The role of the COVID-19 pandemic and economic crisis in insomnia and post-traumatic stress symptoms in the Lebanese population: A cross-sectional assessment

Based on an online cross-sectional survey, this study aimed to evaluate the role of the coronavirus disease 2019 (COVID-19) pandemic and economy-related factors in post-traumatic stress symptoms (PTSSs) and sleep in a sample of the general Lebanese population using the post-traumatic stress disorder checklist. The online survey was conducted between May 10, and May 20, 2020, and 502 Lebanese adults who have access to the internet were enrolled. Results highlighted that positive correlates of PTSS were fear of COVID-19, female gender, and waterpipe smoking; negative correlates were higher family satisfaction, higher financial wellness, older age, having access to healthcare, and never having to work. When including insomnia as an independent variable to explain PTSS, the model did not substantially change. Positive correlates of insomnia included fear of poverty, fear of COVID-19, violence at home, the number of dependent children, having a job, and having a chronic disease. Conversely, higher family satisfaction and financial wellness were associated with lower likelihood of insomnia. When entering PTSS, insomnia remained positively associated with fear of poverty, PTSS, and violence at home. However, fear of COVID-19 was no longer associated with insomnia. We concluded that both the fear of COVID-19 and the economic crisis are correlated with PTSS and insomnia.
Abou Hassan, F.F., Bou Hamdan, M., Ali, F., & Melhem, N.M. (2023). Response to COVID-19 in Lebanon: Update, challenges and lessons learned. Epidemiology and Infection, 151: e23. https://doi.org/10.1017/S0950268823000067
Ahorsu, D.K., Lin, C.Y., Imani, V., Saffari, M., Griffiths, M.D., & Pakpour, A.H. (2022). The fear of COVID-19 scale: Development and initial validation. International Journal of Mental Health and Addiction, 20(3), 1537–1545. https://doi.org/10.1007/s11469-020-00270-8
Al Karaki, G., Hallit, S., Malaeb, D., Kheir, N., Sacre, H., Salameh, P., & Hallit, R. (2020). Prevalence and factors associated with insomnia among a representative sample of the lebanese population: Results of a cross-sectional study. Journal of Epidemiology and Global Health, 10(2): 124-130.https://doi.org/10.2991/jegh.k.200117.001
American Psychiatric Association (APA). (2015). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Available from: https://www.psychiatry.org/psychiatrists/practice/dsm [Last accessed on 2020 Aug 04].
Arezki, R., Mottaghi, L., Barone, A., Fan, R.Y., Harb, A.A., Karasapan, O.M., Matsunaga, H., Nguyen, H., & de Soyres, F. (2018). A New Economy in Middle East and North Africa. Middle East and North Africa Economic Monitor. Available from: http://documents1.worldbank.org/curated/en/331081537883965003/pdf/130143-WP-REVISED-PUBLIC.pdf [Last accessed on 2020 May 22].
Armocida, B., Formenti, B., Palestra, F., Ussai, S., & Missoni, E. (2020). COVID-19: Universal health coverage now more than ever. Journal of Global Health, 10(1): 010350. https://doi.org/10.7189/jogh.10.010350
Bizri, A.R., Khachfe, H.H., Fares, M.Y., & Musharrafieh, U. (2021). COVID-19 pandemic: An insult over injury for Lebanon. Journal of Community Health, 46(3): 487-493. https://doi.org/10.1007/s10900-020-00884-y
Brooks, S.K., Webster, R.K., Smith, L.E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G.J. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet, 395(10227): 912-920. https://doi.org/10.1016/S0140-6736(20)30460-8
Casagrande, M., Favieri, F., Tambelli, R., & Forte, G. (2020). The enemy who sealed the world: Effects quarantine due to the COVID-19 on sleep quality, anxiety, and psychological distress in the Italian population. Sleep Medicine, 75: 12-20. https://doi.org/10.1016/j.sleep.2020.05.011
El Khoury-Malhame, M., Rizk, R., Joukayem, E., Rechdan, A., & Sawma, T. (2023). The psychological impact of COVID-19 in a socio-politically unstable environment: Protective effects of sleep and gratitude in Lebanese adults. BMC Psychology, 11(1): 14. https://doi.org/10.1186/s40359-023-01042-4
Fares, J., Gebeily, S., Saad, M., Harati, H., Nabha, S., Said, N., Kanso, M., Abdel Rassoul, R., & Fares, Y. (2017). Post-traumatic stress disorder in adult victims of cluster munitions in Lebanon: A 10-year longitudinal study. BMJ Open, 7(8): e017214. https://doi.org/10.1136/bmjopen-2017-017214
Farhood, L.F., Fares, S., Sabbagh, R., & Hamady, C. (2016). PTSD and depression construct: Prevalence and predictors of co-occurrence in a South Lebanese civilian sample. European Journal of Psychotraumatology, 7: 31509. https://doi.org/10.3402/ejpt.v7.31509
Farran, N. (2021). Mental health in Lebanon: Tomorrow’s silent epidemic. Mental Health and Prevention, 24: 200218. https://doi.org/10.1016/j.mhp.2021.200218
Felmingham, K., Williams, L.M., Kemp, A.H., Liddell, B., Falconer, E., Peduto, A., & Bryant, R. (2010). Neural responses to masked fear faces: Sex differences and trauma exposure in posttraumatic stress disorder. Journal of Abnormal Psychology, 119(1): 241-247. https://doi.org/10.1037/a0017551
Fleifel, M., & Abi Farraj, K. (2022). The Lebanese healthcare crisis: An infinite calamity. Cureus, 14(5): e25367. https://doi.org/10.7759/cureus.25367
Gallegos, A.M., Trabold, N., Cerulli, C., & Pigeon, W.R. (2019). Sleep and interpersonal violence: A systematic review. Trauma, Violence and Abuse, 22: 359-369. https://doi.org/10.1177/1524838019852633
Good, M.J., Smilkstein, G., Good, B., Shaffer, T., & Arons, T. (1979). The family APGAR index: A study of construct validity. The Journal of Family Practice, 8(3), 577-582.
Hallit, S., Sacre, H., Haddad, C., Malaeb, D., Al Karaki, G., Kheir, N., Hajj, A., Hallit, R., & Salameh, P. (2019). Development of the Lebanese insomnia scale (LIS-18): A new scale to assess insomnia in adult patients. BMC Psychiatry, 19(1): 421. https://doi.org/10.1186/s12888-019-2406-y
Harake, W., & Abou Hamde, N. (2019). Lebanon economic monitor: So when gravity beckons, the poor don’t fall. In: Global Practice for Macroeconomics, Trade and Investment Middle East and North Africa Region. Available from: http://documents.worldbank.org/curated/en/349901579899850508/pdf/ Lebanon-Economic-Monitor-So-When-Gravity-Beckons-the-Poor-Dont-Fall.pdf [Last accessed on 2020 Mar 24].
Hawryluck, L., Gold, W.L., Robinson, S., Pogorski, S., Galea, S., & Styra, R. (2004). SARS control and psychological effects of quarantine, Toronto, Canada. Emerging Infectious Diseases, 10(7): 1206-1212. https://doi.org/10.3201/eid1007.030703
Huang, Y., & Zhao, N. (2020). Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey. Psychiatry Research, 288: 112954. https://doi.org/10.1016/j.psychres.2020.112954
Ibrahim, H., Ertl, V., Catani, C., Ismail, A.A., & Neuner, F. (2018). The validity of Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) as screening instrument with Kurdish and Arab displaced populations living in the Kurdistan region of Iraq. BMC Psychiatry, 18(1): 259. https://doi.org/10.1186/s12888-018-1839-z
Kearns, N.T., Carl, E., Stein, A.T., Vujanovic, A.A., Zvolensky, M.J., Smits, J.A.J., & Powers, M.B. (2018). Posttraumatic stress disorder and cigarette smoking: A systematic review. Depression and Anxiety, 35(11): 1056-1072. https://doi.org/10.1002/da.22828
Kokou-Kpolou, C.K., Megalakaki, O., Laimou, D., & Kousourid, M. (2020). Insomnia during COVID-19 pandemic and lockdown: Prevalence, severity, and associated risk factors in France population. Psychiatry Research, 290: 113128. https://doi.org/10.1016/j.psychres.2020.113128
Koweyes, J., Salloum, T., Haidar, S., Merhi, G., & Tokajian, S. (2021). COVID-19 pandemic in Lebanon: One year later, what have we learnt? mSystems, 6 (2): e00351-21. https://doi.org/10.1128/mSystems.00351-21
Liu, N., Zhang, F., Wei, C., Jia, Y., Shang, Z., Sun, L., Wu, L., Sun, Z., Zhou, Y., Wang, Y., & Liu, W. (2020). Prevalence and predictors of PTSS during COVID-19 outbreak in China hardest-hit areas: Gender differences matter. Psychiatry Research, 287: 112921. https://doi.org/10.1016/j.psychres.2020.112921
Mishra, P., Pandey, C.M., Singh, U., Gupta, A., Sahu, C., & Keshri, A. (2019). Descriptive statistics and normality tests for statistical data. Annals of Cardiac Anaesthesia, 22(1): 67-72. https://doi.org/10.4103/aca.ACA_157_18
Mysliwiec, V., Brock, M.S., Creamer, J.L., O’Reilly, B.M., Germain, A., & Roth, B.J. (2018). Trauma associated sleep disorder: A parasomnia induced by trauma. Sleep Medicine Reviews, 37: 94-104. https://doi.org/10.1016/j.smrv.2017.01.004
Mysliwiec, V., O’Reilly, B., Polchinski, J., Kwon, H.P., Germain, A., & Roth, B.J. (2014). Trauma associated sleep disorder: A proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares, and REM without atonia in trauma survivors. Journal of Clinical Sleep Medicine, 10(10): 1143-1148. https://doi.org/10.5664/jcsm.4120
Prawitz, A., Garman, E.T., Sorhaindo, B., O’Neill, B., Kim, J., & Drentea, P. (2006). Incharge financial distress/financial well-being scale: Development, administration, and score interpretation. Financial Counseling and Planning, 17(1): 34-50. https://doi.org/10.1037/t60365-000
Richards, A., Kanady, J.C., & Neylan, T.C. (2020). Sleep disturbance in PTSD and other anxiety-related disorders: An updated review of clinical features, physiological characteristics, and psychological and neurobiological mechanisms. Neuropsychopharmacology, 45(1): 55-73. https://doi.org/10.1038/s41386-019-0486-5
Rossi, R., Socci, V., Talevi, D., Mensi, S., Niolu, C., Pacitti, F., Di Marco, A., Rossi, A., Siracusano, A., & Di Lorenzo, G. (2020). COVID-19 pandemic and lockdown measures impact on mental health among the general population in Italy. Frontiers in Psychiatry, 11: 790. https://doi.org/10.3389/fpsyt.2020.00790
Sacre, H., Hajj, A., Badro, D.A., Abou Selwan, C., Haddad, C., Aoun, R., & Salameh, P. (2022). The combined outcomes of the COVID-19 pandemic and a collapsing economy on mental well-being: A cross-sectional study. Psychological Reports, 332941221110545. https://doi.org/10.1177/00332941221110545
Salameh, P., Hajj, A., Badro, D.A., Abou Selwan, C., Aoun, R., & Sacre, H. (2020). Mental health outcomes of the COVID-19 pandemic and a collapsing economy: Perspectives from a developing country. Psychiatry Research, 294: 113520. https://doi.org/10.1016/j.psychres.2020.113520
Shaar, K.H. (2013). Post-traumatic stress disorder in adolescents in Lebanon as wars gained in ferocity: A systematic review. Journal of Public Health Research, 2(2): e17. https://doi.org/10.4081/jphr.2013.e17
Sprang, G., & Silman, M. (2013). Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster Medicine and Public Health Preparedness, 7(1): 105-110. https://doi.org/10.1017/dmp.2013.22
Sun, L., Sun, Z., Wu, L., Zhu, Z., Zhang, F., Shang, Z., Jia, Y., Gu, J., Zhou, Y., Wang, Y., Liu, N., & Liu, W. (2021). Prevalence and risk factors of acute posttraumatic stress symptoms during the COVID-19 outbreak. J Affect Disord, 283: 123-129. https://doi.org/10.1016/j.jad.2021.01.050
The United Nations High Commissioner for Refugees (UNHCR). (2023). UNHCR Lebanon at a Glance. Available from: https://www.unhcr.org/lb/at-a-glance [Last accessed on 2020 Mar 24].
The United Nations Office for the Coordination of Humanitarian Affairs (OCHA). (2022). Lebanon. Available from: https://www.acaps.org/country/lebanon/crisis/socioeconomic-crisis [Last accessed on 2020 Mar 24].
Voitsidis, P., Gliatas, I., Bairachtari, V., Papadopoulou, K., Papageorgiou, G., Parlapani, E., Syngelakis, M., Holeva, V., & Diakogiannis, I. (2020). Insomnia during the COVID-19 pandemic in a Greek population. Psychiatry Research, 289: 113076. https://doi.org/10.1016/j.psychres.2020.113076
WHO. (2020). Human Rights and Health. Available from: https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health [Last accessed on 2020 Jun 02].
Wu, D., Yang, T., Hall, D.L., Jiao, G., Huang, L., & Jiao, C. (2021). COVID-19 uncertainty and sleep: The roles of perceived stress and intolerance of uncertainty during the early stage of the COVID-19 outbreak. BMC Psychiatry, 21(1): 306. https://doi.org/10.1186/s12888-021-03310-2
Wu, L., Guo, X., Shang, Z., Sun, Z., Jia, Y., Sun, L., & Liu, W. (2020). China experience from COVID-19: Mental health in mandatory quarantine zones urgently requires intervention. Psychol Trauma, 12(S1): S3-S5. https://doi.org/10.1037/tra0000609
Xu, J., Zheng, Y., Wang, M., Zhao, J., Zhan, Q., Fu, M., Wang, Q., Xiao, J., & Cheng, Y. (2011). Predictors of symptoms of posttraumatic stress in Chinese university students during the 2009 H1N1 influenza pandemic. Medical Science Monitor, 17(7): PH60-PH64. https://doi.org/10.12659/msm.881836
Younes, S., Safwan, J., Rahal, M., Hammoudi, D., Akiki, Z., & Akel, M. (2022). Effect of COVID-19 on mental health among the young population in Lebanon. Encephale, 48(4): 371-382. https://doi.org/10.1016/j.encep.2021.06.007
Zahreddine, N.K., Haddad, S.F., Kerbage, A., & Kanj, S.S. (2022). Challenges of coronavirus disease 2019 (COVID-19) in Lebanon in the midst of the economic collapse. Antimicrobial Stewardship and Healthcare Epidemiology, 2(1): e67. https://doi.org/10.1017/ash.2021.244
Zhang, Y., & Ma, Z.F. (2020). Impact of the COVID-19 pandemic on mental health and quality of life among local residents in Liaoning Province, China: A cross-sectional study. International Journal of Environmental Research and Public Health, 17(7): 2381. https://doi.org/10.3390/ijerph17072381
Zhou, Y.G., Shang, Z.L., Zhang, F., Wu, L.L., Sun, L.N., Jia, Y.P., Yu, H.B., & Liu, W.Z. (2021). PTSD: Past, present and future implications for China. Chinese Journal of Traumatology, 24(4): 187-208. https://doi.org/10.1016/j.cjtee.2021.04.011