay-at-home Public Health Order in 2021 and those who were not.41


Dietary intake was assessed using items adapted from the NSW School Physical Activity and Nutrition Survey.42 Participants self-reported the number of metric cups of SSB usually consumed per week or day. A binary variable was created to reflect high (≥5–6 cups or more/week) and low consumption (≤4 cups/week). Participants reported how often they consume six discretionary food items (hot chips, French fries, wedges or fried potatoes; potato crisps or other salty snacks; snack foods, for example, sweet and savoury biscuits, cakes, doughnuts or muesli bars; confectionary; ice cream or ice blocks; and takeaway meals or snacks). High discretionary food consumption was defined as eating any of the items ‘2 or more times/day’, or eating at least two of the items ‘3–4 times/week’ or more often. Participants reported the number of serves of fruit and vegetables consumed per day, and in line with the Australian dietary guidelines,43 insufficient fruit and vegetable consumption was defined as <2 serves of fruit and <5 serves of vegetables per day, respectively.

Physical activity

A single item was used to assess the number of days over the past week that participants engaged in moderate-to-vigorous physical activity for at least 60 min.44 As per the Australian health guideline, insufficient physical activity was defined as engaging in <60 min of moderate-to-vigorous physical activity/day.45

Recreational screen time

The International Sedentary Assessment Tool46 was used to evaluate free time spent on a typical weekday and weekend day over the past 7 days watching television/DVDs/streaming services or using an electronic device. In line with the Australian health guideline,45 excessive recreational screen time was defined as >2 hours/day.


The Modified Sleep Habits Survey47 was used to assess sleep duration. Total sleep time was calculated by finding the difference between the time participants reported first attempting sleep, and the time they woke up in the morning, minus the reported time taken to fall asleep from first attempt, with a weighted average sleep duration calculated for school and weekend nights. Self-reported bedtime, waketime and sleep duration have been shown to be reliable and valid in adolescent populations.48 49 As per the Australian guidelines, insufficient sleep was defined as an average duration outside of 9–11 hours/night for those aged 11–13 years, or 8–10 hours/night for those aged 14–17 years.45

Alcohol and tobacco use

Alcohol and tobacco use were measured using two dichotomous (yes/no) items drawn from previous large scale trials and population based epidemiological surveys50 51: ‘Have you had a full standard alcoholic drink in the past 6 months?’ and ‘In the past 6 months, have you tried cigarette smoking, even one or two puffs?’

Statistical analysis

Generalised linear mixed models were used to investigate change over time in the Big 6. Owing to the high prevalence of outcomes, we used Robust Poisson methods to generate prevalence ratios (PR) and 95% CIs, to overcome some of the limitations of reporting ORs from logistic regressions, which may appear inflated.52 PR are interpreted as the estimated prevalence of an outcome in one group, compared with another, providing an indication of a change in prevalence, as opposed to risk or odds. All models included a random intercept at the student level and school level, Robust Poisson distribution and a log link function, where time is continuous and represents the prepandemic (2019) and mid-pandemic scores (2021). Group by time interactions were estimated to assess change in the prevalence of the Big 6 over time in relation to gender (female/male, given the low prevalence of the ‘non-binary/gender fluid’ (0.1%) and ‘prefer not to say’ (.5%) subgroups) and the presence of lockdown restrictions during the 2021 survey occasion. All analyses were conducted in Stata V.17.53


Descriptive statistics

The sample included 983 students (baseline Mage=12.6, SD=0.5, 54.8% girl) from 22 schools across NSW, QLD and WA (see table 1 for baseline characteristics). At the 2021 survey occasion, approximately one-third of the sample (32.7%) was under lockdown restrictions. Table 2 presents the prevalence of lifestyle risk behaviours over time.

Table 1

Sample characteristics

Table 2

Prevalence of lifestyle risk behaviours before and during the COVID-19 pandemic

Changes in lifestyle risk behaviours

Change over time in the prevalence of the Big 6 and differences based on lockdown status and gender are illustrated in figure 1, with PR and CIs detailed in online supplemental table 1.

Supplemental material


Figure 1

Figure 1

Change over time in the prevalence of the Big 6 and differences based on lockdown status and gender. a≤13 years old: 9 to 11 hours/night, 14-17years: 8 to 10 hours/night. MVPA, moderate-to-vigorous physical activity; SSB, sugar-sweetened beverage.

Dietary behaviours

SSB consumption

There was no significant change in the prevalence of high SSB consumption over time (PR=0.83 95% CI=0.58 to 1.18). However, the prevalence was 39% lower in individuals under lockdown (PR=0.61, 95% CI=0.64 to 0.83) over time, compared with those not in lockdown.

Discretionary food consumption

There was no significant change in the prevalence of high discretionary food consumption over time (PR=0.97, 95% CI=0.86 to 1.09). However, the prevalence was 27% lower for individuals living under lockdown (PR=0.73, 95% CI=0.64 to 0.83) over time, compared with those not in lockdown.

Fruit and vegetable intake

The prevalence of insufficient fruit intake increased by 50% over time (PR=1.50, 95% CI=1.26 to 1.79). There were no changes in the prevalence of insufficient vegetable intake over time (PR=1.01, 95% CI=0.97 to 1.06), and the presence of lockdown restrictions was not associated with a change in the prevalence of insufficient fruit or vegetable intake over time.

There were no gender-based differences in the prevalence of high SSB consumption, high discretionary food consumption or insufficient fruit/vegetable intake over time.


The prevalence of insufficient sleep decreased by 26% over time (PR=0.74 95% CI=0.68 to 0.81). Girls reported a higher prevalence of insufficient sleep over time, compared with boys (PR=1.24, 95% CI=1.10 to 1.41). The presence of lockdown restrictions was not associated with a change in the prevalence of insufficient sleep over time.

Recreational screen time

There was a 6% increase in the prevalence of excessive recreational screen time over time (PR=1.06, 95% CI=1.03 to 1.11). Gender and the presence of lockdown restrictions were not associated with a change in the prevalence of excessive recreational screen time over time.

Physical activity

There was no change in the prevalence of insufficient physical activity over time (PR=1.03, 95% CI=1.00 to 1.07). Neither gender nor the presence of lockdown restrictions was associated with change in the prevalence of insufficient physical activity over time.

Alcohol use

The prevalence of past 6-month alcohol use increased by 334% over time (PR=4.34, 95% CI=2.82 to 6.67). The prevalence of alcohol use increased more in girls compared with boys (PR=2.34, 95% CI=1.19 to 4.62). The presence of lockdown restrictions was not associated with change in the prevalence of past 6-month alcohol use over time.

Tobacco use

The prevalence of past 6-month tobacco use increased by 305% over time (PR=4.05 95% CI=1.86 to 8.84). Neither gender nor the presence of lockdown restrictions was associated with change in the prevalence of past 6-month tobacco use over time.


This study was the first to explore changes in all of the Big 6 lifestyle risk behaviours among a large, geographically diverse cohort of adolescents, from before (2019) to during (2021) the COVID-19 pandemic, and whether changes varied by gender and lockdown status. Over the 2-year period, the prevalence of excessive recreational screen time, insufficient fruit intake and alcohol and tobacco use increased, with alcohol use increasing among girls in particular. The prevalence of insufficient sleep reduced in the overall sample; yet, increased among girls. Being in lockdown was associated with improvements in SSB consumption and discretionary food intake.

These findings highlight the varied impact of the pandemic across countries. For example, consistent with other Australian findings,3 but in contrast to international research,18 20 the prevalence of discretionary food intake decreased among those in lockdown. Yet in line with some international findings,21 SSB intake reduced among adolescents in lockdown. This may reflect increased parental monitoring during lockdown and reduced opportunistic exposure to fast food due to not being with friends or commuting to school.54 55 As such, continued parental monitoring beyond the lockdown period and the promotion of healthy food options may be beneficial. However, improvements in healthy dietary behaviours were not observed. In fact, the prevalence of insufficient fruit intake increased among the full sample. This may relate to the higher cost of fresh fruit and vegetables in Australia during the pandemic, caused by labour shortages within the farming, wholesale and retail sectors due to fewer working holiday-makers.56 These findings support calls for governments to consider broader policy-level changes to improve diet, such as taxes and subsidies.57

The finding that sleep duration improved from before to during the pandemic is consistent with some Australian28 and international18 20 studies. This contrasts typical trends over adolescence58 59 and was despite an increase in the prevalence of excessive recreational screen time, which is often considered a primary contributor to poor sleep.60 It is posited that the time usually spent getting ready and commuting to school is instead spent getting additional sleep during periods of lockdown, leading to calls for delayed school start times28; however, we found no differences based on lockdown status to support this. The finding that insufficient sleep increased among girls is consistent with international research reporting increased sleep disorders among girls during the pandemic27 and may reflect the association between girl pubertal maturation and the emergence of insomnia symptoms.61 Targeted intervention approaches to address sleep among girls are needed.

Notably, in contrast to previous international and Australian research attributing increased screen time to lockdown and physical distancing measures,3 4 23 we found no difference in the prevalence of excessive recreational screen time between the lockdown and non-lockdown groups. This increase may instead reflect general trends of increasing screen time among adolescents.16 These findings highlight the value of assessing behaviours among adolescents both in lockdown and not in lockdown in the same period for comparability, and the need for effective interventions targeting screen time among adolescents.39

Contrasting typical trends over adolescence and previous pandemic research,4 23 the prevalence of insufficient physical activity did not change over time, nor did it increase more for those in lockdown. Previous studies have attributed reductions in physical activity during the pandemic to government responses, such as the cancellation of organised sport and closure of gyms and recreation centres.1 23 However, given the current data were from the 2021 lockdown, whereas previous studies focused on the initial lockdown in 2020, it may be that over time, adolescents have learnt to adapt to the rapidly changing situation and find other ways to achieve their physical activity goals (eg, replaced organised sport with outdoor gym sessions and training). It may also be that other forms of physical activity, such as light and incidental physical activity, have been more severely impacted. Future research would benefit from assessing how these different forms of physical activities changed throughout the pandemic.

Finally, although alcohol and tobacco use increased over time, the prevalence of these behaviours at the first timepoint, when participants were aged 12, was very low and remained relatively low 24 months later. This increase is to be expected among adolescents62; however, the greater increase in alcohol use among girls was unexpected. Considering this and the increase in prevalence of insufficient sleep, girls may be disproportionately impacted by the pandemic. This may reflect general patterns of higher prevalence and increasing trends of mental health problems among adolescent girls across the globe,63 64 which are often comorbid with poor sleep and substance use; as well as narrowing of the gender gap in alcohol use among more among recent cohorts.35 65 Links between these factors are complex66 and assessing changes in mental health alongside changes in the Big 6 may be a useful future research direction.

Key strengths of this study include having assessment occasions before and during the pandemic, rather than relying on retrospective accounts of perceived changes in behaviours, and a sample comprised of adolescents both in and not in lockdown at follow-up for comparability. However, we cannot rule out the potential impact of other factors, such as maturation or mental health, that could also be influencing the Big 6. Although the study builds on previous research that has focused on the early pandemic period, claims about behavioural shifts across the early and late pandemic periods need to be interpreted with caution. Other limitations include the reliance on self-report measures, and while the sample was more diverse than other Australian studies, it is limited to three Australian states and is therefore not representative of the entire Australian adolescent population.14


Lifestyle risk behaviours, particularly excessive recreational screen time, poor diet, physical inactivity and poor sleep, are prevalent among adolescents and should be addressed with effective behavior change interventions.39 With the pandemic remaining a continually evolving situation across the world, the impact on health behaviors is also likely to be dynamic and diverse. Supporting young people to improve or maintain their health behaviours, regardless of the course of the pandemic, is important, alongside targeted research and intervention efforts to support groups that may be disproportionately impacted, such as adolescent girls.


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University Study Finds Higher Risk Of Psychiatric Diagnoses Among COVID-19 Patients

Authors: Naveen Athrappully via The Epoch Times  June 9,2022

A recent study published by Oregon State University discovered that COVID-19 infected individuals have a higher chance of developing psychiatric disorders within about four months of contracting the virus.

For the study, published in World Psychiatry on May 7, researchers used data from the National COVID Cohort Collaborative (N3C). They matched 46,610 patients infected with COVID-19, which can trigger a respiratory tract infection (RTI), with control patients diagnosed with a different RTI.

This allowed researchers to specifically look into how COVID-19 affected the mental health of infected individuals. No patients with any history of mental illness prior to 21 days after a COVID-19 diagnosis were included in the study. Those with a medical record extending a year prior to their COVID-19 diagnosis were also excluded.

Researchers looked at the rate of psychiatric diagnoses in the 46,610 COVID-19 patients for two time periods—the early post-acute phase between 21 and 120 days from the infection and the late post-acute phase between 121 and 365 days from the infection.

The study discovered that COVID-19 patients had a 3.8 percent rate of developing a psychiatric disorder in the early post-acute phase when compared to just 3 percent for other respiratory tract infections. This amounted to a nearly 25 percent higher risk for COVID-19 patients.

However, the researchers did not find such a “significant difference in risk” when they compared COVID-19 late post‐acute phase patients with individuals with other respiratory tract infections.

When researchers looked at anxiety disorders, they found the incidence proportion of a new‐onset anxiety disorder diagnosis was “significantly higher” for COVID-19 patients when compared to RTI patients. For mood disorders, such significant differences were not observed.

“For people that have had COVID, if you’re feeling anxiety, if you’re seeing some changes in how you’re going through life from a psychiatric standpoint, it’s totally appropriate for you to seek some help,” Lauren Chan, co-author of the study, said according to a June 6 news release by Eurekalert.

“And if you’re a care provider, you need to be on the proactive side and start to screen for those psychiatric conditions and then follow up with those patients.”

Chan stressed that not every COVID-19 infected individual is going to have such psychiatric problems. In the context of the health care infrastructure of the United States, an increase in the number of COVID-19 patients seeking psychiatric care could add more strain on the system, she warned.

Multiple other studies have also suggested that a segment of COVID-19 patients might end up facing psychological issues.

Research published in April 2021 found that 34 percent of the 236,379 COVID-19 survivors included in the study developed neurological and mental disorders in the six months after becoming infected, according to WebMD.

Anxiety was the most commonly found disorder, with 17 percent of subjects reporting it. This was followed by mood disorders at 14 percent, substance abuse disorders at 7 percent, and insomnia at 5 percent.

When it came to neurological problems, 0.6 percent reported brain hemorrhage, 2.1 percent reported ischemic strokes, and 0.7 percent reported dementia. Among patients diagnosed as seriously ill with COVID-19, these rates jumped. Of the patients admitted to the intensive care unit, 7 percent experienced a stroke while 2 percent were diagnosed with dementia.

In another study published on Feb. 16 at BMJ, researchers analyzed records of nearly 153,848 COVID-19 patients in the Veterans Health Administration (VHS) system, comparing them with individuals who had not contracted the virus.

Those who got infected were found to be 35 percent more likely to be diagnosed with anxiety following the infection than uninfected people, 38 percent were more likely to be diagnosed with adjustment and stress disorders, 39 percent were more likely to be diagnosed with depression, and 41 percent were more likely to be diagnosed with sleep disorders.

There appears to be a clear excess of mental health diagnoses in the months after Covid,” Paul Harrison, a professor of psychiatry at the University of Oxford who was not involved in the study, told The New York Times.

However, only 4.4 to 5.6 percent of individuals in the study were diagnosed with anxiety, depression, adjustment, and stress disorders.

“It’s not an epidemic of anxiety and depression, fortunately,” Harrison added. “But it’s not trivial.”

Sleep Disturbances, Fatigue Common In Patients Who Recovered From COVID

 Authors:   Eurasia Review

Nearly all patients who recovered from COVID-19 report lingering fatigue, while half experience sleep disturbances, according to a recent analysis from Cleveland Clinic. Researchers found that race, obesity, and mood disorders are contributors.

Investigators analyzed data from 962 patients from the Cleveland Clinic ReCOVer Clinic between February 2021 and April 2022. The patients were recovered from COVID-19 and completed the sleep disturbance and fatigue questionnaires of the Patient-Reported Outcomes Measurement Information System. More than two-thirds of patients (67.2%) reported at least moderate fatigue, while 21.8% reported severe fatigue. Eight percent of patients reported severe sleep disturbances, and 41.3% reported at least moderate sleep disturbances.

“Sleep difficulties are highly prevalent and debilitating symptoms reported in patients with post-acute sequealae of COVID-19,” said Dr. Cinthya Pena Orbea, a sleep specialist at Cleveland Clinic. “Our study suggests that the prevalence of moderate to severe sleep disturbances is high and that Black race confers increased odds to suffer from moderate to severe sleep disturbances highlighting the importance to further understand race-specific determinants of sleep disturbances in order to develop race-specific interventions.”

Patients with moderate-to-severe compared with normal-to-mild sleep disturbances had higher body mass indices, were more likely to be Black, and had worse general anxiety disorder.

After adjusting for demographics, Black patients were three times more likely to experience moderate-to-severe sleep disturbances.

Warning to anyone who’s had Covid as scientists discover symptoms that can last for TWO YEARS

Authors: Vanessa Chalmers, Digital Health Reporter May 11 2022  May 12 2022

DOCTORS have discovered the symptoms of Covid that can last for two years or more. 

Their research has shown that half of patients admitted to hospital are still likely to have at least one persistent problem two years later.

The study, published in The Lancet Respiratory Medicine, has the longest follow-up period of patients to date. 

Researchers are only able to analyse what symptoms exist after two years given the coronavirus emerged in late 2019.

So it’s possible problems like fatigue and anxiety could stick around even longer.

Lead author Professor Bin Cao, of the China-Japan Friendship Hospital, China, said: “Our findings indicate that for a certain proportion of hospitalised Covid-19 survivors, while they may have cleared the initial infection, more than two years is needed to recover fully from Covid-19.”

The study involved almost 1,200 patients, aged 57 on average, who were infected with the bug in the early phase of the pandemic.

They had all been treated in Wuhan, China, then assessed six months, 12 months and two years after discharge.

Researchers looked at their walking abilities, mental health, quality of life and more.

Covid patients were generally found to be in poorer health than those in the general population two years after infection.

They reported:

  • Fatigue or muscle weakness (31 per cent of Covid patients compared to five per cent in the general population)
  • Sleep difficulties (51 per cent compared with 14 per cent)
  • Pain or discomfort (23 per cent compared with five per cent)
  • Anxiety or depression (12 per cent compared with five per cent)

Joint pain, palpitations, dizziness, and headaches were also more common among previously hospitalised Covid patients.

Not all of those hospitalised were affected, however.

More than half (55 per cent) of participants had at least one symptom of Covid at two years, and were therefore considered “long Covid” patients.

The researchers then compared the long Covid group with the group of participants who had endured Covid, but gotten better. 

Those with long Covid had more pain (35 per cent vs 10 per cent), and mobility issues (five per cent vs one per cent) than their fully recovered counterparts.

Some 13 per cent showed symptoms of anxiety and 11 per cent depression, compared with three per cent and one per cent in non-long Covid patients, respectively. 

The researchers said it’s not possible to say whether problems like these are specific to Covid, or whether other hospital patients experience them.

Long Covid is defined as someone who still battles symptoms beyond four weeks in the UK.

It may be defined as ongoing Covid (four to 12 weeks), or post-Covid syndrome (more than 12 weeks) by medics.

The symptoms may include fatigue, a cough, breathlessness, muscle or joint pain, loss of taste of smell and brain fog.

Different SARS-CoV-2 variants may give rise to different long COVID symptoms, study suggests

Italian study of long-COVID patients suggests those infected with the Alpha variant experienced different neurological and emotional symptoms compared to those who contracted the original form of SARS-CoV-2



New research to be presented at this year’s European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) in Lisbon, Portugal (23-26 April), suggests that the symptoms connected to long COVID could be different in people who are infected with different variants. The study is by Dr Michele Spinicci and colleagues from the University of Florence and Careggi University Hospital in Italy.

Estimates suggest that over half of survivors of SARS-CoV-2 infection experience post-acute sequelae of COVID-19 (PASC), more commonly known as ‘long COVID’ [1]. The condition can affect anyone—old and young, otherwise healthy, and those with underlying conditions. It has been seen in people who were hospitalised with COVID-19 and those with mild symptoms. But despite an increasing body of literature, long COVID remains poorly understood.

In this study, researchers did a retrospective observational study of 428 patients—254 (59%) men and 174 (41%) women—treated at the Careggi University Hospital’s post-COVID outpatient service between June 2020 and June 2021, when the original form of SARS-CoV-2 and the Alpha variant were circulating in the population. The patients had been hospitalised with COVID-19 and discharged 4-12 weeks before attending a clinical visit at the outpatient service and completing a questionnaire on persistent symptoms (an average [median] of 53 days after hospital discharge). In addition, data on medical history, microbiological and clinical COVID-19 course, and patient demographics were obtained from electronic medical records.

At least three-quarters 325/428 (76%) of patients reported at least one persistent symptom. The most common reported symptoms were shortness of breath (157/428; 37%) and chronic fatigue (156/428; 36%) followed by sleep problems (68/428; 16%), visual problems (55/428; 13%), and brain fog (54/428; 13%).

Analyses suggest that people with more severe forms, who required immunosuppressant drugs such as tocilizumab, were six times as likely to report long COVID symptoms, while those who received high flow oxygen support were 40% more likely to experience ongoing problems. Women were almost twice as likely to report symptoms of long COVID compared with men. However, patients with type 2 diabetes seemed to have a lower risk of developing long COVID symptoms. The authors say that further studies are needed to better understand this unexpected finding.

Researchers performed a more detailed evaluation comparing the symptoms reported by patients infected between March and December 2020 (when the original SARS-COV-2 was dominant) with those reported by patients infected between January and April 2021 (when Alpha was the dominant variant) and discovered a substantial change in the pattern of neurological and cognitive/emotional problems.

They found that when the Alpha variant was the dominant strain, the prevalence of myalgia (muscle aches and pain), insomnia, brain fog and anxiety/depression significantly increased, while anosmia (loss of smell), dysgeusia (difficulty in swallowing), ad impaired hearing were less common (figure 2 in notes to editors).

“Many of the symptoms reported in this study have been measured, but this is the first time they have been linked to different COVID-19 variants”, says Dr Spinicci. “The long duration and broad range of symptoms reminds us that the problem is not going away, and we need to do more to support and protect these patients in the long term. Future research should focus on the potential impacts of variants of concern and vaccination status on ongoing symptoms.”

The authors acknowledge that the study was observational and does not prove cause and effect, and they could not confirm which variant of the virus caused the infection in different patients—which may limit the conclusions that can be drawn.

Nearly 3 in 5 people worldwide have suffered sleep problems during COVID pandemic

Authors: by Study Finds South West News Service writer William Janes contributed to this report

TEMPE, Ariz. — Find yourself struggling to fall asleep and stay asleep more often during the pandemic? You’re far from alone. In fact, sleeping issues are burdening people around the world, with more than nearly six out of 10 people across the globe suffering from poor sleep during COVID, new research shows.

The study involving people from 79 countries around the globe reveals that 56.5 percent of people have experienced some kind of sleep disturbance in the pandemic. Almost two-thirds of those polled dealt with a “delayed sleep” pattern, which was associated with little change in sleep duration or time spent in bed, but a later bedtime and increased nightmares and naps.

The second most common sleep pattern change, experienced by one in five people, was the “sleep lost and fragmented” pattern. Scientists say these people went to bed later and had a shorter time in bed attempting to sleep – in essence, their sleep was restricted, lower in quality, and they were less likely to compensate for it with naps. Women are more likely to experience this disruption than men, results show.

Around one in 10 tended to be “sleep opportunists,” meaning they had significantly restricted sleep opportunities before the pandemic, but spent a lot more time in bed and had the longest sleep duration compared to any of the others. Despite the better sleep, those people also reported the greatest change in their daily routines, which was associated with a lower likelihood of being employed and greater family stress.

The least common sleep pattern was “dysregulated and distressed.” This was experienced by 5 percent of people surveyed. These individuals had the worst sleep deterioration along with more nightmares and naps, and had the worst insomnia symptoms.

“Overall, sleep disturbances were heightened, with 56.5 per cent of our sample reporting clinical levels of insomnia symptoms during the pandemic,” says Dr. Megan Petrov, an assistant professor in the College of Nursing and Health Innovation at Arizona State University, in a statement. “Sleep is an essential part of living, just like air, water and food. Your health and functioning are compromised when the quality of the air you breathe, the water you drink and the food you eat are poor. This is also the case if your sleep is poor quality and insufficient in quantity.”

The findings are published in the journal Sleep Health.

New Study Shows Insomnia More Common in COVID-19 Survivors

Updated April 14, 2021

Authors: Written by Elise Chahine

COVID-19 infection may have a large neurological and psychiatric impact on as many as one-third of its survivors.

A study published by Lancet Psychiatry finds that insomnia may be one of the most common neurological and psychiatric outcomes from COVID-19. Researchers evaluated the electronic health records of TriNetX, a global health research network, for approximately 236,000 patients, 10 years of age and older, who tested positive for COVID-19 from January 20, 2020 and were recorded as still alive on December 13, 2020 (see table for baseline characteristics). There was an estimated incidence of 14 neurological and psychiatric outcomes in the 6 months following a confirmed diagnosis of COVID-19, which included (but are not limited to) brain hemorrhage, stroke, muscle disease, dementia, mental health disorders, and insomnia. COVID-19 infection group’s outcomes were compared with flu and other respiratory tract infection groups’ outcomes.

Baseline Characteristics

CharacteristicsAll Patients
Cohort size236,379 (100.0%)
Age range, years26.3-65.7
  Male104,015 (44.0%)
  Female131,460 (55.6%)
  Other904 (0.4%)
  White135,143 (57.2%)
  Black, African-American44,458 (18.8%)
  Unknown48,085 (20.3%)
  Hispanic or Latino37,772 (16.0%)
  Not Hispanic or Latino134,075 (56.7%)
  Unknown64,532 (27.3%)

Researchers found that approximately 34% of their COVID patient population experienced at least 1 of the 14 neurological and/or psychiatric outcomes. While 5.4% of all patients in the study experienced insomnia, the number only increased with infection severity and need for hospitalization. With only 5.2% of non-hospitalized patients experiencing insomnia, the number jumps significantly upon hospital-entry to 6% and again to 7.5% and 10% for Intensive-Therapy-Unit–admitted and encephalopathy patients, respectively. It should be noted, this trend—an escalation in incidence with increased infection severity—was seen throughout the patient population despite neurological or psychiatric outcomes experienced.

Researchers speculate that some potential reasons for the neurological attack is viral invasion of the central nervous system, blood clotting disorders, and/or the toll immune response can take on our nervous system. The risks for these particular diagnoses may be small, but spread across a population can prove to have massive repercussions.

This study is further shedding light on the long-term implications COVID-19 will leave in its wake, plus the need for a more robust healthcare system to meet the needs of its population.

Sleep problems during the COVID-19 pandemic by population: a systematic review and meta-analysis

Authors: Haitham Jahrami 1 2Ahmed S BaHammam 3 4Nicola Luigi Bragazzi 5Zahra Saif 1MoezAlIslam Faris 6Michael V Vitiello 7 PMID: 33108269 PMCID: PMC7853219 (available on 2022-02-01) DOI: 10.5664/jcsm.8930


Study objectives: No systematic review or meta-analysis has yet been conducted to examine the impact of the pandemic on the prevalence of sleep problems among the general population, health care workers, or patients with COVID-19. Therefore, this systematic review was conducted to assess the impact and prevalence of sleep problems among those categories.

Methods: American Psychological Association PsycINFO, Cochrane, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCOhost, EMBASE, Google Scholar, MEDLINE, ProQuest Medical, ScienceDirect, Scopus, and Web of Science from November 1, 2019 to July 5, 2020 were used. Additionally, 5 preprints servers (;;;; were also searched for papers accepted after peer review but not yet published and indexed. There was no language restriction. The random-effect models meta-analysis model was used with the DerSimonian and Laird methodology.

Results: Forty-four papers, involving a total of 54,231 participants from 13 countries, were judged relevant and contributed to the systematic review and meta-analysis of sleep problems during COVID-19. The global pooled prevalence rate of sleep problems among all populations was 35.7% (95% confidence interval, 29.4-42.4%). Patients with COVID-19 appeared to be the most affected group, with a pooled rate of 74.8% (95% confidence interval, 28.7-95.6%). Health care workers and the general population had comparative rates of sleep problems, with rates of 36.0% (95% confidence interval, 21.1-54.2%) and 32.3% (95% confidence interval, 25.3-40.2%), respectively.

Conclusions: The prevalence of sleep problems during the COVID-19 pandemic is high and affects approximately 40% of people from the general and health care populations. Patients with active COVID-19 appeared to have a higher prevalence rates of sleep problems.

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Prevalence of Depression, Anxiety, and Stress during COVID-19 Pandemic

Authors: Ram Lakhan 1Amit Agrawal 2Manoj Sharma 3


The coronavirus disease 2019 (COVID-19) crisis has greatly affected human lives across the world. Uncertainty and quarantine have been affecting people’s mental health. Estimations of mental health problems are needed immediately for the better planning and management of these concerns at a global level. A rapid scoping review was conducted to get the estimation of mental health problems in the COVID-19 pandemic during the first 7 months. Peer-reviewed, data-based journal articles published in the English language were searched in the PubMed, Medline, and Google Scholar electronic databases from December 2019 to June 2020. Papers that met the inclusion criteria were analyzed and discussed in this review. A total of 16 studies were included. Eleven studies were from China, two from India, and one from Spain, Italy, and Iran. Prevalence of all forms of depression was 20%, anxiety 35%, and stress 53% in the combined study population of 113,285 individuals. The prevalence rate of all forms of depression, anxiety, stress, sleep problems, and psychological distress in general population was found to be higher during COVID-19 pandemic.

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