Insomnia is a key risk factor for persistent anxiety and depressive symptoms: a 12-month longitudinal cohort study during the COVID-19 pandemic
Abstract
Background Insomnia is a risk factor for affective disorders. This study examined whether individuals with insomnia symptoms early in the pandemic, either pre-existing or new-onset, were more vulnerable to anxiety and depressive symptoms over time than those who maintained normal sleep. Additionally, sleep-related factors such as pre-sleep arousal were assessed for their influence on clinically significant anxiety and depression risk.Methods Using a global online survey with 3-, 6-, and 12-month follow-ups between April 2020 and May 2021, data from 2069 participants (M = 46.16 ± 13.42 years; 75.3 % female) with pre-existing, new-onset, or no insomnia symptoms was examined using mixed-effects and logistic regression models.Results New-onset and pre-existing insomnia predicted persistent anxiety and depressive symptoms longitudinally (p's < 0.001), over other known risk factors, including age, sex, and previous psychiatric diagnoses. Anxiety and depressive symptoms in both insomnia groups remained above clinically significant thresholds at most time points, whereas normal sleepers remained subclinical. Pre-sleep arousal was found to increase the risk of clinically significant anxiety (OR = 1.05) and depressive symptoms (OR = 1.09) at 12-months. Sleep effort contributed to anxiety (OR = 1.06), whereas dysfunctional sleep-related beliefs and attitudes predicted clinically significant depression (OR = 1.22).Limitations Insomnia group categorization was based on self-report at baseline supported by a validated measure. High participant attrition was observed at 3-months (53 %; n = 971), but retention remained steady till 12-months (63 %, n = 779).Conclusions Insomnia is a modifiable risk factor for persistent anxiety and depressive symptoms that needs to be addressed in mental healthcare. Additionally, pre-sleep arousal may be an important transdiagnostic process linking insomnia with affective disorders.
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Attrition may have led to higher retention of participants with more chronic, persistent insomnia symptoms rather than those with acute insomnia at baseline who subsequently remitted.
“This may have led to higher retention of participants with more chronic, persistent insomnia symptoms, rather than those who experienced acute insomnia symptoms at baseline who subsequently remitted [32, 69].”
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Badinlou, F., Rahimian, F., Hedman-Lagerlöf, M., Lundgren, T., Abzhandadze, T., & Jansson-Fröjmark, M. (2024) · BMC Public Health · doi:10.1186/s12889-024-17997-x · Cited by 28 · see citing works
Reffi, A. N., Kalmbach, D. A., Cheng, P., & Drake, C. L. (2023) · Journal of Sleep Research · doi:10.1111/jsr.13892 · Cited by 25 · see citing works
Effects of Commonly Prescribed Medications on Sleep: A Review of the Literature
Klugherz, L. J., Mansukhani, M. P., & Kolla, B. P. (2025) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2025.02.005 · Cited by 22 · see citing works
Żełabowski, K., Petrov, W., Wojtysiak, K., Ratka, Z., Biedka, K., Wesołowski, M., Fus, K., Ślebioda, D., Rusinek, M., Sterkowicz, M., et al. (2025) · International Journal of Molecular Sciences · doi:10.3390/ijms26178700 · Cited by 22 · see citing works
Saravanan, K., Downey, L. A., Sawyer, A., Jackson, M. L., Berlowitz, D. J., & Graco, M. (2023) · Journal of Neurotrauma · doi:10.1089/neu.2023.0033 · Cited by 21 · see citing works
Liu, D., Zhou, Y., Tao, X., Cheng, Y., & Tao, R. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2024.1374667 · Cited by 14 · see citing works
Meaklim, H., Rehm, I. C., Junge, M. F., Monfries, M. M., Kennedy, G. A., Bucks, R. S., Meltzer, L. J., & Jackson, M. L. (2023) · Behavioral Sleep Medicine · doi:10.1080/15402002.2022.2164766 · Cited by 12 · see citing works
Gizdic, A., Baxter, T., Barrantes-Vidal, N., & Park, S. (2023) · Psychiatry Research Communications · doi:10.1016/j.psycom.2023.100126 · Cited by 13 · see citing works
Anxiety, insomnia and family support in nurses, two years after the onset of the pandemic crisis
Sikaras, C., Tsironi, M., Zyga, S., & Παναγιώτου, Α. (2023) · AIMS Public Health · doi:10.3934/publichealth.2023019 · Cited by 11 · see citing works
Garcia, M. A., & Cooper, T. V. (2024) · Psychiatric Quarterly · doi:10.1007/s11126-024-10085-8 · Cited by 12 · see citing works
Liu, Y., Yu, Y., Lu, S., Tan, K., Jiang, P., Liu, P., & Peng, Q. (2025) · Frontiers in Microbiology · doi:10.3389/fmicb.2025.1596990 · Cited by 11 · see citing works
Kałuża, J., Łożyńska, K., Rudzińska, J., Granda, D., Sicinska, E., & Szmidt, M. K. (2023) · Nutrients · doi:10.3390/nu15030725 · Cited by 11 · see citing works
The Human Superorganism: Using Microbes for Freedom vs. Fear
Dietert, R. R., & Dietert, J. M. (2023) · Applied Microbiology · doi:10.3390/applmicrobiol3030061 · Cited by 11 · see citing works
Meaklim, H., Le, F., Drummond, S. P. A., Bains, S. K., Varma, P., Junge, M. F., & Jackson, M. L. (2024) · Sleep · doi:10.1093/sleep/zsae028 · Cited by 10 · see citing works
“This may have led to higher retention of participants with more chronic, persistent insomnia symptoms, rather than those who experienced acute insomnia symptoms at baseline who subsequently remitted [32, 69].”
BackgroundSleep effort and its measurement: A scoping review
Marques, D. R., Pires, L., Broomfield, N. M., & Espie, C. A. (2024) · Journal of Sleep Research · doi:10.1111/jsr.14206 · Cited by 9 · see citing works
Rogowska, A. M., & Lechowicz, O. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm14134652 · Cited by 10 · see citing works
Zagaria, A., & Ballesio, A. (2024) · Sleep Medicine · doi:10.1016/j.sleep.2024.09.020 · Cited by 9 · see citing works
Cheung, D. S. T., Yu, B. Y.-M., Lam, S. C., Leung, D. Y. P., Chung, K.-F., Ho, F. Y.-Y., Chen, S.-C., & Yeung, W.-F. (2024) · Sleep and Biological Rhythms · doi:10.1007/s41105-023-00486-w · Cited by 6 · see citing works
Hua, H., Yang, K., Wei, Z., Hu, W., Jin, S., & Wang, J. (2025) · BMC Public Health · doi:10.1186/s12889-025-23241-x · Cited by 6 · see citing works
Chu, Z., Xie, J., Liu, R., Ou, L., Zheng, L., Liang, J., & Xie, G. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1580013 · Cited by 9 · see citing works
Guerrera, C. S., Boccaccio, F. M., D’Antoni, R. A., Riggio, F., Varrasi, S., Platania, G. A., Torre, V., Pesimena, G., Gangemi, A., Pirrone, C., et al. (2025) · Psychiatry International · doi:10.3390/psychiatryint6030085 · Cited by 4 · see citing works
Wilhelmsen‐Langeland, A., Børtveit, T., Jürgensen, M., Søfteland, E. W., Hystad, S. W., & Kvale, G. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-05786-0 · Cited by 4 · see citing works
Reffi, A. N., & Cheng, P. (2023) · SLEEP · doi:10.1093/sleep/zsad064 · Cited by 4 · see citing works
Reffi, A. N., Jankowiak, L., Iqal, J., Jovanović, T., & Drake, C. L. (2024) · Current Sleep Medicine Reports · doi:10.1007/s40675-024-00279-8 · Cited by 4 · see citing works
Latt, P. M., Soe, N. N., Xu, X., Bao, Y., Lee, D. M., Ong, J. J., Chow, E. P. F., Zhang, L., & Fairley, C. K. (2025) · BMC Public Health · doi:10.1186/s12889-025-25064-2 · Cited by 3 · see citing works
Sleep characteristics and risk factors in patients of insomnia comorbid with anxiety
Wang, C., Lin, S., Xu, W., Bing, X.-H., Fang, C., Wan, Y., Jiang, S., Zhao, N., & Xie, C. (2026) · BMC Psychology · doi:10.1186/s40359-026-04009-3 · Cited by 3 · see citing works
Hein, M., Wacquier, B., Conenna, M., Lanquart, J., & Point, C. (2024) · Clocks & Sleep · doi:10.3390/clockssleep6030026 · Cited by 3 · see citing works
Si, J., Zhang, Y., Li, M., & Liu, T. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1554239 · Cited by 2 · see citing works
Doğru, M. C., & Türk-Kurtça, T. (2025) · Psychiatric quarterly · doi:10.1007/s11126-025-10235-6 · Cited by 2 · see citing works
Tao, R., Li, W., Min, K., Mo, D., Geng, F., Xia, L., Liu, T., Liu, Y., Jiang, F., Liu, H., et al. (2024) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1342528 · Cited by 2 · see citing works
Lee, G., Park, D., Ryu, S., Ha, J. H., & Jeon, H. J. (2023) · Chronobiology in Medicine · doi:10.33069/cim.2023.0007 · Cited by 1 · see citing works
Garcia, M. A., Vernon, A. R., Pérez-Martinez, R. F., Romero, E. J., Aguirre, A. P., Cooper, T. V., & Volpert‐Esmond, H. I. (2026) · Sleep Health · doi:10.1016/j.sleh.2026.05.009 · Cited by 1 · see citing works
Insomnia and Snoring in Relation to Future Psychological Distress and Daytime Symptoms in Women
Frustaci, G., Lindberg, E., & Theorell‐Haglöw, J. (2026) · Journal of Sleep Research · doi:10.1111/jsr.70407 · Cited by 1 · see citing works
Amri, A. A., Alshahrani, M. A. A., Asiri, M. A., Abdulrahman, M. A., Alshehri, A. Y. A., Alqahtani, M. M. M., Oraydan, A. A. A., Summan, S. I., Alqahtani, T. S., & Hunaif, A. M. A. (2023) · Cureus · doi:10.7759/cureus.44749
Luân, P. T., Anh, N. H., Giang, N. T., Diệp, N. B., & Giang, L. M. (2024) · Tạp chí Nghiên cứu Y học · doi:10.52852/tcncyh.v170i9.1888
The COVID-19 pandemic, mental health, and sleep: Linking depression, anxiety, and perceived stress
Bücker, J., Rosa, A. R., & Czepielewski, L. S. (2024) · Elsevier eBooks · doi:10.1016/b978-0-323-95650-5.00011-2
Nursing intervention in older adults with insomnia
Eugenio, E. R. M., & López, V. I. E. (2024) · Salud Ciencia y Tecnología · doi:10.56294/saludcyt2024.1343
Maruta, N., Fedchenko, V. Y., Панько, Т. В., Yavdak, I. O., & Semikina, O. (2024) · Здобутки клінічної і експериментальної медицини · doi:10.11603/1811-2471.2024.v.i3.14902
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Melatonin Use as a Dietary Supplement: A Narrative Review of Efficacy and Risks
Park, H. J. (2025) · Food Supplements and Biomaterials for Health · doi:10.52361/fsbh.2025.5.e1
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Dyssomnia in the structure of post-covid syndrome
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Stress and Affective Dysregulation in Depression and Insomnia
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- Authors
- Meaklim, H., Saunders, W. J., Byrne, M. L., Junge, M. F., Varma, P., Finck, W. A., & Jackson, M. L.
- Affiliations
- Monash University (AU)
- University of Oregon (US)
- Corresponding author
- Jackson, Melinda L.
- ORCID
- Venue
- Journal of Affective Disorders
- Publisher
- Elsevier BV
- Published
- 2023-02
- Volume
- 322
- Pages
- 52-62
- ISSN
- 0165-0327 (ISSN-L)
- OpenAlex
- W4308956573
- Cited by
- 55
- References
- 97
- Citations by year
- 2026: 12 · 2025: 15 · 2024: 17 · 2023: 11
- FWCI
- 9.90
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- Locations
- Journal of Affective Disorders (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Monash University
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Clinical Psychology › COVID-19 and Mental Health
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- insomnia, anxiety symptoms, depressive symptoms, COVID-19 pandemic, pre-sleep arousal, sleep effort, transdiagnostic mechanisms, mood disorders
- MeSH terms
- COVID-19, Anxiety, Depression, Female, Humans, Sleep Initiation and Maintenance Disorders, Longitudinal Studies, Male, Risk Factors, Cohort Studies, Pandemics
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