Insomnia and common mental disorder among patients with pre-existing chronic non-communicable diseases in southern Ethiopia: a survey during COVID-19 pandemic

Background COVID-19 has been causing significant mental health problems and other health-related issues. Despite the fact that COVID-19 has a significant impact on chronic disease patients, there is scant research on insomnia, common mental health disorders (CMD), and their associated factors among chronic disease patients. Objective The purpose of this study was to assess the prevalence of insomnia and common mental disorders (CMD) and their associated factors among patients with pre-existing chronic NCDs in Sidama, southern Ethiopia. Methods A multicenter cross-sectional study was undertaken between June 1 and September 1, 2021. The study included 633 participants. CMD and insomnia were assessed using a 20-item Self-Reported Questionnaire (SRQ-20) and a 7—item Insomnia Severity Index (ISI) scale, respectively. To describe the various variables, descriptive statistics were used. We performed multivariable logistic regression analysis to identify independent factors associated with CMD and insomnia. A value of p < 0.05 was considered statistically significant at a 95% confidence interval. Results The prevalence of insomnia and CMD was found to be 39.3% and 46.8%, respectively. Being merchant (AOR = 0.33; 95% CI = 0.13, 0.82), having a diagnosis of diabetes mellitus (AOR = 1.89; 95% CI = 1.04, 3.46), comorbid diagnosis (AOR = 3.96; 95% CI = 2.27, 6.89), low social support (poor (AOR = 3.37; 95% CI = 1.51, 7.57) and moderate (AOR = 3.13; 95% CI = 1.46, 6.69)), symptoms of insomnia (AOR = 12.08; 95% CI = 7.41, 19.72) and poor quality of life (QOL) (AOR = 1.67; 95% CI = 1.04, 2.72) were independent predictors of CMD. We also found out that, having cardiovascular disorders (CVDs) (AOR = 2.48; 95% CI = 1.18, 5.19), CMD (AOR = 12.09; 95% CI = 7.46, 19.61), and poor QOL (AOR = 2.04; 95% CI = 1.27, 3.26) were significantly associated with insomnia symptoms. Conclusion Our study suggests that substantially high prevalence of CMD and insomnia. Significant association between CMD and occupation, diagnosis, comorbidity, social support, insomnia, and QOL were found. We also revealed that having CVDs, CMD, and poor QOL were significantly associated with insomnia symptoms. Therefore, dealing with the mental health problems of patients with chronic NCDs is an essential component of public health intervention during the COVID-19 pandemic.


Introduction
Noncommunicable diseases (NCDs) are a group of chronic diseases that significantly increase morbidity and mortality in the community, including cardiovascular disease, stroke, cancer, diabetes, and mental health issues.NCDs have been exerting a significant global burden and considered as primary public health agenda for decades (1).NCDs account for three out of every 4 years lived with disability (YLD), whereas mental disorders contribute for nearly one-fourth of all YLD (2,3).Mental illness and NCDs are commonly related by underlying individual, community, and social characteristics, and they commonly have a bidirectional relationship (4).Chronic NCDs, for instance, can lead to depression and anxiety, while mental disorders may result in decreased treatment seeking, poor adherence to treatment, and worse the outcome of NCD (5).Studies have discovered an association between chronic pain, long-term neurological conditions, or kidney illness, and depression, anxiety, and sleep problems (6)(7)(8).
COVID-19 also known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV2), first appeared in the year 2020, causing a global health crisis and the collapse of several healthcare systems (9,10).The ongoing COVID-19 outbreak overwhelmed the healthcare system, resulting in remarkable impact in the clinical management of patients with pre-existing chronic illness (11).Patients with pre-existing medical disorders such as diabetes mellitus (DM), hypertension, and cancers are considered to be among the most sensitive to COVID-19 infection, with higher severity and death (12).Patients with hypertension (6%), diabetes (7.3%) and cardiovascular disease (10.5%) had a higher case-fatality rate than the general population (2.3%) (13).
The COVID-19 pandemic is claimed to be the cause of a significant increase in the global prevalence of mental disorders such as sleep problems, anxiety and depression.In addition, WHO expressed concern regarding the influence of COVID-19 on an individual's mental health and psychosocial implications (14).Evidences showed that individuals' mental health were worsened during and after the COVID-19 pandemic, compared to before the pandemic (15, 16).Another study found that COVID-19 lockdown was linked to poor quality of sleep, sleep deprivation, and depressed symptoms (17).Moreover, a systematic review found that the COVID-19-affected population in many nations experienced somewhat high rates of insomnia, anxiety, depression, posttraumatic stress disorder, and psychological distress symptoms (18).
People may exhibit signs of depression, anxiety, and stress such loneliness, denial, insomnia, despair, boredom, and irritability, and they even face a greater chance of committing suicide (19).Isolation and loneliness, a lack of treatment options, and limited access to medical care, as well as widespread media coverage of COVID-19 infection's high infectivity, mortality, and diseases predisposing to an adverse course, all contribute to a significant psychological burden that leads to distress and sleep disturbances (20,21).
Insomnia is described as subjective complaints about difficulty of falling asleep, nocturnal awakenings, early morning awakening, or non-refreshing sleep (22).Insomnia is one of the most common sleep related disorder, affecting 5-19% of people globally (23,24).According to Budhiraja and colleagues, one-fourth (27.3%) of people with chronic obstructive lung disease had sleep problems (25).One of the most prevalent issues during the pandemic is sleep disturbance.According to a recent systematic review and meta-analysis (SRMA) study, patients with COVID-19 (57%) had the highest pooled prevalence of insomnia, followed by healthcare professionals (31%), and the general population (18%) (26).The pooled prevalence of insomnia in the Chinese population was 39.1%, according to a recent systematic review (27).A similar review indicated that the prevalence of insomnia in Africa during the pandemic were found to be 28.1%, with higher prevalence in North Africa than Sub-Saharan Africa (31% Vs 24%) (28).
A study was conducted during the initial period of COVID-19 outbreak in China, and it indicated that 8.1% had moderate to severe level of stress, 16.5% had moderate to severe symptoms of depression, and 28.8% had moderate to severe symptoms of anxiety (29).A national survey found that distress was highly prevalent in the general population, with rates of 35, 60, and 45% in China, Iran, and the United States, respectively (30).
Furthermore, sleep disturbances were associated with higher levels of mental distress (26).Sleep is essential for both mental and physical well-being, and it can even enhance immunity and resistance to infections, not to mention the different metabolic, autonomic, and inflammatory systems that are impacted by sleep deprivation (31,32).Insomnia is becoming more often considered as a distinct and comorbid disorder that requires sleep-focused therapy, despite the fact that sleep disturbance can be an indication of psychological problems (33).In addition to resulting in distress, insomnia initiates and/or worsens other mental health problems, contributes to stress and disability when associated with mental disorders, and frequently remains after other symptoms of mental disorders have subsided.This could be because lack of sleep sensitizes the stress system even more, resulting in more stressful impressions of life events as well as diminished resilience and stress recovery (34-39).
It has been established that the COVID-19 pandemic significantly affects the development of the illness and survival of NCD patients.As a result, worries regarding the mental health of NCD patients have increased.Comorbid anxiety and depression make it difficult for patients to take their medications, which decreases therapeutic safety and efficacy and raises the risk of disability and death.Comorbid mental problems, however, are frequently ignored and sometimes not adequately treated (40).Despite the fact that COVID-19 has a significant impact on chronic disease patients, there is scant research on insomnia, CMD, and their associated factors among chronic disease patients.We hypothesized that COVID-19 has increased the risk of developing insomnia and mental disorders in patients with pre-existing chronic medical illnesses.As a result, the purpose of this study was to examine the prevalence of insomnia and CMD of patients with pre-existing common chronic medical conditions throughout the COVID-19 pandemic times, as well as the factors that contributed to them.The research will provide evidence to policymakers, program planners, and health care practitioners to help them make better decisions, as well as be valuable for evidence-based interventions in treatment of common mental health concerns during a future pandemic.

Study design, area and period
We conducted a cross-sectional study at four hospitals in Sidama National Regional State, southern Ethiopia, between June 1 and September 1, 2021 [Hawassa university comprehensive specialized hospital (HUCSH), Adare general hospital (AGH), Yirgalem general hospital (YGH), and Leku Primary hospital (LPH)].The Hawassa University comprehensive specialized hospital, with about 500 beds in southern Ethiopia, serves a population of over 18 million in the Sidama region and surrounding regions of southern Ethiopia, Oromia and Somalia.It is the only specialized hospital in the region.It was provided inpatient services for COVID-19 patients and isolation center in the region and surroundings.Yirgalem General Hospital is found in Yirgalem town and it is one of the General Hospitals in Sidama region serving about 4 million people in the region and nearby.Adare general hospital is located in Hawassa city and serves for communities from Hawassa and nearby cities. Leku primary hospital is one of the primary hospitals found in Sidama region located around 25 kilo meter away from Hawassa city.

Study participants
In this study we have included patients with chronic NCDs such as diabetes, hypertension, chronic cardiovascular diseases, respiratory diseases such as asthma, and others who had regular follow-up visit at the selected hospitals.Individuals with pre-existing chronic medical illnesses receiving follow-up care in the outpatient departments (OPDs) of the four hospitals were contacted and requested to take part in the study if they met the following criteria: (I) patients above the age of 18 with confirmed chronic NCDs; (II) patients with stable clinical condition and able to understand the objective of the survey; and (III) patients with no known serious mental or neurocognitive problems.Patients with pre-existing chronic NCDs who were admitted to the emergency or inpatient units for any reason were not included in the study.The required sample size was estimated using single population proportion formula: where n is the sample size, z is the standard normal score set at 1.96, d is the desired degree of accuracy and p is the estimated proportion of the target population.By taking p = 50% (because there were no similar study in the area and to get adequate or maximum sample size), Zα/2 = 1.96 and d = 5%, the computed sample size was 384; and by taking 10% non-response rate, the total sample size computed was 422.Using design effect 1.5, our final sample size was estimated to be 633 (we used level of hospitals as a cluster, i.e., primary, general and specialized hospital).Sample size was proportionally allocated to each hospital based on the patient flow of the hospitals.

Data collection methods
A standardized structured interviewer administered questionnaire was used to collect data.The questionnaire included items or scales that assess patients' socio-demographic characteristics, clinical characteristics, social support, common mental disorders (CMD), insomnia, and quality of life (QOL).The questionnaire was written in English before being translated into Amharic, the local language.The questionnaire was translated from English into Amharic by native speakers of the language who are fluent in English, then backtranslated into English by other translators to guarantee consistency.Finally, the Amharic version of the questionnaire was used to collect data.
Data were collected by nurses who had received 2 days of training on data collection processes and assessment tools.A pretest was performed on 5% of the sample to discover potential difficulties with the data collection procedures, as well as to assess the consistency of the questionnaires and the competency of the data collectors.The investigators reviewed each questionnaire for completeness on a regular basis during data collection.

Social support
Social support of patients with pre-existing chronic NCDs was measured using the three-item Oslo social support scale (OSSS).The scale has a score of minimum 3 and maximum 14.It has three categories.A score of 3-8, 9-11, and 12-14 indicates poor, moderate, and strong social support, respectively (41).

Insomnia
The nature, intensity, and effects of insomnia are evaluated using the ISI, a seven-item self-assessment questionnaire (48).The following

Quality of life
To analyze the impact of the COVID-19 pandemic on QOL, we used an adapted version of 12 items (51), from the WHOQOL-BREF scale (52,53).The 12-item WHOQOL-BREF scale that was modified had a minimum score of 12 and a maximum score of 60.Due to the detrimental impacts of the COVID-19 pandemic, low scores indicate a lower QOL.In a prior study, the modified WHOQOL-BRIEF (12-items) showed acceptable internal consistency (Cronbach's alpha = 0.81) (51).The 12-item WHOQOL-BRIEF that was used in our study had good internal consistency (Cronbach's alpha = 0.82).

Data analysis
For analysis, the data collected were entered into Epi-data version 3.1 and exported to SPSS version 24 for Windows.Various variables were described using descriptive statistics such as frequency, percentage, mean, standard deviation, and median.Binary and multivariable logistic regression were used to identify independent factors of insomnia and CMD.The Hosmer-Lemeshow test was used to assess model fitness.At 95% confidence interval (CI), p-values of <0.05 were considered as statistically significant.

Socio-demographic characteristics of study participants
A total of 633 patients with pre-existing chronic NCDs were involved in this study.Majority were male 357(56.4%),410(64.8%)participants were married, 352(55.6%)were Protestant by religion and about one-fourth 175(27.6%)were illiterate.Of the total participants, about one-fifth 144(22.7%)were farmer by occupation and majority 353(55.8%)were urban residents.The mean age of the respondents was 46.49 ± 17.71 as described in Table 1.

Clinical characteristics of study participants
About half 336(53.1%) of the participants were diagnosed with diabetes mellitus followed by hypertension 111(17.5%)and nearly one-third 200(31.6%)participants had comorbid diagnosis.Majority 364(57.5%) of the participants were ill for ≤5 years, 61(9.6%) and 49(7.7%)participants were using alcohol and khat in the past three months, respectively.Among the total participants, more than one-third 224(35.4%)and about half 332(52.4%)had poor and moderate social support, respectively.Moreover, 293(46.3%) of participants were poor QOL (Table 2).

Independent predictors of CMD and insomnia
In a multivariable logistic regression model, occupation, diagnosis, comorbid diagnosis, social support, insomnia, and quality of life were all significantly associated with CMD.When compared to government employees, being a merchant is 66% (AOR = 0.33; 95%  4).

Discussion
The COVID-19 pandemic appears to be having a severe impact on the mental health of individuals with pre-existing medical conditions.In this study, we examined the prevalence and predictors of COVID-19 pandemic related common mental disorders (CMD) and insomnia in patients with chronic medical conditions in south Ethiopia.CMD and insomnia levels were surprisingly high, according to our research.Being a merchant, having diabetes mellitus, having a longer illness duration, having comorbid diagnoses, having low social support, having comorbid insomnia, and having a poor quality of life (QoL) were significant predictors of CMD.Additionally, a significant association between a high risk of insomnia and a diagnosis of cardiovascular disorders, concurrent CMD, and poor QoL was found.The prevalence of insomnia and CMD indicates a need for mental health and psychosocial support (MHPSS) during the COVID-19 pandemic.
CMDs such as anxiety and depression were found to be more common in pre-existing physical conditions with a higher risk of COVID-19 infection in previous studies (54,55).Our finding suggests that nearly half (46.8%) of the participants experience CMD.Comparable findings were reported from previous studies in India (52.9%),Saudi Arabia (45.6%), and China (45%) (56)(57)(58).This shows that COVID-19 had a serious impact on the mental health of

Prevalence of CMD and Insomnia
Prevalence of insomnia and CMD study participants at Sidama National Regional State, southern Ethiopia, 2021 (n = 633).people with pre-existing NCDs.Mental health of the population was significantly impacted by the public health measures implemented to stop the spread of COVID-19 and the fear of getting the infection (59).The association between chronic medical problems and mental disorders is generally speculated to be bidirectional.People suffering from a significant mental illness are more likely to develop a variety of chronic physical illnesses.People with chronic medical illnesses, on the other hand, more likely to experience psychological problems than the general population (60).For instance, compliance with chronic medication use and regular use of the healthcare system may be challenging during infectious disease outbreaks, adding to psychological distress.However, lower prevalence were reported in Ethiopia (22.8%) (61), and India (33.2%) (62).A similar study conducted in Bangladesh found a low prevalence of anxiety (35.2%) and depression (38.9%) (60).On the other hand, higher prevalence were also reported in studies conducted in Harar (62%) (60), and Mettu Karl Referral Hospital 55.7% (depression) and 61.8% (anxiety) (59).Moreover, other pre-COVID-19 researches indicated higher estimates of mental health problems in different parts of the world such as 63.3% in Ethiopia (63), 60.2% in Pakistan (64), 64.4% in Nigeria (65), and (58.7%) in Delhi, India (66).These disparities could be due to changes in sample size, inclusion criteria, screening instrument, setting, study period, and study population.Consequently, physical illnesses were associated with a higher likelihood of mental health problems, which could be explained by underlying physical disorders and a lack of medical help during an epidemic (67,68).The findings suggested that different strategies should be designed to address mental health issues during epidemics.
Being a governmental employee increases the likelihood to have CMD as compared to merchants.This finding is consistent with a recent study (82).The civil servants who participated in COVID-19 control were reported to have various types of psychological disorders (83).It has been noted that lack of public support, long working hours, a high degree of work related stress, work instability, and an unfavorable physical environment are risk factors for the development of symptoms of mental disorders in government employees (84)(85)(86).Furthermore, many government employees encounter emotional distress due to psychological disorders like depression and anxiety during and even after pandemics (87).
Similarly, those with inadequate (poor and moderate) social support were more likely to have CMD than those with strong social support, which is consistent with previous studies (59, 88, 89).Individuals with higher levels of social support may be more likely to believe they will obtain the necessary assistance when confronted with the stressful event of a pandemic outbreak.This idea would improve their views about dealing with adversity and difficulty in the fight against COVID19, resulting in greater levels of resilience (88).This could be associated with the fact that those who did not have social support throughout the pandemic are more vulnerable to mental illness since their social health is disrupted (61).Furthermore, a lack of social support has a detrimental effect on self-care, adherence, and the ability to react to or deal with stressful events, and it may lead to the development of depression (90).Also, perceived social support may help individuals resist and successfully cope the risk factors associated with their mental health (91).As a result, our findings highlight the importance of strong social support during pandemics, as it may have a positive impact on mental health.
This study indicated that patients diagnosed with diabetes were more prone to develop CMD as compared to hypertension.Mental health problems such as depression is more likely to occur in people with diabetes (92)(93)(94).Several studies have recently revealed that patients with diabetes mellitus had significant psychological problems during the COVID-19 pandemic (95)(96)(97)(98).This has been linked to hypothalamic-pituitary-adrenal (HPA) dysfunction in both diabetes and depression (99).The immune system, glucose metabolism, and sleep-indicators of impaired health in both diseases-are regulated by this route, which is crucial under stress (100).Moreover, we found out that patients diagnosed with cardiovascular disorders such as heart failure were more likely to develop insomnia as compared to patients with hypertension.Previous studies suggested that patients with CVD are more prone to sleep disturbances (101, 102).Insomnia is linked to fatigue, depressed symptoms, daytime sleepiness, and decreases in self-reported and objective functional status, all of which  In this study, participants with CMD were more likely to be at risk to develop insomnia and vice versa.In general, there is evidence that mental health problems are associated to sleep disturbances and that insomnia is related to the psychological stress.That is, a bidirectional relationship between insomnia and psychological problems were clearly demonstrated (105).Furthermore, people who have a chronic medical condition may experience severe physical discomfort, which can lead to anxiety and depression and disturbed sleep (106).The conclusion could be attributed to COVID-19's direct psychosocial effects on those with chronic medical conditions, fear of contracting COVID-19, and the virus's deadly effect on chronic medical patients.
Our study also showed that participants who had poor QoL were more likely to develop CMD and insomnia.Similarly, recent studies have discovered that poor QoL is associated with insomnia and poor sleep quality (107, 108) and lower QoL scores were indicated by individuals who felt more stress, depression, and anxiety (51).Previous research has shown that there is an inverse relationship between QOL and mental health disorders such as depression and anxiety (109) and sleep disturbances (110).As a result, it is not surprising that poor QOL in individuals with chronic medical illnesses has an impact on mental health and sleep, as shown in this study.
There were certain limitations in this study.First, due to the study's cross-sectional methodology, it was unable to demonstrate causal links between the variables investigated.Second, because all of the data was self-reported and the participants' responses were not independently validated, social desirability bias and recall bias could have occurred.Third, because the study's participants were all people with chronic illnesses, the findings cannot be generalized to the general public.

Conclusion
This study highlights the prevalence of CMD and Insomnia among patients with chronic NCDs were found to be considerably high.Occupation, diagnosis, comorbid diagnosis, social support, insomnia, and quality of life were all significantly associated with CMD.We also found out that, having CVDs, CMD, and poor QOL significantly increases the likelihood of having insomnia symptoms.As a result, addressing mental health issues among patients with chronic CMD is an essential component of public health interventions during the COVID-19 pandemic.

TABLE 2
Clinical characteristics of study participants at Sidama National Regional State, southern Ethiopia, 2021 (n = 633).

TABLE 3
Factors associated with CMD among patients with chronic NCDs during COVID-19 pandemic in selected hospitals of Sidama national regional state, 2021 (n = 633).

TABLE 3 (
Continued) (102)ajor issues for CVD patients (103).This could be explained by the hypothalamic-pituitary axis (HPA) dysregulation, inappropriate modulation of the autonomic nervous system, elevated sympathetic nervous system activity, and systemic inflammation that are all factors in the etiology of cardiovascular disease(102).In addition, several pandemic-specific factors, such as fear of acquiring the virus and

TABLE 4
Factors associated with Insomnia among patients with chronic NCDs during COVID-19 pandemic in selected hospitals of Sidama national regional state, 2021 (n = 633).unable to visit loved ones, suggest that insomnia may increase during this time (104).