Effect of insomnia on anxiety about COVID-19 patients :The mediating role of psychological capital

doi:10.21203/rs.3.rs-4694918/v1

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Effect of insomnia on anxiety about COVID-19 patients :The mediating role of psychological capital

https://doi.org/10.21203/rs.3.rs-4694918/v1

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Introduction: The outbreak of Corona Virus Disease (COVID-19) in 2019 has continued until now, posing a huge threat to the public’s physical and mental health, resulting in different degrees of mental health problems. Previous studies have shown that insomnia is one of the main influences on anxiety. However, due to the specificity of the disease and the situation of centralized treatment of COVID-19 patients in mobile cabin hospitals, insomnia interventions are limited. Therefore, it is necessary to find the complex mediating variables between insomnia and anxiety to provide new ideas for the prevention and intervention of anxiety caused by insomnia in COVID-19 patients.

Methods: The measurement tools were the Athens Insomnia Scale, Psychological Capital Questionna-

ire, and Self-Rating Anxiety Scale. Statistical analysis was performed using SPSS 25.0 software, and a mediator model was established and corrected using Amos software.

Results: More than one in five patients in this study had anxiety, and the total score was significantly higher than the Chinese standard total score. Insomnia was positively correlated with anxiety, but negatively correlated with psychological capital; and psychological capital was negatively correlated with anxiety. Psychological capital can act as a mediating factor in the relationship between insomnia and anxiety. Psychological capital played a mediating role in the relationship between insomnia and anxiety among COVID-19 patients, that is, insomnia not only directly affected anxiety, but also indirectly affected anxiety through the mediating role of psychological capital.

Conclusion: It is recommended that patients and health care professionals increase the psychological capital of COVID-19 patients through various methods to counter the effects of insomnia on anxiety.

Insomnia

Psychological capital

Anxiety

Mediating effect

Since January 31, 2020, the COVID-19 pandemic has been classified by the WHO as a public health emergency of international concern (PHEIC) [1]. As of April 2022, with 510 million confirmed cases and more than 6.23 million deaths worldwide, to contain the rapid spread of the epidemic, the Chinese government activated a public health incident level 1 response and established a mobile cabin hospital to focus on isolating patients with mild and asymptomatic infections. This approach can effectively isolate and control the source of infection and reduce the load on public hospital [2, 3]. Although the rapid spread of the epidemic was quickly contained, the sudden outbreak of the epidemic led to psychological problems such as depression, anxiety, and even suicide, which cannot be ignored [4]. A study showed that COVID-19 led to an increase in the global anxiety rate of 25.6% in 2020 [5, 6]. In the current study, the study sites were multiple mobile cabin hospitals in Shanghai, China, and the study subjects were each newly coronavirus-infected patients in mobile cabin hospitals. Isolate infected population is an important link in the prevention and treatment of infectious diseases. Therefore, this study can provide clinical basis for the treatment and care of the patients in centralized isolation of such infectious diseases in various countries or regions.

Anxiety is a bodily emotion involving restlessness and nervousness experienced in the face of a threat. Studies have found that patient anxiety reduces adherence to treatment and leads to psychological stress responses, aggressive behaviors and even suicidal behaviors [7]. For family members, the incidence of psychological problems increases, and the sense of security decreases, especially for families with relatives who have passed away or are at risk of passing away. Hospitals and society face economic and order problems, and the work pressure and psychological burden on medical staff have increased; therefore, reducing the incidence of anxiety is an important task during the isolation period [8–10]. Epidemiological studies have shown that about 50% of people with anxiety disorders were affected by sleep disorders, especially insomnia, which could be triggered or further exacerbated by insomnia deprivation [11]. Insomnia is a kind of insomnia disorder characterized by frequent difficulty in falling ainsomnia or difficulty in maintaining sleep, resulting in insufficient sleep satisfaction [9]. Insomnia has been previously found to be a common subjective complaint in patients with anxiety, and increases the prevalence of anxiety [11–13].

Insomnia frequently occurs among COVID-19 patients in mobile medical facilities due to the noisy environment, prolonged exposure to light, and high patient volume, all of which have a negative impact on patients' sleep quality. Insomnia leads to dysfunction in the insula and medial prefrontal cortex (MPFC) regions of the brain, resulting in compromised emotional regulation and increased anxiety [14, 15]. Studies have demonstrated that intervening to improve sleep quality in patients with insomnia can directly reduce their anxiety levels [16]. However, due to the unique circumstances of the novel coronavirus disease and the situation of centralized treatment for a large number of COVID-19 patients in mobile cabin hospitals, insomnia is an inevitable issue for these patients, and there are limitations when it comes to providing intervention for their insomnia. Therefore, identifying the mediating variable between insomnia and anxiety is of paramount importance in reducing patients' anxiety levels by intervening with the mediating variable to counteract the impact of insomnia on anxiety.

Psychological capital is the positive core psychological ability of an organism to face challenging dilemmas, which is a protective resource and can be a good buffer in the face of threats [17, 18], and includes four dimensions: hope, self-efficacy, resilience, optimism [19]. Hope enables setting goals and improving self-confidence; self-efficacy is the belief in the ability to control behaviors and thoughts; resilience is the ability to be psychologically resilient and recover in the face of adversity; and optimism is the ability to face adversity in a positive state. The adjusted invasion hypothesis offers a compelling theoretical foundation for investigating the link between insomnia and anxiety via the role of psychological capital [20].According to this theory, initial externalizing problems such as insomnia can impact future susceptibility to internalizing symptoms like psychological capital, which in turn exacerbate anxiety issues[20]. Research indicates that insomnia may lead to a reduction in an individual's psychological capital [21], while the potential of psychological capital to alleviate anxiety levels has been established [22, 23]. During challenging events or in a new environment, individuals with a high psychological capital have the confidence to adapt; they can set reasonable goals and make positive plans, have expectations, have strong motivation, and be hopeful of achieving the goals; they are optimistic, attributing their failures to unstable external factors and their successes to internal factors; and they are not willing to give up easily even when they encounter setbacks and failures and can persist to the end [19]. The positive role of Psychological capital in different occupations has been explored [24]. Therefore, we hypothesized that psychological capital would mediate the relationship between insomnia and anxiety.

This study intends to explore the effects of insomnia on anxiety in COVID-19 patients and the role of psychological capital in mediating insomnia and anxiety to find new ideas for interventions to combat the effects of insomnia on anxiety in COVID-19 patients.

2.1 Participants

This study employed a cross-sectional descriptive correlational survey.The study population comprised patients with a confirmed diagnosis of COVID-19 in a mobile cabin hospital from April 20-May 6, 2022; the patients were informed of the purpose of the study and provided anonymous responses after informed consent was obtained. Inclusion criteria were those between 18 and 65 years who were 1) able to understand and complete the questionnaire independently; 2) voluntarily and with informed consent; 3) no mental disorder. Exclusion criteria: 1) patients with organic brain lesions; 2) patients who did not have basic reading and comprehension skills. The questionnaire was filled out anonymously.

2.2 Procedure

The questionnaire was sent and received via cell phone using the internet platform "Questionnaire Star". The researcher was familiar with the content of the questionnaire before conducting the survey, and the purpose and content of the questionnaire were explained to the participants to ensure the authenticity of the questionnaire. After obtaining the informed consent of the patients, the questionnaire was completed anonymously, and the patients were informed that they could with draw from the study at any time. A WeChat group was established to answer their questions. A total of 690 questionnaires were collected, and 30 copies with invalid data were removed, resulting in 660 valid questionnaires (4 copies were completed in less than 300 seconds, 1 copy was obviously completed incorrectly, 10 copies had high homogeneity, and 15 copies were completed by individuals outside the age range).

2.3 Assessment Questionnaire

General information questionnaire

The questionnaire collected basic demographic information, including sex, education level, age, place of residence, percapita monthly household income, marital status, and the presence of chronic diseases.

Athens Insomnia Scale

Developed by Hamiltony in 1959, the Athens Insomnia Scale is an internationally recognized self-rating scale of insomnia quality. This questionnaire includes 8 items scored on a four-point scale from 0 (no effect) − 3 (severe effect), with a total score < 4 points indicating no insomnia disorder,a score of 4–6 indicating suspected insomnia, and a score > 6 indicating insomnia. The study showed that this scale has good reliability and validity [25]. The Cronbach's alpha coefficient of the scale was 0.884.The alpha coefficient of the subscale Krenbach is 0.885.

Psychological Capital Questionnaire: Psychological capital was measured using the Psychological Capital Questionnaire developed by Luthans et al. in 2007 [18]. There are four dimensions: self-efficacy, hope, resilience, and optimism. This questionnaire includes 24 itemsscored on a 7-point scale from 1 (very dissatisfied) to 6 (very satisfied). The higher the total score of the subject is, the higher the level of psychological capital.Previous studies have shown that this scale has good reliability and validity [19, 22]. This study used the average score as the criterion for high psychological capital versus low psychological capital. The Cronbach's alpha coefficient of the scale was 0.942. The four subscales of the Psychological Capital Scale ( hope, self-efficacy, resilience, optimism) Cronbach's alphas were 0.876、0.901、0.805、and 0.784.

Self-Rating Anxiety Scale

The participants’ anxiety standard was measured using the Self-Rating Anxiety Scale developed by Zung et al. in 1971, which is widely used to measure anxiety levels. The scale uses a standard score to measure anxiety levels. This questionnaire includes 20 items scored on a 4-point scale from 1 (no or very little time is available) to 6 (most or all of the time) (Standard score = total score * 1.25 and rounded to the nearest whole number). A standard score of 50–59 indicates mild anxiety,60–69 indicates moderate anxiety, and above 70 indicates severe anxiety. Previous studies have shown that the scale has good reliability and validity. The Cronbach's alpha coefficient of the scale was 0.853.

2.4 Common method deviation test

Data collection involved a risk of common method bias, tested by the Harman univariate method, which showed that 8 factors had feature roots greater than 1; among these factors, the first factor explained 24. 322% and less than 40%, indicating that there was no significant common method bias problem in this study.

2.5 Statistical analysis

SPSS 25.0 statistical software and Amos 24.0 were used for statistical analysis. General quantitative data counts are expressed using the mean ± standard deviation and percentages (%). The T test and chi-square test were used to assess the relationship between demographic data and anxiety. Pearson correlation analysis was used for correlations between variables.The mediation model evaluation indicators include χ², χ²/df, NNFI, NFI, CFI, TLI and RMSEA.All tests conducted were two-sided, with a significance level of 0.05.

3.1Participants

Descriptive analysis, independent sample t-test and one-way analysis of variance were used to describe and compare the general demographic data (gender, age, marital status, education, Chronic disease) and the distribution of anxiety scores, as shown in Table 1.The results of one-way ANOVA showed that the educational background (F = 7.588, P < 0.001) of COVID-19 patients had a significant effect on anxiety and chronic diseases (F = 3.100, P < 0.005) on anxiety, as shown in Table 1.

Table 1

The hierarchical multiple regression analysis of COVID-19 patients anxiety(N = 660)
Variable	N (%)	SAS (M ± SD)	t/F	P
Sex Male	403 (61.1%)	44.21 ± 8.92	-1.476	0.140
Female	257 (38.9%)	45.26 ± 8.94
Marital status			1.096	0.350
Single	233 (35.3%)	44.52 ± 9.08
Married	405 (61.4%)	44.84 ± 8.92
Separated	17 (2.6%)	40.88 ± 7.63
Other	5 (0.08%)	43.75 ± 6.37
Age			1.177	0.309
Young	465 (70.5%)	44.34 ± 8.80
Middle-aged	168 (25.5%)	45.03 ± 9.25
Older	27 (4.1%)	46.76 ± 9.30
Educational background			7.588	0.000
Junior high school or below	282 (42.7%)	46.37 ± 9.05
High school or technical secondary school	185 (28.0%)	43.86 ± 8.67
College or undergraduate	176 (26.7%)	42.51 ± 8.47
Master's degree or above	17 (2.6%)	45.51 ± 9.57
Income			1.352	0.256
< 2000	55 (8.3%)	46.43 ± 9.55
2000–5000	161 (24.4%)	44.62 ± 9.17
5000–10000	337 (51.1%)	44.68 ± 8.43
> 10000	107 (16.2%)	43.47 ± 9.74
Chronic disease			3.100	0.002
Yes	80 (12.1%)	47.50 ± 10.66
No	580 (87.9%)	44.22 ± 8.61
Note: The SAS is the sum of the total anxiety scores; M is the mean, and SD is the standard deviation

As shown in Table 2, The results show that insomnia is negatively correlated with psychological capital (r= -0.185, P < 0.01,). Insomnia was positively correlated with anxiety (r = 0.392, P < 0.01); Psychological capital was negatively correlated with anxiety (r= -0.370, P < 0.01).

Table 2

:The correlation between insomnia, psychological capital, and anxiety.
	M ± SD	Insomnia	Psychological capital	Anxiety
Insomnia	6.01 ± 4.62	1
Psychological capital	104.6 ± 17.01	−0.185^**	1
Anxiety	44.62 ± 8.94	0.392^**	−0.370^**	1
Note: ** p < 0.01

Based on previous studies, a model with insomnia as the independent variable, anxiety as the dependent variable and psychological capital as the mediating variable was established to explore the mediating role of psychological capital between insomnia and anxiety. The model construction among the three variables was shown in Fig. 1 (χ²/df = 2.961, RMSEA = 0.055, GFI = 0.963, AGFI = 0.940, RMSEA = 0.055, NNFI = 0.963, IFI = 0.975, CFI = 0.975, P < 0.001), and the results showed a good degree of fit. In order to verify the mediation model, Bootstrap 95% confidence interval verification was adopted, and the results showed that the 95% confidence interval was [0.032,0.418], and its confidence interval did not include 0, which proved that the model was valid.

The positive prediction effect of insomnia on anxiety was significant (β = 0.369, P < 0.01), and the direct positive prediction effect of insomnia on anxiety was still significant when the intermediate variable psychological capital was included (β = 0.369, P < 0.01). The negative prediction effect of insomnia on psychological capital was significant (β= -0.182, P < 0.01). Psychological capital also had a significant negative predictive effect on anxiety (β= -313, P < 0.01). It shows that psychological capital plays an intermediary role in insomnia - psychological capital - anxiety model.

Table 3 shows that the total effect of insomnia on anxiety is 0.426, of which the indirect effect accounts for 13.4% and the direct effect accounts for 86.6%. It can be seen that psychological capital plays an intermediary role between insomnia and anxiety.

Table 3

The path coefficients of the mediation model.
Model path	Estimate	P	Boot SE	Effect ratio
Insomnia→ anxiety	0.369	^***	0.067	86.6%
Insomnia→Psychological capital→ anxiety	0.057	^**	0.029	13.4%
Total effect	0.426	^***	0.073	100%

Note: β, the standardized path coefficient; SE,, the critical ratio.*** p<0.001

This study explored the Associations among insomnia, psychological capital and anxiety, and examined the Psychological capital of the Mediating Role of PsyCap between insomnia and anxiety. Education and chronic disease were risk factors for anxiety; a significant association between insomnia, social support and anxiety. Structural equation models showed that insomnia has a positive effect on anxiety and a negative effect on psychological capital, and that psychological capital has a negative effect on anxiety. We found and validated a hypothetical model that insomnia negatively affects anxiety in COVID-19 patients through psychological capital. The higher the insomnia level of COVID-19 patients, the lower the psychological capital level, and the lower the psychological capital level, which further leads to the increased anxiety level of the patients.

Analysis of demographic data found education and chronic illness as risk factors for anxiety(F = 7.588 P < 0.001), which is consistent with previous studies [26, 27]. Patients with lower education are more likely to have anxiety. Patients with low education are less able to receive, process, integrate, and understand information, which can easily cause panic and anxiety; patients with combined chronic diseases are more prone to anxiety than those without chronic diseases. In China, Qi Houxing et al. showed that the level of anxiety in coronary heart disease was related to serum oxidized low-density lipoprotein ox-LDL, and the serum ox-LDL concentration was significantly higher in patients with severe anxiety disorders [28].

Chronic hyperglycemia in diabetic patients can lead to adverse emotions and affect the neuroendocrine system, which can increase the chances of anxiety and depression [29]. During the intensive isolation of COVID-19 patients with comorbid chronic diseases, chronic disease-related treatments, follow-ups, medical appointments and lifestyle interventions cannot be carried out normally, further aggravating patient anxiety [30]. We as healthcare professionals are reminded that we should pay more attention to patients with low education and chronic diseases, and effectively guide patients in the treatment of chronic diseases to relieve their anxiety.

Research has shown that higher psychological capital can perceive greater social support and positive coping styles as protective factors for anxiety symptoms. In the correction of anxiety caused by insomnia, positive guidance and other psychological interventions could relieve patients’ negative emotions, and improve patients’psychological capital such as self-efficacy and hope in the face of the disease, to avoid the generation of irritability, dissatisfaction, anxiety and other emotions caused by negative suggestions and poor self-evaluation [31]. Studies have shown that psychological capital could regulate the influence of insomnia on anxiety, and this suggests that during the treatment of anxiety caused by insomnia, the level of psychological capital can be improved in order to regulate the bad mood and thus improve the patient's anxiety [32] .

Direct effect of insomnia on anxiety

This study found that insomnia positively predicted anxiety ( β = 0.369, P < 0.001), which verified the direct path of insomnia to anxiety, indicating that the higher the degree of insomnia, the higher the level of anxiety, similar to the results of a meta-analysis of six observational studies by Elisabeth, which showed that insomnia was a major predictor of anxiety attacks (odds ratio 3.2) [20]. For COVID-19 patients, centralized isolation faces a variety of problems such as restricted food, clothing, housing and transportation, disrupted life patterns, crowded and unfamiliar environments, inadequate temporary facilities of all kinds, and uncertainty about the prognosis and treatment of the disease, leading to insomnia. Insomnia and its accompanying symptoms are associated with certain neurotransmitters, such as the neurotransmitter 5-HT, which is involved in the function of the sleep-wake system. 5-HT is secreted by the hypothalamus, which regulates the body’s emotional physiological responses and the functioning of the sleep and wake systems. Serum 5-HT level can reflect the central activity state, and reduced 5-HT secretion will cause insomnia, anxiety and depression [33]. Patients with insomnia and then irritability, multiple cycles cause patient anxiety [34].

Mediating mechanism of psychological capital

This study showed that insomnia negatively predicted psychological capital (β=-0.182, P<0.001) and psychological capital negatively predicted anxiety (β=-0.313, P<0.001). Psychological capital has a mediating effect between insomnia and anxiety (13.4%). In this study, in the relationship between insomnia and anxiety, the influence of insomnia on anxiety becomes smaller after the addition of psychological capital; The hypothesis that psychological capital can be used as a mediating variable is verified. The higher the level of psychological capital, the lower the level of anxiety, which also verifies that psychological capital can be used as a protective factor for anxiety [33]. Studies have shown that psychological capital could regulate the influence of insomnia on anxiety, which indicates that in the treatment process of anxiety caused by insomnia, psychological capital such as psychological resilience can be improved to regulate bad emotions and thus improve the anxiety of patients [32]. Individuals are advised to consciously develop psychological capital to face work and life more positively, optimistically and resolutely, and to cope effectively with various pressures to improve mental health.

This study also has some limitations, firstly, the cross-sectional study design did not confirm the causal relationship between variables, which still needs to be further explored in a longitudinal study. Secondly, the short duration of hospitalization of the investigated subjects did not allow for the implementation of complete interventions, and finding and verifying effective interventions to improve insomnia in patients still needs to be further explored in a large number of studies.

This study used a mediation model to explore the relationship between insomnia and anxiety in Chinese COVID-19 patients. The psychological properties of patients in mobile cabin hospitals cannot be ignored. The results of the present study suggest that a reduction in insomnia is sequentially associated with an increase in psychological capital. Therefore, focusing on improving the psychological capital of patients can help alleviate the anxiety caused by insomnia in COVID-19 patient.

Ethics considerations

This study was in accordance with the ethical standards formulated in the Declaration of Helsinki and approved by hospital’s Institutional Review Board (IRB) [No: TDLL-202209-02] before data collection began.

Consent for publication

Not applicable.

Competing interests

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

All grants for this study are from key science and technology research and development projects in Shaanxi Province, China,Project number:2021SF-017.

Author Contribution

Chun-Ni Heng, Wei Jiang designed the study. Chun-Ni Heng, Juan Du, Ling Li contributed to data collection and analysis. Juan Du, Na Zhang were responsible for clinical quality control. Chun-Ni Heng, Wei Jiang drafted the article. Juan Du, Na Zhang critically reviewed the manuscript and made constructive suggestions. All authors contributed to the study and approved the final submission.

Availability of data and materials

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patient(s) to publish this paper.Data Availability Statement: The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

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Effect of insomnia on anxiety about COVID-19 patients :The mediating role of psychological capital

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Abstract

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1 INTRODUCTION

2 METHODS

2.1 Participants

2.2 Procedure

2.3 Assessment Questionnaire

2.4 Common method deviation test

2.5 Statistical analysis

3 RESUITS

3.1Participants

4 DISUSSION

5 LIMITATIONS

6 CONCLUSIONS

Declarations

Consent for publication

Competing interests

Funding

Author Contribution

Availability of data and materials

References

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