Overview of sleep management during COVID-19.

May combine two claims.

Pollack et al. found no high-quality studies and only six moderate-quality studies since 2002 on interventions for frontline worker resilience and mental health.

“Pollack et al. identified no studies of high quality and only six of moderate quality since 2002.”

• cites [44] Pollock, 2020, Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review, Cochrane Database Syst Rev sourceDisputed

  The Certainty/confidence in the evidence section says there were no high-confidence findings and six moderate-confidence findings—not six moderate-quality studies. The Objective 2 qualitative evidence synthesis section also rates four studies as having no or few methodological limitations, contrary to the claim that no studies were of high quality. No page numbers were provided in our copy. (LLM, conf=0.87)

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured

May combine two claims.

For specific management of COVID-19 sleep dysfunction, five CBT studies were available: two controlled insomnia trials, one worry/secondary insomnia study, one case study, and one small online child study.

“As to specific management of sleep dysfunction during COVID-19, five studies of cognitive behavioral therapy (CBT) were available – two controlled trials of insomnia [11,12], one focused on worry and secondary insomnia [13], one case study [14] and a small online study in children [15].”

• cites [11] Philip, 2020, Smartphone-based virtual agents to help individuals with sleep concerns during COVID-19 confinement: feasibility study, J Med Internet Res sourceDisputed

  The citation is attached to the claim that this paper is one of two controlled CBT trials for insomnia. The Introduction calls it a proof-of-concept study, while Methods > Statistical Analyses and Results > Evolution of ISI Score compare app users’ measurements over time, not intervention and control arms. The paper describes digital behavioral advice, but does not identify this study as a controlled CBT trial; our copy provides no page numbers. (LLM, conf=0.88)

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured
• cites [12] Cheng, 2020, Digital cognitive behavioral therapy for insomnia promotes later health resilience during the coronavirus disease 19 (COVID-19) pandemic, Sleep sourceSupported
• cites [13] Wahlund, 2020, Brief online cognitive behavioural intervention for dysfunctional worry related to the COVID-19 pandemic: a randomised controlled trial, Psychother Psychosom sourceSupported
• cites [14] Álvarez-García, 2020, Effectiveness of a brief behavioral intervention for insomnia (BBII) during the COVID-19 pandemic: Mexican case report, Sleep Sci sourceSupported

• AssumptionRests on an assumption: The 53 publications included in the overview are sufficiently representative of the available literature on COVID-related sleep disturbance to support the overview's conclusions.

Probably not a substantial claim: may not pass S3 (load-bearing).

PAP therapy is considered first-line for the hypersomnic OSA patient.

“PAP therapy is considered first-line for the hypersomnic OSA patient [55].”

• cites [55] Patil, 2019, Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of sleep medicine clinical practice guideline, J Clin Sleep Med sourceSupported

• AssumptionRests on an assumption: Established pre-pandemic treatment guidelines for common sleep disorders remain applicable and adaptable for managing sleep problems during the COVID-19 pandemic.

Probably not a substantial claim: may not pass S3 (load-bearing).

During the pandemic, nearly one in four adults had significant acute and traumatic stress and were considered candidates for intervention.

“During the pandemic nearly one-in-four adults had significant acute and traumatic stress and were considered candidates for intervention [25].”

• cites [25] Cooke, 2020, Prevalence of posttraumatic and general psychological stress during COVID-19: a rapid review and meta-analysis, Psychiatr Res sourceSupported

May combine two claims.

In the KANOPEE digital app study of 2069 French adults, 76% completed online screening, 27% rated the app highly, 22% of those with clinical insomnia completed a one-week sleep diary, and 2.3% completed the 10-day intervention.

“Approximately 76% completed the online screening interview, but only 27% (431/1574) of respondents rated the app highly. Of 773 screened users who reported clinical insomnia (Insomnia Severity Index score >14), only 22% completed a one-week sleep diary, then only 2.3% (47/2069) completed the 10-day therapeutic intervention”

• cites [11] Philip, 2020, Smartphone-based virtual agents to help individuals with sleep concerns during COVID-19 confinement: feasibility study, J Med Internet Res sourcePartly supported

  The Results (Characteristics of App Users) report 2069 adult users, 1574 (76%) completing screening, and 773 scoring above the clinical insomnia threshold. The Discussion (Principal Findings) reports that 21.5% of those with significant sleep complaints completed the sleep diary, and the Results (Evolution of ISI Score) report 47 completing Step 2—about 2.3% of all 2069 users. But the Results (Trust and Acceptance of Virtual Agents) say 431/1574 (27.4%) answered acceptance questionnaires, not that only 27% rated the app highly; among those who answered, 61.7% were very satisfied with usability. (LLM, conf=0.90)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

Professional sleep medicine organizations using the GRADE protocol recommend CBT-i as first-line treatment for insomnia disorder.

“Based on study by professional sleep medicine organizations using the GRADE protocol [27,28], cognitive behavioral therapy of insomnia (CBT-i) is recommended as first-line treatment of insomnia disorder”

• cites [27] Edinger, 2021, Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline, J Clin Sleep Med sourceSupported
• cites [28] Riemann, 2017, European guideline for the diagnosis and treatment of insomnia, J Sleep Res sourceNot checked — no full text of the source

• AssumptionRests on an assumption: Established pre-pandemic treatment guidelines for common sleep disorders remain applicable and adaptable for managing sleep problems during the COVID-19 pandemic.

May combine two claims.

In a randomized trial by Cheng and colleagues, the digital CBT-i group had significantly fewer insomnia symptoms, stress, cognitive intrusions, and depression than the education-only control during the pandemic.

“The digital CBT-i group had significantly less insomnia symptoms, stress, cognitive intrusions and depression [12].”

• cites [12] Cheng, 2020, Digital cognitive behavioral therapy for insomnia promotes later health resilience during the coronavirus disease 19 (COVID-19) pandemic, Sleep sourcePartly supported

  The Results sections on insomnia, stress, and health during COVID-19 report significantly lower insomnia symptoms, COVID-related cognitive intrusions, and depressive symptoms in the prior dCBT-I group than in the sleep-education control. COVID-specific stress was also significantly lower, but general stress showed only a trend (p = 0.055), so the claim overstates the significance of the general-stress finding. (LLM, conf=0.90)

  Experimental — accuracy not yet measured

May combine two claims.

Disordered sleep is not expected to resolve once infection is controlled, so interventions are urgently needed.

“Disordered sleep is not expected to disappear with control of infection, making interventions acutely necessary.”

• Also stated in: § Introduction · plain

  “particularly since disordered sleep does not return to base rates even after control of infection [44].”

• cites [44] Pollock, 2020, Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review, Cochrane Database Syst Rev sourceCould not verify

  The Background discusses possible long-term mental health problems, and Implications for research calls for research on long-term intervention outcomes. Neither passage says that disordered sleep persists after infection is controlled or that this makes sleep interventions urgently necessary. Searches for sleep persistence and infection control found only references to sleep-related works; the available copy is truncated. (LLM, conf=0.72)

  Experimental — accuracy not yet measured

May combine two claims.

In a survey of 994 medical and nursing staff in Wuhan, 36% used mental health books, 50.4% used online coping methods, and 17.5% had participated in counseling or psychotherapy.

“To manage distress, 36% accessed books on mental health, 50.4% sought online coping methods, and 17.5% had participated in counseling or psychotherapy.”

• cites [42] Kang L, Ma S, Chen M et al. Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional study. Brain Behav Immun. ;87:11-17. doi: 10.1016/j.bbi.2020.03.028. July; Epub 2020 Mar 30. sourcePartly supported

  The Results (‘Accessed mental healthcare services’; page not provided) report 36.3% receiving psychological materials, 50.4% obtaining resources through media, and 17.5% participating in counseling or psychotherapy. The Methods (‘Questionnaire’; page not provided) define those materials as leaflets, brochures or books, and media as online platforms or TV news. The claim correctly conveys the percentages approximately, but the source does not establish that all 36% accessed books or that all 50.4% used online methods. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A Chinese online survey of nearly 57,000 responders reported pandemic-related symptoms: 29.2% insomnia, 27.9% depression, 31.6% anxiety, and 24.4% acute stress.

“A Chinese study of nearly 57,000 responders to an online survey reported emergent sleep and mental health symptoms from pandemic restrictions: 29.2% for insomnia, 27.9% for depression, 31.6% for anxiety, and 24.4% for acute stress [5].”

• cites [5] Shi, 2020, Prevalence of and risk factors associated with mental health symptoms among the general population in China during the coronavirus disease 2019 pandemic, JAMA Netw Open sourcePartly supported

  The Results report the four stated percentages, and the Strengths and Limitations section describes the nearly 57,000-person study as an online survey. But the paper does not establish that these symptoms newly emerged because of pandemic restrictions: it reports associations with quarantine and cautions that its cross-sectional design cannot establish causation. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

May combine two claims.

A Swedish randomized study of 670 subjects found that a 3-week digital CBT intervention significantly reduced dysfunctional worry and improved insomnia, mood, daily functioning, and uncertainty compared with a waiting list.

“The 3-week digital intervention significantly reduced dysfunctional worry while improving symptoms of insomnia, mood, daily functioning, and uncertainty [13].”

• cites [13] Wahlund, 2020, Brief online cognitive behavioural intervention for dysfunctional worry related to the COVID-19 pandemic: a randomised controlled trial, Psychother Psychosom sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Insomnia complaints during COVID-19 are two to three times higher than in prior years.

“Insomnia complaints are two to three times higher during COVID-19 compared to prior years [4].”

• cites [4] Cénat, 2021, Prevalence of symptoms of depression, anxiety, insomnia, posttraumatic stress disorder, and psychological distress among populations affected by the COVID-19 pandemic: a systematic review and meta-analysis, Psychiatr Res sourcePartly supported

  The Discussion (page not provided) reports significantly higher insomnia prevalence in populations affected by COVID-19 than in the general population under normal circumstances. It does not quantify the increase as two to three times higher. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Medications have a secondary role in chronic insomnia unless CBT-i has failed, is unavailable, or insomnia occurs with major depression or other psychiatric disorders.

“Medications have a secondary role in therapy of chronic insomnia unless CBTi has failed, is unavailable, or insomnia is concomitant with major depression or other psychiatric disorders [28,57].”

• cites [28] Riemann, 2017, European guideline for the diagnosis and treatment of insomnia, J Sleep Res sourceNot checked — no full text of the source
• cites [57] Sateia, 2017, Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of sleep medicine clinical practice guideline, J Clin Sleep Med sourcePartly supported

  The Aims section says CBT-I should be the primary intervention and medications should be considered mainly when patients cannot participate in CBT-I or remain symptomatic after it. It does not identify major depression or other psychiatric disorders as a general exception; the Clinical Guidelines and Practice Parameters section mentions mood disorders only in discussing the choice of certain drugs. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

• AssumptionRests on an assumption: Established pre-pandemic treatment guidelines for common sleep disorders remain applicable and adaptable for managing sleep problems during the COVID-19 pandemic.

May combine two claims.

Frontline health workers have higher rates of insomnia and posttraumatic stress.

“Frontline health workers have higher rates of insomnia and posttraumatic stress [40]”

• cites [40] da Silva, 2021, Psychological effects caused by the COVID-19 pandemic in health professionals: a systematic review with meta-analysis, Prog Neuro-Psychopharmacol Biol Psychiatr sourcePartly supported

  The Results (page unavailable) report higher insomnia prevalence among medical health workers than non-medical health workers, and the Introduction says frontline professionals are more susceptible to psychological suffering than those not directly treating patients. The Discussion (page unavailable) mentions posttraumatic stress among health professionals, but does not establish a higher rate of it among frontline workers. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

Insomnia disorder should initially be managed with cognitive behavioral therapy according to the American Academy of Sleep Medicine and the European Sleep Research Society.

“It should initially be managed with cognitive behavioral therapy according to the American Academy of Sleep Medicine and the European Sleep Research Society [27,28].”

• cites [27] Edinger, 2021, Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline, J Clin Sleep Med sourceSupported
• cites [28] Riemann, 2017, European guideline for the diagnosis and treatment of insomnia, J Sleep Res sourceNot checked — no full text of the source

• AssumptionRests on an assumption: Established pre-pandemic treatment guidelines for common sleep disorders remain applicable and adaptable for managing sleep problems during the COVID-19 pandemic.

May combine two claims.

Fluvoxamine stimulates the sigma-1 receptor to reduce inflammatory response and nearly triples nocturnal plasma melatonin levels.

“Fluvoxamine stimulates the sigma-1 receptor to reduce inflammatory response, but it also nearly triples nocturnal plasma levels of melatonin [53].”

• cites [53] Anderson, 2021, Fluvoxamine, melatonin and COVID-19, Psychopharmacology sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Patients infected with COVID-19 experience very high rates of neuropsychiatric symptoms.

“Patients infected with COVID-19 experience very high rates of neuropsychiatric symptoms.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The PubMed literature search returned 352 citations as of February 2021.

“Three hundred and fifty-two citations were returned as of February 2021.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Depression and anxiety are common complaints during pandemic restrictions.

“Depression and anxiety are prominent complaints during pandemic restrictions.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Four similar treatment trials had begun or been proposed.

“Four similar treatment trials have begun or been proposed (see Table 1 ).”

• AssumptionRests on an assumption: The 53 publications included in the overview are sufficiently representative of the available literature on COVID-related sleep disturbance to support the overview's conclusions.

May combine two claims.

Somryst underwent two randomized controlled trials and received FDA approval for treating insomnia disorder.

“Somryst having undergone two randomized controlled trials that resulted in FDA approval for treatment of insomnia disorder [30].”

• cites [30] Morin, 2020, Profile of Somryst prescription digital therapeutic for chronic insomnia: overview of safety and efficacy, Expet Rev Med Dev sourceNot checked — no full text of the source

May combine two claims.

The populations affected by pandemic-related sleep problems include the general public and health care workers.

“Affected populations include the public and health care workers.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Before COVID-19, moderate to severe insomnia affected 10-20% of the U.S. population.

“Even before COVID-19, moderate to severe insomnia was prevalent at 10–20% of the U.S. population [1].”

• cites [1] Buysse, 2013, Insomnia, JAMA. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The overview includes 53 articles, many of which referenced treatment only through general recommendations or expert opinion.

“Fifty-three articles are included in the overview although the articles often referenced treatment with general recommendations or expert opinion.”

• AssumptionRests on an assumption: The 53 publications included in the overview are sufficiently representative of the available literature on COVID-related sleep disturbance to support the overview's conclusions.

May combine two claims.

Exogenous melatonin up to 10 mg and ramelteon 8 mg modestly improved sleep in ICU patients and were associated with larger decreases in delirium prevalence and ICU length of stay.

“Exogenous administration of melatonin up to 10 mg and ramelteon 8 mg have modestly improved the sleep of ICU patients with more significant decreases in the prevalence of delirium and ICU length of stay [47].”

• cites [47] Zhang, 2019, Prophylactic use of exogenous melatonin and melatonin receptor agonists to improve sleep and delirium in the intensive care units: a systematic review and meta-analysis of randomized controlled trials, Sleep Breath sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

Nearly every article referenced in the overview calls for research to better understand pandemic-related sleep disorders and their effective treatment.

“In summary, nearly every article referenced in this overview calls for research to allow a fuller understanding of current and future characteristics of pandemic-related sleep disorders and their effective treatment.”

• AssumptionRests on an assumption: The 53 publications included in the overview are sufficiently representative of the available literature on COVID-related sleep disturbance to support the overview's conclusions.

Probably not a substantial claim: may not pass S2 (checkable).

Management and interventions must occur before chronicity, substance abuse, and suicide increase.

“Management and interventions must occur before chronicity, substance abuse and suicide increase [10]”

• cites [10] Sher, 2020, The impact of the COVID-19 pandemic on suicide rates, QJM sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

Management of disturbed sleep and mental health is especially needed for frontline health care workers.

“Management of disturbed sleep and mental health is particularly needed in frontline health care workers.”

Probably not a substantial claim: may not pass S4 (based).

A society with widespread sleep deprivation faces greater burdens from COVID-related economic disruption, psychosocial problems, substance abuse, and suicide.

“A sleep deprived society faces the increased burden of COVID-related economic disruption, psychosocial problems, substance abuse, and suicide.”

Probably not a substantial claim: may not pass S2 (checkable).

Government programs, global health care systems, and primary and specialty providers will face an ongoing need for effective therapies for disturbed sleep and sleep disorders.

“Government programs, global health care systems, and primary/specialty providers will face an ongoing need for effective therapies of disturbed sleep and sleep disorders.”