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. Author manuscript; available in PMC: 2021 Oct 20.
Published in final edited form as: Psychol Sex Orientat Gend Divers. 2020 Aug 27;8(2):213–219. doi: 10.1037/sgd0000441

Keeps me awake at night: The potential of the COVID-19 pandemic to affect sleep quality among sexual minority men in the U.S.A.

Brett M Millar 1, Trinae Adebayo 1, Trey V Dellucci 1,2, Evelyn Behar 1,2, Tyrel J Starks 1,2
PMCID: PMC8528152  NIHMSID: NIHMS1627544  PMID: 34676277

Abstract

Sleep health, a crucial component and predictor of physical and mental health, has likely been adversely impacted by the stress and disruption wrought by the COVID-19 pandemic. This brief report sought to assess self-reported sleep quality among sexual minority men across the U.S.A. in the early months of the pandemic. In a cross-sectional online survey of a racially-diverse sample of 477 sexual minority men (mean age of 41.2; range 18–75 years) recruited from popular geo-social networking apps in early May 2020, participants reported on their recent experiences regarding sleep and mental health (anxiety, depression, and pessimistic repetitive future thinking). Almost 75% endorsed some level of restless sleep in the past week, 203 (42.6%) reported worse-than-usual sleep quality since the pandemic, and 77 (16.1%) reported sleeping longer than usual but not feeling better rested. Further, of the 280 reporting worse-than-usual sleep or feeling not rested, almost 85% reported that worry about the pandemic had been contributing to their troubles with falling or staying asleep. Rates of worsened sleep were highest among those whose financial situation had been adversely affected and those not in full-time employment, whereas restless sleep was highest among those in the Northeast region of the U.S.A., which, during the study’s timeframe of late April and early May 2020, was the most severely affected by the pandemic. Greater emotional distress was associated with each sleep variable. Addressing and improving sleep health is critical to overall health and requires particular attention during the COVID-19 pandemic.

Keywords: tiredness, gay, bisexual, queer, corona virus, stress

Introduction

In the early months of the COVID-19 pandemic, various researchers and organizations—such as the American Academy of Sleep Medicine (Kancherla et al., 2020) and the European Cognitive Behavioral Therapy for Insomnia Academy (Altena et al., 2020)—were quick to recognize the potential for worsened sleep as a result of the pandemic and the changes it imposed on daily life, whether by increased insomnia, increased sleep disturbances, or reduced consistency in sleep-wake schedules. In the U.S.A., Jackson and Johnson (2020) highlighted the potential for COVID-19 to further exacerbate existing disparities in sleep health, especially among racial and ethnic minority individuals. Researchers in China noted substantial insomnia rates among health care workers treating COVID-19 patients (Lai et al., 2020), and among individuals self-isolating during periods of lockdown (Xiao, Zhang, Kong, Li, & Yang, 2020). Researchers in Italy also noted substantial changes in sleep patterns during lockdown in late March 2020 (Cellini, Canale, Mioni, & Costa, 2020), including later sleep- and wake-times and, despite more time spent in bed, lower sleep quality, especially among those with higher stress, anxiety, and depression, highlighting the importance of sleep health.

This recent work on the impact of the COVID-19 pandemic on sleep aligns with a wealth of sleep research prior to the pandemic which showed that everyday stress (Hall et al., 2015; Johnson et al., 2016), worry (McGowan, Behar, & Luhmann, 2016), anxiety (see Cox & Olatunji, 2016), and depression (Morphy, Dunn, Lewis, Boardman, & Croft, 2007) can detrimentally affect sleep quality. In addition, having poor sleep can subsequently impair the ability to cope with stress (Williams, Cribbet, Rau, Gunn, & Czajkowski, 2013), threatening stimuli (Goldstein-Piekarski, Greer, Saletin, & Walker, 2015), and uncertainty (Panjwani, Millar, & Revenson, 2020). Indeed, persisting sleep problems often increase the risk of major depressive episodes (Buysse, Angst, Gamma, Ajdacic, Eich, & Rössler, 2008), as well as suicidal ideation and behavior (Pigeon, Pinquart, & Conner, 2012). Further, a small number of studies have looked at sleep health in sexual minority populations, noting sleep disparities relative to heterosexuals (see Butler, McGlinchey, & Juster, 2020; Millar, Goedel, & Duncan, 2019) and links to depression (Duncan et al., 2016).

In addition to the potential for COVID-19-related stress to affect sleep health, changes in daily life—such as staying at home, working or studying from home, or having reduced work hours—are also likely to be influential. Disruption of daily schedules and routines is likely to result in loosened or less-regulated sleep-wake patterns for people whose days have become less time-structured by in-person work, school, or social commitments. The potential for altered sleep schedules is concerning given the importance of maintaining consistency in sleep-wake patterns, as less consistency has been associated with greater psychological strain (Barber, Munz, Bagsby, & Powell, 2010).

Addressing sleep health is critical to mental and physical health in the general population. Furthermore, addressing sleep health is especially important for sexual minority individuals, especially given evidence of existing sleep disparities relative to heterosexuals mentioned above and the impact of various sources of minority stress (Brooks, 1981; Meyer, 1995) on sleep, such as discrimination (Slopen, Lewis, & Williams, 2016) and poor family support (Patterson, Tate, Sumontha, & Xu, 2018). Further, in previous research on sexual minority men, links have been observed between poor sleep and increased alcohol use (Millar, Rendina, Starks, & Parsons, 2018), poorer medication adherence for men living with HIV (Downing, Millar, & Hirshfield, 2019; Tello-Velasquez et al., 2015), and increased sexual risk-taking (Duncan et al., 2016; Millar, Starks, Rendina, & Parsons, 2018). Given the potential for the COVID-19 pandemic to detrimentally affect a number of factors related to sleep health, we asked a sample of sexual minority men from across the U.S.A. to participate in an online survey study to determine whether their self-reported sleep had been affected in the early months of the pandemic. We sought to explore demographic correlates of worsened sleep quality and associations with anxiety, depressive symptoms, and the tendency to engage in pessimistic repetitive future thinking.

Methods

Between May 6th to 17th in 2020, we administered an online Qualtrics-based survey to participants across the U.S.A. who were recruited from mobile phone-based social networking and dating applications. Eligibility criteria included being aged 18 or older, residing in the U.S.A, and being willing to complete the survey in English. For the current analyses, we included participants who provided complete responses and who identified as sexual minority, cisgender men. Participants who clicked on the advertisement in the app (which displayed the text: “COVID-19: How are you coping? Stay connected while social distancing. Tell us how you are doing”) were directed to a landing page containing consent information. Those interested in completing the study indicated consent by clicking a button to proceed with the survey. Participants were not compensated for participating but were entered into a random draw to receive a $50 Amazon gift card. All study protocols were approved by the relevant Institutional Review Board.

Measures

Demographics

Participants reported their age, race and ethnicity, sexual and gender identity, HIV status, education, employment status, and annual income. Participants also indicated whether their financial situation had changed in the past three months.

Anxiety

The Generalized Anxiety Disorder Scale (GAD-7; Spitzer, Kroenke, Williams, & Löwe, 2006) is a 7-item scale assessing frequency of being bothered by anxiety symptoms in the past two weeks. Response options included: 1 (not at all), 2 (several days) 3, (over half the days), and 4 (nearly every day). The GAD-7 has good convergent and discriminant validity, and evidences moderate to excellent sensitivity (.74–.92) and poor to acceptable specificity (.54–.70) in detecting anxiety disorders (Beard & Björgvinsson, 2014; Johnson, Ulvenes, Øktedalen, & Hoffart, 2019). In the current study, the scale exhibited strong internal consistency, α = .93.

Depression

The 10-item version of the Center for Epidemiologic Studies Depression Scale (CESD-10; Andresen, Malmgren, Carter, & Patrick, 1994; Radloff, 1977) assesses frequency of depressive symptoms in the past seven days, with response options including: 0 (not at all; less than 1 day), 1 (some or a little of the time; 1–2 days), 2 (occasionally or a moderate amount of the time; 3–4 days), and 3 (most or all of the time; 5–7 days). The CES-D evidences excellent convergent and discriminant validities, as well as excellent sensitivity (.89 – .91) but poor specificity (.35–.47; Björgvinsson, Kertz, Bigda-Peyton, McCoy, & Aderka, 2013). One of the items assesses sleep (“my sleep was restless”) and was thus removed from the total score, consistent with previous research on sleep and depression (Assari, Sonnega, Pepin, & Leggett, 2017). Scores for the 9-item scale used here range from 0–27. In the current study, the scale exhibited strong internal consistency, α = .86.

Pessimistic Repetitive Future Thinking

Eight items from the Future-Oriented Repetitive Thought (FoRT) scale (Miranda, Wheeler, Polanco-Roman, & Marroquín, 2017) form the Pessimistic Repetitive Future Thinking subscale. Participants were asked to rate the frequency with which they engage in pessimistic future thinking (e.g., “think about the worst possible things that could happen”) on a scale from 0 (never) to 3 (almost always), with total scores ranging from 0 to 24. The FoRT evidences acceptable convergent validity with other measures of repetitive thought (Miranda et al., 2017). In the current study, this subscale exhibited strong internal consistency, α = .91.

Sleep

In addition to the sleep item from the CESD-10 (“my sleep was restless”), participants also responded to two newly-devised questions regarding sleep. For the item “How has your sleep changed in the last few weeks,” participants chose from four options: (a) my sleep has not really changed lately, (b) in the last few weeks, I have been sleeping better than I usually do, (c) in the last few weeks, I have been sleeping worse than usual, or (d) in the last few weeks, I have been sleeping for longer than I usually do but I still do not feel better rested. We combined options such that the first two options indicated “non-worsened sleep” whereas the latter two options indicated “worsened sleep.” Participants who selected options C or D were then asked “Have you been having trouble falling asleep or staying asleep because you are worrying about the current COVID-19 situation?” with options including 0 (not at all), 1 (a little bit), 2 (quite often), and 3 (almost every night). These options were dichotomized such that the first option indicated worry not affecting sleep, whereas the latter three options indicated some level of worry affecting sleep. The response options for the CESD-10 sleep item were similarly dichotomized into “any restless sleep” vs. none.

Results

The demographic characteristics of the analytic sample are presented in Table 1, along with comparisons for whether there were differences in frequencies on any of the three sleep items. The sample was predominantly comprised of participants identifying as gay (74.4%) or bisexual (20.5%), and White (49.3%) or Black (27.7%). The average age was 41.2 (SD = 13.4), ranging from 18 to 75 years.

Table 1.

Demographic characteristics and recent sleep

Total Restless Sleep1 (past week) Worsened sleep or unrested Sleep bothered by COVID worries2
n (%) n (%) n (%) n (%)
477 (100) 477 (100) 477 (100) 280 (100)
Age (range: 18–75 years) χ2(3) = 1.27 χ2(3) = 2.01 χ2(3) = 0.70
 Aged 18 to 29 108 (22.6) 93 (76.2) 78 (63.9) 55 (70.5)
 Aged 30 to 49 223 (46.8) 174 (74.7) 136 (58.4) 103 (75.7)
 Aged 50 or older 146 (30.6) 103 (70.5) 81 (55.5) 60 (74.1)
Race and Ethnicity χ2(3) = 2.26 χ2(3) = 2.33 χ2(3) = 4.71
 Black 132 (27.7) 93 (70.5) 74 (56.1) 48 (64.9)
 Latino 65 (13.6) 44 (67.7) 35 (53.8) 28 (80.0)
 Multiracial or Other 45 (9.4) 33 (73.3) 25 (55.6) 17 (68.0)
 White 235 (49.3) 178 (75.7) 146 (62.1) 112 (76.7)
Sexual Identity χ2(2) = 1.38 χ2(2) = 2.67 χ2(2) = 3.06
 Gay 355 (74.4) 257 (72.4) 213 (60.0) 156 (73.2)
 Bisexual 98 (20.5) 71 (72.4) 51 (52.0) 40 (78.4)
 Queer or Other 24 (5.0) 20 (83.3) 16 (66.7) 9 (56.3)
Education χ2(3) = 2.11 χ2(3) = 3.94 χ2(3) = 3.36
 High School, GED, or less 66 (13.8) 53 (80.3) 46 (69.7) 29 (63.0)
 Some college 145 (30.4) 104 (71.7) 82 (56.6) 61 (74.4)
 Bachelor degree 137 (28.7) 98 (71.5) 78 (56.2) 60 (77.9)
 Graduate degree 129 (27.0) 93 (72.1) 75 (58.1) 55 (73.3)
Annual Income χ2(2) = 5.83 χ2(2) = 8.16* χ2(2) = 2.12
 Less than $20K 124 (26.0) 98 (79.0) 79 (63.7)a 53 (67.1)
 Between $20K and $50K 150 (31.4) 113 (75.3) 97 (64.7)a 73 (75.3)
 $50K or more 203 (42.6) 137 (67.5) 104 (51.2)b 79 (76.0)
Employment Status χ2(2) = 1.06 χ2(2) = 6.69* χ2(2) = 1.95
 Full-time 227 (47.6) 163 (71.8) 122 (53.7)a 93 (76.2)
 Part-time or Student 64 (14.4) 50 (78.1) 45 (70.3)b 30 (66.7)
 Disability or Unemployed 154 (34.6) 114 (74.0) 96 (62.3)a,b 67 (69.8)
Financial situation (past 3M) χ2(2) = 6.25* χ2(2) = 13.69** χ2(2) = 4.14
 Gotten worse 207 (43.4) 161 (77.8)a 141 (68.1)a 105 (74.5)
 Remained the same 212 (44.4) 151 (71.2)ab 111 (52.4)b 84 (75.7)
 Gotten better 58 (12.2) 36 (62.1)b 28 (48.3)b 16 (57.1)
HIV Status χ2(2) = 3.32 χ2(2) = 1.89 χ2(2) = 0.54
 Positive 111 (23.3) 74 (66.7) 59 (53.2) 42 (69.5)
 Negative 347 (72.7) 261 (75.2) 210 (60.5) 156 (74.3)
 Unknown 19 (4.0) 13 (68.4) 11 (57.9) 8 (72.7)
U.S. Region χ2(3) = 10.09* χ2(3) = 6.53 χ2(3) = 1.95
 Northeast 117 (24.8) 95 (81.2)a 79 (67.5) 61 (77.2)
 Midwest 87 (18.4) 66 (75.9)ab 54 (62.1) 37 (68.5)
 South 175 (37.1) 114 (65.1)b 94 (53.7) 66 (70.2)
 West 93 (19.7) 70 (75.3)ab 51 (54.8) 39 (76.5)
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Note

1

Endorsed restless sleep in the past 7 days (more than “not at all”).

2

Endorsed that COVID worries impacted ability to fall or stay asleep (more than “not at all”).

*

p <.05

**

p <.01.

Superscripts indicate significant differences between groups within columns in post-hoc pairwise comparisons at p <.05.

Regarding mental health, the average score for the full 10-item scale of the CESD-10 was 12.38 (SD = 6.7), the average total for the GAD-7 was 7.43 (SD = 6.0), and the average total for the Pessimistic Repetitive Future Thinking subscale of the FoRT was 9.32 (SD = 5.18). Correlations between these mental health variables showed that they were strongly related to each other. Bivariate correlations between anxiety (GAD-7) and depression (the CESD-9 total) and between anxiety and depression (the CESD-10 total) were .74 and .76, respectively (both p <.001)—and the CESD-9 and CESD-10 were extremely highly correlated at r = .99 (p <.001), indicating that the removal of the sleep item from the CESD-10 did not substantially compromise the scale. Bivariate correlations between the FoRT subscale and anxiety, and between the FoRT subscale and depression (the CESD-9 total) were .58 and .61, respectively (both p <.001).”

Of the 477 participants, almost 75% endorsed some level of restless sleep in the past week on the CESD sleep item: 27.7% reported restless sleep some or a little of the time (1–2 days), 25.8% occasional or a moderate amount of the time (3–4 days), and 19.5% on most or all days (5–7 days). Only 27.0% reported no restless sleep at all. In response to the item asking about changes in sleep in the last few weeks, 203 (42.6%) reported worse-than-usual sleep quality since the COVID-19 pandemic, and 77 (16.1%) reported sleeping longer than usual but not feeling better rested. Only 153 (32.1%) reported that their sleep had “not really changed lately” and 44 (9.2%) reported sleeping better than usual. Further, of the 280 participants reporting worse-than-usual sleep or feeling not rested, almost 85% reported that worrying about the pandemic was contributing to their trouble falling or staying asleep: 105 (37.5%) responded “a little bit,” 62 (22.1%) responded “quite often,” and 38 (13.6%) responded “almost every night.”

Comparisons across demographic groupings (utilizing chi-square tests of independence and post-hoc tests when significant at p <.05) showed that restless sleep was disproportionately endorsed by those whose financial situation had been adversely affected recently and those in the Northeast region of the U.S.A. (compared to those in the South). Experiencing worsened sleep or feeling unrested was also more often endorsed by those in lower income ranges and those with financial situations that had been adversely affected, as well as by those working part-time or as students, compared to those working in full-time positions. We also tested whether restless or worsened sleep was more common among those working in essential industries (n = 159) or among those who either tested positive for COVID-19 or believed that they have had it but were not tested (n = 50), but significant differences were not observed.

In ANOVA analyses (see Table 2), significantly higher scores on anxiety, depression, and pessimistic repetitive future thinking were observed for those with greater frequencies of past-week restless sleep, as well as for those with worse-than-usual sleep or longer sleep but not feeling well-rested (compared to those whose sleep had not changed or had improved). Finally, for the 280 participants who reported worse-than-usual sleep or sleeping longer but not feeling well-rested, significantly higher scores on anxiety, depression, and pessimistic repetitive future thinking were observed for those with greater frequencies of sleep being bothered by worrying about the pandemic.

Table 2.

Differences in anxiety, depression, and pessimistic repetitive future thinking, by sleep variable

Restless Sleep (past week; CESD item)
None at all (n = 129) Some or a little of the time (n = 132) Occasionally or moderate amount of time (n = 123) Most or all of the time (n = 93) Test Statistic
M (SD) M (SD) M (SD) M (SD) F(df), p
Anxiety (GAD-7 total) 3.14 (3.7)a 6.09 (4.3)b 9.14 (5.3)c 13.04 (6.4)d 81.00 (3,473), <.001
Depression (CESD-9 total) 6.43 (4.5)a 9.80 (4.6)b 13.23 (5.0)c 16.09 (5.3)d 84.62 (3,473), <.001
Pessimistic RFT 6.91 (4.5)a 8.55 (4.3)b 9.98 (4.6)c 12.86 (5.8)d 29.97 (3,473), <.001
Changes in Sleep Quality in past few weeks
Better than usual (n = 44) No change (n = 153) Worse than usual (n = 203) Slept longer, not well-rested (n = 77) Test Statistic
M (SD) M (SD) M (SD) M (SD) F(df), p
Anxiety (GAD-7 total) 5.16 (5.6)a 4.99 (5.3)a 9.15 (5.8)b 9.06 (6.2)b 19.80 (3,473), <.001
Depression (CESD-9 total) 8.11 (5.4)a 8.37 (5.5)a 12.98 (5.7)b 12.66 (5.2)b 26.51 (3,473), <.001
Pessimistic RFT 8.25 (4.6)a 7.85 (4.9)a 10.25 (5.0)b 10.39 (5.8)b 8.37 (3,473), <.001
Trouble Falling or Staying Asleep Due to Worry About COVID-19
Not at all (n = 75) A little bit
(n = 105)		 Quite often
(n = 62)		 Almost every night (n = 38) Test Statistic
M (SD) M (SD) M (SD) M (SD) F(df), p
Anxiety (GAD-7 total) 7.04 (5.9)a 8.09 (5.4)a 10.98 (5.3)b 13.08 (6.2)b 13.43 (3,276), <.001
Depression (CESD-9 total) 11.33 (5.8)a 12.30 (5.3)a 14.18 (5.1)b 15.50 (5.3)b 6.65 (3,276), <.001
Pessimistic RFT 9.99 (5.8) 9.70 (4.8) 10.71 (4.6) 11.82 (5.7) 1.76 (3,276), .16
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Note. GAD = Generalized Anxiety Disorder. CESD = Center for Epidemiologic Studies Depression. RFT = Repetitive Future Thinking. Superscripts indicate significant differences between groups within rows in post-hoc pairwise comparisons at p <.05.

Discussion

This exploratory study examined sleep quality among a sample of sexual minority men across the U.S.A in the weeks immediately post-COVID. Findings illustrate substantial sleep challenges and the relevance of sleep to mental health. Almost 75% of our participants reported past-week restless sleep and almost 60% reported either worsened sleep or sleeping longer but not feeling well-rested—and of those, the vast majority (84.3%) attributed their worsened sleep to some level of pandemic-related worry. These high rates of self-reported restless sleep were even higher among those whose financial situation had recently worsened, and those in the Northeast region of the U.S.A. High rates of self-reported worsened sleep were even higher among those in the lower income ranges and those whose financial situation had recently worsened—especially part-time workers and students.

Additionally, restless sleep, diminished sleep quality, and the subjective attribution of pandemic-related sleep disruptions were each associated with significantly higher scores on anxiety, depression, and pessimistic repetitive future thinking. Although directionality cannot be confirmed in this cross-sectional study, it is plausible that at the same time that impaired sleep is likely exacerbating mental health distress among our sample, the tendency towards pessimistic future repetitive thinking may be one of the mechanisms linking pandemic-related worry to worsened sleep. Future research with longitudinal data should explore the possible meditational role of this tendency linking worry to worsened sleep.

Restless sleep was most commonly reported by participants in the Northeast region of the U.S.A. (81.2%) compared to those in the South (65.1%), and furthermore, those in the Northeast were also highest on diminished sleep quality and COVID-related worry as a factor in worsened sleep. This is consistent with the fact that the Northeast region of the U.S.A. was the most heavily affected by the pandemic in late April and early May (i.e., the timeframe referred to in the survey). Subsequent increases in the South, West, and Midwest regions that occurred later may shift these rates.

It is noteworthy that scores on anxiety and depression were, on average, markedly higher than norms published for the general population and rates observed in previous studies of sexual minority populations. For example, 31.3% of our sample scored at or above the cut-off of 9 on the GAD-7 measure of anxiety, compared to the rate of 6% for the general population in Löwe and colleagues (2008) and the rate of 17.1% in Hickson et al.’s (2017) study of sexual minority men in the U.K. In terms of depression, the sample mean of 12.4 on the CESD-10 depression scale is substantially higher than the mean of 4.7 observed in Andresen et al. (1994) as well as the mean of 4.0 observed in a study of Black sexual minority men (English et al., 2020). Further, 58.9% of our sample had scores meeting or exceeding the CESD-10’s cut-off score of 10 (Andresen et al., 1994), compared to the rate of 29.6% observed among the 1,500+ sexual minority men surveyed in Fredriksen-Goldsen et al. (2013). These elevated rates observed in our sample potentially reflect the heightened mental health distress wrought in the early months of the COVID-19 pandemic.

Although it is likely that elevations in mental health distress would also be occurring in the wider population, a key question for minority health researchers is how existing burdens facing sexual and gender minority populations may be magnifying the impacts of the pandemic on mental health and sleep. These include: various sources of minority stress (Brooks, 1981; Meyer, 1995) and resulting mental health disparities (Gonzales & Henning-Smith, 2017), disproportionately high rates of HIV (CDC, 2020) and the HIV-related stigma that persists (Earnshaw & Kalichman, 2013), pronounced social isolation (Harley, Gassaway, & Dunkley, 2016) and, for many, inadequate or non-existent support from families (Ryan, Huebner, Diaz, & Sanchez, 2009). Considering sources of intersectional minority stress is particularly important, as is work that seeks to address the social and environmental factors contributing to and maintaining disparities in sleep health (Jackson & Johnson, 2020).

Although the majority of the participants reporting diminished sleep quality or not feeling rested subjectively attributed this to pandemic-related worry, it should be noted that 15% did not. While this finding vividly highlights the subjective importance of the epidemic for sleep, it also underscores the fact that sleep has multiple determinants, such as disruptions to daily routines and schedules. Although such disruptions were not assessed in the current study, future research on how the pandemic has contributed to changes in wake-sleep patterns and consistency is warranted, especially with respect to whether differences were greater for those with a morning or evening chronotype.

Limitations of this exploratory study include its cross-sectional design which limits the ability to examine temporal ordering of changes in sleep health and mental health. Additionally, the sample was recruited from mobile phone-based networking apps which may limit its generalizability to the wider population. Further, sleep was subjectively estimated by retrospective self-report, with two newly-created items which have not yet been psychometrically validated (though we consider them to have high face validity), and we did not have pre-COVID sleep data on these individuals. The need for objective assessments of sleep by actigraphy is perhaps heightened given the elevated rates of mental health distress in the current sample. Finally, our sample consisted of cisgender sexual minority men, and future research should consider other minority groupings such as sexual minority women and transgender and gender-expansive individuals.

Given the benefits that good, restful, and consistent sleep confers upon physical and mental health and the capacity to cope during stressful times, addressing disruptions to sleep is of great importance. Our findings showed that in the early months of the COVID-19 pandemic in the U.S.A, many SMM experienced sub-optimal sleep and co-occurring mental health challenges. Although we expect that similar trends would be found among the wider population—which is important given the overall importance of sleep for physical (Grandner, Jackson, Pak, & Gehrman, 2012) and mental health (see Babson & Feldner, 2015)—this consideration of sleep health among our sample of racially-diverse sexual minority men is especially important given recent evidence of pre-COVID sleep disparities for sexual and gender minority populations (see Butler et al., 2020; Millar et al., 2019), for racial and ethnic minority individuals (see Jackson, 2017), and for those of lower socioeconomic status (Williams, Jean-Louis, Blanc, & Wallace, 2019). It is plausible, if not likely, that many of our participants were reporting on sleep quality that was already disparately poor or insufficient, prior to being worsened by the COVID-19 pandemic.

Public Significance Statement.

This study documents the detrimental impact that the COVID-19 pandemic may have exerted on self-reported sleep health in a sample of sexual minority men in the U.S.A. More than half of participants reported experiencing decreased sleep quality or not feeling rested in the early months of the pandemic, and this was even more prevalent among those whose financial situation had recently worsened and/or who were not in full-time employment. Sleep disturbance was associated with greater emotional distress, further highlighting for health care providers the importance of attending to, and improving, sleep health in the community.

Acknowledgements

Analyses of these data were supported in part by a grant from the National Institute on Drug Abuse (R01 DA045613, PI: Starks). The authors thank the participants for their time and engagement. The authors also thank S. Scott Jones for his assistance, Ruben Jimenez, Cynthia Cabral, Christine Cowles, Michael Suarez, Kory Kyre, Sugandha Gupta, Stephen Bosco, Kendell Doyle, and Daniel Sauermilch.

Footnotes

Conflict of interest:

The authors declare that they have no conflict of interest.

Ethical Approval:

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

References

  1. Andresen EM, Malmgren JA, Carter WB, & Patrick DL (1994). Screening for depression in well older adults: Evaluation of a short form of the CES-D. American Journal of Preventive Medicine, 10(2), 77–84. [PubMed] [Google Scholar]
  2. Assari S, Sonnega A, Pepin R, & Leggett A (2017). Residual effects of restless sleep over depressive symptoms on chronic medical conditions: Race by gender differences. Journal of Racial and Ethnic Health Disparities, 4(1), 59–69. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Babson K, & Feldner M (Eds.). (2015). Sleep and affect: Assessment, theory, and clinical implications. Academic Press. [Google Scholar]
  4. Barber LK, Munz DC, Bagsby PG, & Powell ED (2010). Sleep consistency and sufficiency: Are both necessary for less psychological strain? Stress and Health, 26(3), 186–193. [Google Scholar]
  5. Beard C, & Björgvinsson T (2014). Beyond generalized anxiety disorder: Psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. Journal of Anxiety Disorders, 28(6), 547–552. [DOI] [PubMed] [Google Scholar]
  6. Björgvinsson T, Kertz SJ, Bigda-Peyton JS, McCoy KL, & Aderka IM (2013). Psychometric properties of the CES-D-10 in a psychiatric sample. Assessment, 20(4), 429–436. [DOI] [PubMed] [Google Scholar]
  7. Brooks VR (1981). Minority stress and lesbian women. Free Press. [Google Scholar]
  8. Buysse DJ, Angst J, Gamma A, Ajdacic V, Eich D, & Rössler W (2008). Prevalence, course, and comorbidity of insomnia and depression in young adults. Sleep, 31(4), 473–480. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Butler ES, McGlinchey E, & Juster RP (2020). Sexual and gender minority sleep: A narrative review and suggestions for future research. Journal of Sleep Research, e12928. [DOI] [PubMed] [Google Scholar]
  10. Centers for Disease Control and Prevention. HIV Surveillance Report, 2018. (Updated); vol.31. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2020. Accessed May 20, 2020. [Google Scholar]
  11. Cellini N, Canale N, Mioni G, & Costa S (2020). Changes in sleep pattern, sense of time and digital media use during COVID-19 lockdown in Italy. Journal of Sleep Research, e13074. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Cox RC, & Olatunji BO (2016). A systematic review of sleep disturbance in anxiety and related disorders. Journal of Anxiety Disorders, 37, 104–129. [DOI] [PubMed] [Google Scholar]
  13. Downing MJ, Millar BM, & Hirshfield S (2019). Changes in sleep quality and associated health outcomes among gay and bisexual men living with HIV. Behavioral Sleep Medicine, 18(3), 406–419. DOI: 10.1080/15402002.2019.1604344 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Duncan DT, Goedel WC, Mayer KH, Safren SA, Palamar JJ, Hagen D, & Jean-Louis G (2016). Poor sleep health and its association with mental health, substance use, and condomless anal intercourse among gay, bisexual, and other men who have sex with men. Sleep Health, 2(4), 316–321. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Earnshaw VA, & Kalichman SC (2013). Stigma experienced by people living with HIV/AIDS. In Stigma, discrimination and living with HIV/AIDS (pp. 23–38). Springer, Dordrecht. [Google Scholar]
  16. English D, Carter JA, Forbes N, Bowleg L, Malebranche DJ, Talan AJ, & Rendina HJ (2020). Intersectional discrimination, positive feelings, and health indicators among Black sexual minority men. Health Psychology, 39(3), 220. DOI: 10.1037/hea0000837 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Goldstein-Piekarski AN, Greer SM, Saletin JM, & Walker MP (2015). Sleep deprivation impairs the human central and peripheral nervous system discrimination of social threat. Journal of Neuroscience, 35(28), 10135–10145. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Gonzales G, & Henning-Smith C (2017). Health disparities by sexual orientation: Results and implications from the Behavioral Risk Factor Surveillance System. Journal of community health, 42(6), 1163–1172. [DOI] [PubMed] [Google Scholar]
  19. Grandner MA, Jackson NJ, Pak VM, & Gehrman PR (2012). Sleep disturbance is associated with cardiovascular and metabolic disorders. Journal of Sleep Research, 21(4), 427–433. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Hall MH, Casement MD, Troxel WM, Matthews KA, Bromberger JT, Kravitz HM, … & Buysse DJ (2015). Chronic stress is prospectively associated with sleep in midlife women: the SWAN sleep study. Sleep, 38(10), 1645–1654. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Harley DA, Gassaway L, & Dunkley L (2016). Isolation, socialization, recreation, and inclusion of LGBT elders. In Handbook of LGBT Elders (pp. 563–581). Springer, Cham. [Google Scholar]
  22. Hickson F, Davey C, Reid D, Weatherburn P, & Bourne A (2017). Mental health inequalities among gay and bisexual men in England, Scotland and Wales: a large community-based cross-sectional survey. Journal of Public Health, 39(2), 266–273. [DOI] [PubMed] [Google Scholar]
  23. Jackson CL (2017). Determinants of racial/ethnic disparities in disordered sleep and obesity. Sleep Health, 3(5), 401–415. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Jackson CL, & Johnson DA (2020). Sleep disparities in the era of the COVID-19 pandemic highlight the urgent need to address social determinants of health like the virus of racism. Journal of Clinical Sleep Medicine. DOI: 10.5664/jcsm.8570 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Johnson DA, Lisabeth L, Lewis TT, Sims M, Hickson DA, Samdarshi T, … & Roux AVD (2016). The contribution of psychosocial stressors to sleep among African Americans in the Jackson Heart Study. Sleep, 39(7), 1411–1419. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Johnson SU, Ulvenes PG, Øktedalen T, & Hoffart A (2019). Psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. Frontiers in Psychology, 10, 1713. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Kancherla BS, Upender R, Collen JF, Rishi MA, Sullivan SS, Ahmed O, … & Aurora RN (2020). Sleep, Fatigue and Burnout Among Physicians: An American Academy of Sleep Medicine Position Statement. Journal of Clinical Sleep Medicine: JCSM, 16(5), 803–805. DOI: 10.5664/jcsm.8408 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, … & Tan H (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA network open, 3(3), e203976–e203976. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Löwe B, Decker O, Müller S, Brähler E, Schellberg D, Herzog W, & Herzberg PY (2008). Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical Care, 266–274. [DOI] [PubMed] [Google Scholar]
  30. McGowan SK, Behar E, & Luhmann M (2016). Examining the relationship between worry and sleep: A daily process approach. Behavior Therapy, 47(4), 460–473. [DOI] [PubMed] [Google Scholar]
  31. Meyer IH (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 38–56. [PubMed] [Google Scholar]
  32. Millar BM, Goedel W, & Duncan D (2019). Sleep health among sexual and gender minorities. In Duncan D, Kawachi I, & Redline S (Eds.). Social epidemiology of sleep. Oxford University Press. [Google Scholar]
  33. Millar BM, Rendina HJ, Starks TJ, Grov C, & Parsons JT (2018). The role of chronotype, circadian misalignment, and tiredness in the substance use behaviors of gay and bisexual men. Psychology of Sexual Orientation and Gender Diversity, 6(1), 96–106. DOI: 10.1037/sgd0000311 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Millar BM, Starks TJ, Rendina HJ, & Parsons JT (2018). Three reasons to consider the role of tiredness in sexual risk-taking among gay and bisexual men. Archives of Sexual Behavior, 48(1), 383–395. DOI: 10.1007/s10508-018-1258-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Miranda R, Wheeler A, Polanco-Roman L, & Marroquín B (2017). The future-oriented repetitive thought (FoRT) scale: A measure of repetitive thinking about the future. Journal of Affective Disorders, 207, 336–345. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Morphy H, Dunn KM, Lewis M, Boardman HF, & Croft PR (2007). Epidemiology of insomnia: a longitudinal study in a UK population. Sleep, 30(3), 274–280. [PubMed] [Google Scholar]
  37. Panjwani A, Millar BM, & Revenson TA, (2020). Tolerating uncertainty in the dark: Insomnia symptoms, distress, and well-being among parents of adolescents and young adults with cancer. International Journal of Behavioral Medicine, DOI: 10.1007/s12529-020-09869-6 [DOI] [PubMed] [Google Scholar]
  38. Patterson CJ, Tate DP, Sumontha J, & Xu R (2018). Sleep difficulties among sexual minority adults: Associations with family relationship problems. Psychology of Sexual Orientation and Gender Diversity, 5(1), 109–116. DOI: 10.1037/sgd0000264. [DOI] [Google Scholar]
  39. Pigeon WR, Pinquart M, & Conner K (2012). Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. The Journal of Clinical Psychiatry, 73(9), e1160–e1167. DOI: 10.4088/JCP.11r07586 [DOI] [PubMed] [Google Scholar]
  40. Radloff LS (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385–401. [Google Scholar]
  41. Ryan C, Huebner D, Diaz RM, & Sanchez J (2009). Family rejection as a predictor of negative health outcomes in White and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123(1), 346–352. [DOI] [PubMed] [Google Scholar]
  42. Slopen N, Lewis TT, & Williams DR (2016). Discrimination and sleep: a systematic review. Sleep Medicine, 18, 88–95. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Spitzer RL, Kroenke K, Williams JB, & Löwe B (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. [DOI] [PubMed] [Google Scholar]
  44. Tello-Velasquez JR, Diaz-Llanes BE, Mezones-Holguin E, Rodriguez-Morales AJ, Huamani C, Hernandez AV, & Arevalo-Abanto J (2015). Poor quality of sleep associated with low adherence to highly active antiretroviral therapy in Peruvian patients with HIV/AIDS. Cadernos de saude publica, 31(5), 989–1002. [DOI] [PubMed] [Google Scholar]
  45. Williams N, Jean-Louis G, Blanc J, & Wallace DM (2019). Race, socioeconomic position and sleep. In Grandner M (ed.). Sleep and Health (pp. 57–76). Academic Press. [Google Scholar]
  46. Williams PG, Cribbet MR, Rau HK, Gunn HE, & Czajkowski LA (2013). The effects of poor sleep on cognitive, affective, and physiological responses to a laboratory stressor. Annals of Behavioral Medicine, 46(1), 40–51. [DOI] [PubMed] [Google Scholar]
  47. Xiao H, Zhang Y, Kong D, Li S, & Yang N (2020). Social capital and sleep quality in individuals who self-isolated for 14 days during the coronavirus disease 2019 (COVID-19) outbreak in January 2020 in China. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 26, e923921–1. [DOI] [PMC free article] [PubMed] [Google Scholar]

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