Stress and the hypothalamic–pituitary–adrenal axis: How can the COVID ‐19 pandemic inform our understanding and treatment of acute insomnia?

Greg J. Elder, Ellemarije Altena, Laura Palagini, Jason G. Ellis
Journal of Sleep Research. 2023-02-07; :
DOI: 10.1111/jsr.13842

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Elder GJ(1), Altena E(2), Palagini L(3)(4), Ellis JG(1).

Author information:
(1)Northumbria Sleep Research, Northumbria University, Newcastle upon Tyne, UK.
(2)Institut de Neurosciences Cognitives et Intégratives d’Aquitaine-UMR 5287
CNRS, Team Neuroimaging and Human Cognition, Université de Bordeaux, Bordeaux,
(3)Department of Neuroscience and Rehabilitation, Psychiatric Section University
of Ferrara, Ferrara, Italy.
(4)Department of Clinical and Experimental Medicine, Psychiatric Section,
University of Pisa, Azienda Ospedaliera Universitaria Pisana (AOUP), Pisa,

Stress and sleep are very closely linked, and stressful life events can trigger
acute insomnia. The ongoing COVID-19 pandemic is highly likely to represent one
such stressful life event. Indeed, a wide range of cross-sectional studies
demonstrate that the pandemic is associated with poor sleep and sleep
disturbances. Given the high economic and health burden of insomnia disorder,
strategies that can prevent and treat acute insomnia, and also prevent the
transition from acute insomnia to insomnia disorder, are necessary. This
narrative review outlines why the COVID-19 pandemic is a stressful life event,
and why activation of the hypothalamic-pituitary-adrenal axis, as a biological
marker of psychological stress, is likely to result in acute insomnia. Further,
this review outlines how sleep disturbances might arise as a result of the
COVID-19 pandemic, and why simultaneous hypothalamic-pituitary-adrenal axis
measurement can inform the pathogenesis of acute insomnia. In particular, we
focus on the cortisol awakening response as a marker of
hypothalamic-pituitary-adrenal axis function, as cortisol is the end-product of
the hypothalamic-pituitary-adrenal axis. From a research perspective, future
opportunities include identifying individuals, or particular occupational or
societal groups (e.g. frontline health staff), who are at high risk of
developing acute insomnia, and intervening. From an acute insomnia treatment
perspective, priorities include testing large-scale online behavioural
interventions; examining if reducing the impact of stress is effective and,
finally, assessing whether « sleep vaccination » can maintain good sleep health by
preventing the occurrence of acute insomnia, by preventing the transition from
acute insomnia to insomnia disorder.

© 2023 The Authors. Journal of Sleep Research published by John Wiley & Sons Ltd
on behalf of European Sleep Research Society.


Auteurs Bordeaux Neurocampus