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Abstract

Objectives:

Study objectives were to: (1) better understand sleep experiences and unhealthy alcohol use among Veterans with long COVID and (2) explore providers’ perceptions of barriers and facilitators to delivering evidence-based care for sleep problems and unhealthy alcohol use in patients with long COVID.

Methods:

VA electronic health records were used to conduct chart reviews (n = 57) of patients evaluated in a VA COVID-19 Recovery Clinic during 1 calendar year; semi-structured interviews were completed with Veterans (n = 5) and clinicians (n = 7) recruited from the clinic. Veteran participants also completed quantitative, self-report measures assessing sleep- and alcohol-related experiences and behaviors.

Results:

Data from chart reviews and interviews suggested that Veterans with long COVID often had pre-existing sleep problems that were exacerbated during long COVID. Patients and providers agreed that sleep interventions would be beneficial and acceptable in the COVID-19 Recovery clinic. Conversely, few Veterans with long COVID had a pre-existing alcohol use disorder (AUD) diagnosis; alcohol use occurred less frequently and was less often discussed between patients and providers. Providers had mixed viewpoints on delivering alcohol-related care in the clinic; some were highly amenable, others were unsure whether patients would be receptive.

Conclusions:

This study is among the first to take a mixed-method approach to understanding experiences of sleep-wake behaviors and unhealthy alcohol use in Veterans with long COVID. Characterizing sleep and alcohol-related experiences, examining associations with functioning, and exploring perspectives on treatment approaches is critical to support efforts to refine, personalize, and optimize evidence-based sleep and alcohol care for Veterans living with long COVID.

Keywords

sleep alcohol long COVID qualitative research veterans

Introduction

More than 100 million people in the United States have been diagnosed with COVID-19¹ and, in 2022, 6.9% endorsed having a history of “long COVID.”² Although variably defined, the CDC defines long COVID as “signs, symptoms, and conditions that continue or develop after acute COVID-19 infection.”³ Recent data estimates that 69% of individuals with long COVID had ongoing symptoms for over 1 year and over 3-quarters of these individuals indicated that long COVID limited their functioning due to symptoms like cognitive impairment and fatigue.⁴

National Veterans Health Administration (VA) electronic health records (EHR) data have indicated that, compared to a non-infected contemporary control group, Veterans who had a positive test for SARS-CoV-2, had a higher risk of developing mental health disorders like depression, substance use, and sleep disorders, with sleep-wake and alcohol use disorder (AUD) being among the most common. Specifically, Veterans with a positive test for SARS-CoV-2 evidenced a 41% increased risk of diagnosis with an incident sleep disorder and 29% increased risk of diagnosis with an AUD⁵; these risks are likely higher due to the underdiagnosis of sleep-wake disorders and AUD across the VHA. This underdiagnosis may stem from the under-recognition of both classes of disorders by clinicians as well as the reluctance of patients to report unhealthy alcohol use.^6
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Little is known about the subjective nature of sleep problems and unhealthy alcohol use in Veterans with long COVID. In studies of community populations/clinics, 35% to 82% of adults with long COVID reported poor sleep quality and up to 95% reported fatigue.^10
-13 Despite being one of the most common symptoms experienced by individuals with long COVID, few studies have probed the nature of subjective sleep problems among Veterans; this is problematic as research indicates Veterans are more often afflicted by sleep problems than non-Veterans.^14,15 Unhealthy alcohol use may also be common in Veterans with long COVID but, again, research is scant. COVID-19 and AUD seem to be bidirectionally related in that those with an AUD are more likely to later develop COVID-19 and those with COVID-19 may have an increased risk of developing an AUD.¹⁶ In one of the few studies to examine self-reported alcohol use in long COVID patients, 45% reported engaging in unhealthy alcohol use during the first several months after their first long COVID clinic visit; 7 to 14 months later, rates increased to 71.8%.¹⁷ To our knowledge, no other research has examined alcohol as it relates to long COVID, but work examining Veterans with long COVID using VA EHR data suggest an increased burden of AUD compared to Veterans not infected with COVID-19.¹⁸

Emerging evidence also suggests that untreated sleep problems and unhealthy alcohol use likely adversely affect health and functioning among Veterans with long COVID. Among individuals presenting for care in a long COVID recovery clinic, worse sleep quality was associated with higher anxiety, depression, and trauma symptoms.¹³ Additionally, compared to persons without an AUD, those with an AUD and comorbid COVID-19 experienced increased odds of hospitalization and death.¹⁹ Moreover, there is a bidirectional relationship with alcohol use and sleep disorders. Individuals who drink alcohol are more likely to meet criteria for obstructive sleep apnea,²⁰ ~58% of individuals with AUD report clinically significant insomnia symptoms,²¹ and 7% of individuals with insomnia symptoms report unhealthy alcohol use.^22,23

Therefore, the purpose of this mixed-methods study was twofold: (1) to better understand subjective sleep-wake behaviors and unhealthy alcohol use among Veterans with long COVID and (2) to explore providers’ perceptions of barriers and facilitators to delivering evidence-based care for sleep problems and unhealthy alcohol use in patients with long COVID.

Method

Procedures and Sample

We used a mixed-methods approach to better understand Veterans’ sleep-wake and alcohol use behaviors, their impact on health, functioning, and quality of life, and perceptions of evidence-based sleep and alcohol interventions. We conducted chart reviews and semi-structured interviews with patients and providers to explore questions of interest. All study procedures were approved by the VA Pittsburgh Institutional Review Board. A waiver of HIPAA Authorization was obtained for study procedures; verbal informed consent was obtained by all interview participants.

Chart review

Using VA EHR, we conducted structured chart reviews of all patients evaluated in a COVID-19 Recovery Clinic in a Mid-Atlantic VA medical center during 1 calendar year (N = 57; year is not specified to protect privacy). We first obtained data on socio-demographic characteristics and information about current and historical sleep and alcohol-related diagnoses. We then extracted survey data assessing insomnia symptoms and alcohol use via the Insomnia Severity Index (ISI)²⁴ and the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C)²⁵; these surveys are administered and stored in the EHR during routine care in the COVID-19 Recovery Clinic and/or during annual primary care visits. Chart reviews were conducted by a trained research staff member who met regularly with co-PIs to resolve questions and ensure reliability.

Patient interviews

We prospectively administered self-report measures and conducted semi-structured interviews with a sample of patients who were evaluated and/or treated in the COVID-19 Recovery Clinic. Patients (n = 5) were recruited through their clinical providers. Verbal informed consent and study procedures were conducted remotely via VA-approved technology. Semi-structured interviews were recorded and transcribed for analysis. Veterans were compensated $40.

Provider interviews

We conducted semi-structured interviews with providers involved in caring for Veterans seen in the COVID-19 Recovery Clinic (n = 7). Providers spanned clinical disciplines (eg, internal medicine, psychology, and occupational therapy) and interviews assessed barriers, facilitators, and ways to improve evidence-based care for Veterans with sleep problems and/or unhealthy alcohol use. Providers were recruited via email and secure messages. Consistent with VA policy, providers were not compensated for participation.

Recruitment strategy

For our qualitative interviews, we used 2 purposive sampling strategies which included using both criterion sampling (selecting participants that meet a “predetermined criterion of importance”) and maximum variation sampling (where the goal was to speak with different people/diverse cases to understand possibly unique and varied perspectives; see p. 535).²⁶ Criterion sampling allowed us to interview clinicians affiliated with the COVID-19 Recovery clinic as the assumption was that these clinicians, regardless of clinical specialization, possess the knowledge and experience with long COVID necessary to provide detailed and possibly generalizable information related to treating Veterans in this clinic. We also took a maximum variation sampling approach by including COVID-19 Recovery clinicians, regardless of clinician type (eg, physician and psychologist). This allowed us to understand varied perspectives on treating unhealthy alcohol use and sleep disturbances in a long COVID clinic. The maximum variation sampling approach with patients also allowed us to understand varied perspectives from Veterans with long COVID.

Measures

Patient interviews

Prospective interviews were semi-structured, following an interview guide developed by the study team; the International Classification of Functioning, Disability and Health from the World Health Organization²⁷ was used as a guiding framework to query about the nature of sleep-wake and alcohol use behaviors currently and prior to developing long COVID, the perceived impact they have on functioning, and the perceived impact of contextual factors. Demographics were assessed via questionnaire. A structured sleep disorder symptom checklist was administered as a brief screening tool for sleep disorders including: REM sleep behavior disorder, parasomnias, restless legs syndrome, sleep apnea, insomnia, circadian rhythm sleep-wake disorders, and hypersomnias. The PROMIS^® v1.0 Sleep Disturbance Short Form 8a and PROMIS^® v1.0 Sleep-Related Impairment Short Form 8a scales assessed global sleep disturbance and sleep-related impairment.^28,29 Unhealthy alcohol use, risk of AUD, and associated functional impact were assessed with the Alcohol Use Disorder Identification Test (AUDIT; Saunders et al³⁰) and the PROMIS^® v1.0 Alcohol Use Short Form 7a, Positive Consequences Short Form 7a, and Negative Consequences Short Form 7a.^31,32

Provider interviews

Semi-structured provider interviews probed facilitators, barriers, and utility of intervening on sleep-wake behaviors and unhealthy alcohol use to promote functional recovery among Veterans with long COVID. Interviews were guided by the Consolidated Framework for Implementation Research (CFIR),³³ which systematically guides evaluations across clinical contexts to identify barriers and facilitators to care that fall within 5 domains, including: Intervention characteristics (eg, complexity), Inner setting (eg, clinic culture), Outer setting (eg, patient needs), Characteristics of clinicians (eg, knowledge), and Implementation process (eg, engaging leaders). “Care” in this context aimed to understand barriers and facilitators to providing VA-concordant evidence-based care for sleep problems and unhealthy alcohol use within the COVID-19 Recovery clinic.^15,34

Data Analysis

Descriptive statistics were calculated to describe each sample and quantitative measures of sleep, alcohol use, and functioning. Chart review descriptive data were coarsened in accordance with cell size suppression policies.³⁵ Self-report measures for patients recruited for interviews were summed and converted to scaled T-scores when appropriate (ie, PROMIS measures). For semi-structured interviews, a thematic content analysis was conducted using a rapid qualitative analysis approach.^36,37 Neutral domain names were generated corresponding to each interview question. Then, a structured participant by domain matrix was created to organize and summarize narrative data. Each interview transcript was summarized by 1 qualitative analyst and reviewed for consensus by a second analyst. The completed matrix was used to evaluate trends in responses and synthesize points of emphasis across participants.

Results

Sample

Chart review

The chart review sample included all 57 patients evaluated in the COVID-19 Recovery Clinic during the study timeframe. Most patients (>75%) identified as male, White, and were 35 to 86 years old (M = 62.1 years, SD = 13.0 years). Due to minimum sample size requirements needed to protect privacy, data on other demographic characteristics are not reported.

Patient interviews

Patient participants (N = 5) were 61 to 75 years old (M = 69.2, SD = 6.3). All identified as non-Hispanic, retired or disabled, and cisgender men; 4 identified their race as White, 1 as Black. Three had at least a college degree, 2 had a high school degree/GED or some college.

Provider interviews

Provider participants (N = 7) represented clinical disciplines including medicine, nursing, psychology, speech language pathology, and physical therapy. Providers reported working at the VA for an average of 12.8 years (SD = 12.2) and all but 1 reported working in the COVID-19 Recovery clinic since its inception. Providers reported spending an average of 20 h/week (SD = 10.5) directly caring for patients and approximately 3 h/week (SD = 3.3) treating patients in the COVID-19 Recovery clinic.

Patient and Provider Perspectives on Sleep

Chart reviews: Sleep

Approximately 40% of Veterans had a current or historical sleep disorder diagnosis; breathing-related sleep disorder diagnoses (eg, obstructive sleep apnea) were most common (~28% of the total sample), followed by insomnia disorder diagnoses (<20% of the total sample). No other sleep disorders were identified via chart review. A minority of Veterans with a sleep disorder diagnosis also carried an alcohol-related diagnosis and there was not a significant association between a documented sleep disorder diagnosis and documented alcohol-related diagnosis (χ² = .94, P = .33). About half of all charts reviewed had a documented ISI score during their COVID-19 Recovery Clinic intake; among those with documented ISI scores, the average score was 7.9 (SD = 6.5, Median = 7.0), suggestive of subthreshold insomnia symptoms.

Patient interviews: Sleep

Among Veterans who completed semi-structured interviews (N = 5), PROMIS Sleep Disturbance scores ranged from 30 to 69.5 (within normal limits to moderate sleep disturbance; M = 55.5, SD = 15.7). Sleep-Related Impairment scores ranged from 46.7 to 62.6 (within normal limits to moderate sleep-related impairment; M = 53.8, SD = 7.3). On the structured sleep disorder questionnaire, 4 of the 5 respondents endorsed symptom frequency and associated distress and/or functional impact suggestive of a sleep disorder. The number of presumed sleep disorders ranged from 0 to 3 per person, with 2 of 5 participants having 2 to 3 presumed sleep disorders; presumed sleep disorders included restless legs syndrome, insomnia, circadian rhythm disorders, and hypersomnias. Two participants also endorsed symptoms characteristic of sleep apnea (ie, snoring, gasping, pauses in breathing), but with low frequency and severity (eg, no impact on daily functioning).

Patient participants discussed varying changes to their sleep post-COVID, including difficulty falling asleep, frequent awakenings, changes in sleep timing, not getting restful sleep, and periods of tiredness during the day which impacted their daily routine and functioning. One participant identified that, post-COVID, fear of dying contributed to difficulties sleeping at night; they also noted consistent use of their bilevel positive airway pressure (Bi-PAP) device to help ensure uninterrupted breathing during the night. Another participant reported that, post-COVID, their sleep is “sporadic” and “not a restful sleep”; they attributed this primarily to coughing spells. Some participants expressed concern for the change in their sleep pattern and the perception that it was not normal or predictable. Participants generally desired to “be back to normal” and return to their pre-COVID sleep patterns. All participants had sought prior treatment for sleep concerns, and 3 were current positive airway pressure (PAP) users. They were receptive to getting help for sleep concerns through the COVID-19 Recovery Clinic and speculated that these providers could help them return to normal functioning, especially in cases where past sleep treatment was not perceived as helpful (see Table 1 for relevant quotes).

Table 1.

Representative Quotes and Corresponding Domain Regarding Sleep and Alcohol Concerns From Veteran and Provider Participants During Qualitative Interviews.

Domain	Representative patient quotes	Representative provider quotes
Nature of sleep concerns	“When I first got out of the hospital, I really couldn’t sleep at night. It’s gonna sound crazy. I was afraid of dying. So I just, I wouldn’t sleep at night. I didn’t sleep hardly at all. . . And that went on for months. Just months and months and months.” (V-B) “[Sleep] has been the most dramatic result, I should say, with this. Sleep has been very sporadic, very sporadic. I probably would sleep about 2 hours and then wake up and then 2 hours and then wake up and all that stuff . . . So it’s not a restful sleep if you will.” (V-C)	“I do hear occasionally that they are having problems getting good sleep, like deep sleep. But fatigue and sleep seem to be one of the main topics as far as how much they’re sleeping, which is a lot more than normal, not being recharged and feeling refreshed after they sleep.” (P-D) “I’ve noticed. . .both ends of the spectrum. I’ve had Veterans that have had sleep deprivation that they’ve been experiencing since contracting the virus. And then on the other side of it, I’ve had a handful of Veterans that they have very low energy levels and actually find themselves sleeping much more throughout the day.” (P-F) “They have a lot of things going on that could contribute to poor sleep that may have had nothing to do with their COVID infection, that existed long before they ever contracted COVID.” (P-E)
Nature of alcohol use/concerns	“. . .[Contracting COVID] didn’t let my guard down, but it changed my viewpoint about enjoying what’s there and just going ahead and not overdoing it [drinking].” (V-E) “. . .with the COVID I haven’t [drank]. I don’t go out much. The few times that I have, once I start yawning, . . . I have to leave wherever I am just because the yawning is so embarrassing. . .it also tells my body just it needs to lie down somewhere.” (V-D)	“I think I’ve only seen one patient that has met criteria for an alcohol use disorder. However. . .to what degree COVID exacerbated that, I’m not sure.” (P-A) “I can say that just from recollection, there hasn’t been a lot of reported changes in alcohol consumption following a COVID infection. I haven’t run into many people that have used it as a coping mechanism or have increased their consumption. . . .But to me, alcohol has not necessarily played a large role, at least in the cohort of patients that I’ve seen . . .” (P-E)
Sleep treatment approaches	“I’d like to get back into a pattern where I can fall asleep. I know that whatever I do during the day, I’m gonna be able to sleep at night. I’m gonna be refreshed in the morning and be able to get up and go again if I want to. But right now, I’m not like that . . . So yeah, I would be really interested in somebody can help me out.” (V-D)	“I think there’s a lot less shame around sleep issues than there is alcohol issues. So I think there would be a more of a positive reaction overall. . . I think the response would be overwhelmingly positive if they understood the relationship between sleep and all the other functions.” (P-E) “You know, I think they would be very open to . . .finding ways to improve that. Because I think even a non-medically trained just layperson that comes in, they feel the effects of having sleep deprivation, and it kind of . . . has that snowball effect on them. And they are never fearful of talking about it. I have patients bring it up all the time.” (P-F) “What they’re looking for a lot of times is. . .to sleep better. They want to be able to think more clearly, and unfortunately, the sleep and the thinking are so closely tied” (P-E)
Alcohol treatment approaches	“The hepatology doctor talked to me straight out and was very honest and upfront with me and took very aggressive steps to assess where I was physically because of my drinking. And his honesty and directness and he was a past officer. . . he was open, honest, direct communication is probably the best that I could ask for or hope for.” (V-E) “I would have to say it’s gonna be somebody in the medical field. . .I think it would have to come from a doctor who said, ‘You have to stop.’. . .it would have to be somebody I trusted very well. Somebody who I thought knew me well enough to say, ‘You’re going down a road that we don’t want you to go down, and you don’t wanna go down.” (V-D)	“And we would have to ask the questions [about alcohol use]. And I think it’s important, I think a lot of these providers and myself have that – I feel comfortable asking questions, so it’s just making sure you have a nurse and a doctor who feel comfortable spending the time. Because sometimes, you know . . . I have the time to spend with these patients, where some days. . . you may be more of a time crunch because you’re handling different clinics and different providers. So it’s just that time and comfort level asking questions.” (P-D) “I think whether or not people wanna try these [alcohol-related interventions], I think they always appreciate that you at least have an honest conversation with them. I’ve never had anyone respond poorly to like to a thoughtful conversation. Now obviously sometimes we can be judgmental, and sometimes people have had bad experiences. But I think if you just like treat them like normal human beings, that’s what they, they’re still human. So I think that they would respond well to like a thoughtful person.” (P-B)
Barriers to sleep treatment	“Yeah, I’ve been going to the VA hospital quite a lot because of this lack of sleep. I’ve talked to my renal doctor. I’ve talked to the primary doctor. I’ve talked to the cardiologist and the ENT doctors I’ve talked to quite a few people there. Yeah, quite a few specialists. And it’s all conjecture on their part. ‘It may be this, it may be that. Try this, try that. Try this. Try that.’” (V-C) “No, nothing helps. I mean some of the stuff that [psychologist] helped me with, you know, like taking the TV out. Going to bed, you know, maybe a little later. Stuff like that. It helped at first, but then then my body, it was so used to going to bed this time, getting up at this time. And it’s just once you get in that routine, your body’s just used to this and this and this.” (V-B)	“I do think related to like sleep studies, if they’re working, like sometimes some of those can be challenging to schedule and work into your life. And so things like that might be a challenge. . .” (P-C) “. . .we have these, all these great resources, and we only have that Veteran for that short period of time. And yes, they’re telling us that they have that buy in. You could see that they are opening up. You can see that they’re absorbing the information. But then what happens to them once they leave that clinic, or they leave that facility that day? It’s kind of out of our control. So I think that would be a barrier.” (P-F)
Barriers to alcohol treatment	“The first thing that has to happen is acknowledgement. Acknowledgement that you have a problem with that. Because most people are in denial about that. ‘Ohh yeah, I can quit anytime any day,’ . . . But it’s a whole lot harder to do it than saying it. . .It may take a while for them to acknowledge that this in fact is my, is a problem of mine and then go and seek treatment from that point of, from then on. But as long as you do not accept the problem that you have, nah, nothing will happen.” (V-C) “. . .not all Veterans have access to somebody who is gonna reach out to them and say, ‘Hey, you consider these things with alcohol.’ You’d like to think that they would listen after a while, particularly if somebody is able to demonstrate, ‘this is what’s happening to your body.’” (V-D)	“For me, it really does kind of boil down to that motivation. I mean, we have so many options for service delivery now, where it could be telehealth. I think in the past, I may have said something like, ‘they don’t want to come in,’ or, ‘they don’t wanna do an intensive program like [the substance use disorder specialty clinic].’ But I know we have so many different options available that in my mind, the biggest barrier is the wanting to make the change.” (P-C) “I think probably the biggest things that might be helpful would be one of the things we don’t necessarily do every time right now is that behavioral health doesn’t necessarily screen every single patient that presents to COVID recovery clinic. I guess that would be something that could be trialed to see if it’s more effective.” (P-G)

Abbreviations: V, Veteran participants; P, provider/clinician participants.

Provider interviews: Sleep

Providers discussed seeing long COVID patients with sleep issues on “both ends of the spectrum,” ranging from sleep deprivation to excessive sleepiness. Difficulties getting to sleep, frequent awakenings, and non-restorative sleep were among other sleep symptoms identified by providers. Several providers commented on the co-occurrence and interrelationship among sleep difficulties with other commonly reported symptoms (eg, “brain fog” and fatigue). Some provider comments highlighted that sleep difficulties were multifactorial and not necessarily new following COVID (Provider-G [P-G]: “Some people were at home and started to drink more, and drinking impacted their sleep. And then there are some people who have neither of those things who have sleep and could have had past medical issues, like sleep apnea or could have also had things like congestive heart failure, where they’re up at night peeing. . .So the sleep thing tends to be multifactorial.”). Several providers noted that sleep is often a patient-identified treatment goal; they endorsed enthusiasm for including sleep treatment in the COVID-19 Recovery Clinic and thought that sleep treatment would benefit nearly any patient (P-D: “Who doesn’t want to get a good night’s sleep?”). Providers also speculated that sleep treatment may be more well-received than alcohol treatment, given that there may be less stigma associated with this care. Most providers endorsed that the COVID-19 Recovery Clinic was already reasonably well-resourced and set up to provide sleep treatment. Identified barriers for treatment mostly fell within the CFIR construct of the Inner Setting (eg, difficulties scheduling consistent follow up, time commitment, knowledge about sleep interventions and their benefits; see Table 1 for example quotes).

Patient and Provider Perspectives on Alcohol

Chart reviews: Alcohol

Chart review data revealed that less than 37% of patients had a current or historical alcohol-related diagnosis; among those with an alcohol-related diagnosis, the majority (>75%) carried an AUD diagnosis while nearly one-third carried an alcohol-related medical condition diagnosis (eg, alcohol hepatitis). Over 50% of those with an alcohol-related diagnosis also had a sleep disorder documented in the EHR. All patients with an alcohol-related diagnosis had discussion of alcohol use in the chart during their presenting appointment in the COVID-19 Recovery Clinic. Most patients disclosed cessation or reduced drinking; approximately less than a quarter discussed interest in seeking treatment for alcohol use. The majority of patients in the full sample (n = 54) received an AUDIT-C within 1 to 2 years of their COVID-19 Recovery Clinic encounter. The average score was 0.9 (SD = 1.5, Median = 0, range = 0-8), indicating that on average, patients were reporting minimal past-year alcohol use.

Patient interviews: Alcohol

Among patient participants who completed semi-structured interviews (n = 5), 3 reported drinking any alcohol in the past 30 days. PROMIS Alcohol Use T-scores for current drinkers ranged from 38.9 to 52.1 (M T-score = 43.3, SD = 7.6) indicating that participants reported less alcohol use, less cravings, or minimal difficulty controlling their drinking than the average adult. Similar findings emerged for the PROMIS Alcohol-related Negative Consequences scale (M T-Score = 41.9, SD = 8.0) and Positive Consequences scale (M T-Score = 46.2, SD = 11.6), indicating that the current sample is experiencing fewer negative and fewer positive consequences than the average adult. AUDIT scores (M = 2.0, SD = 2.3; range = 0-6) indicated that most endorsed minimal alcohol-related problems and use in the past year.

Participants reported mixed experiences with past alcohol use, but of those that used to drink, all had stopped or significantly reduced their drinking prior to getting COVID. No participants quit drinking directly because of long COVID. Conversely, some described small increases in alcohol use. One participant described being more open to drinking after having COVID (Veteran-E [V-E]: “It didn’t let my guard down, but it changed my viewpoint about enjoying what’s there and just going ahead and not overdoing it.”). Another participant discussed that they did not go out for social drinking during the height of COVID but now have resumed those activities. No participant had a history of prior alcohol treatment, but some reported reducing alcohol use on their own. Multiple factors helped them reduce alcohol, including medical providers who used “open, honest, direct communication,” commitments to family, and time/financial costs of drinking. Although participants were not familiar with formal alcohol treatment, they speculated treatment may be beneficial for other patients if offered in the COVID-19 Recovery Clinic. Many noted that reducing drinking is part of “getting better,” could help in determining the cause of long COVID symptoms, and that patients may benefit from having someone “reach out to them” about their drinking (Table 1).

Provider interviews: Alcohol

Many providers believed that reducing alcohol use was important to improving health and some discussed the concern that alcohol use could worsen sleep quality (P-G: “So things that I think I’ve had concerns about are again [alcohol] can impact things like sleep. So, you know, people may fall asleep, but then wake frequently, and that sleep is not restful”) and worsen mood in long COVID patients (P-F: “. . .through conversations with patients. . .and through research. . . I know that alcohol can obviously impact the level of depression in a negative way.”). However, most noted that alcohol concerns were not systematically assessed or discussed in the COVID-19 Recovery Clinic, despite concerns that drinking increased for some during the pandemic. A few providers did, however, screen for alcohol use in all long COVID patients using unstandardized measures (P-B: “I ask everyone in the intake”). Most said they rarely encountered long COVID patients with alcohol concerns, but 1 provider hypothesized this may be due to the lack of systematic screening (P-D: “I don’t think it’s one that would come out when you’re talking to somebody about long COVID, what their alcohol use is unless somebody asks the question.”). Another provider noted that they educate all long COVID patients about the negative effects alcohol use has on cognition regardless of current use (P-E: “We talk about the role that alcohol can play in terms of being detrimental, and so while I haven’t had any patients . . . that have necessarily fit the bill . . .they do all receive that education that limiting alcohol use . . . particularly when you’re having cognitive symptoms is good practice.”). All providers knew about their VA substance use program; some were comfortable delivering alcohol-related interventions, while others less so (eg, unsure of the criteria for referral, unclear on VA substance use clinical guidelines).

Many barriers to providing alcohol care in the COVID-19 Recovery Clinic fell within the CFIR construct of the Inner Setting (eg, varying knowledge and comfortability discussing alcohol). Providers also wished they had more resources to give patients interested in treatment (eg, handouts listing 12-step programs). Other barriers fell within the CFIR construct of the Outer Setting (eg, difficulty hiring staff that could provide intramuscular AUD medication). Many also discussed patient barriers, including distance from the clinic, motivation for change, and patients’ comfort with discussing alcohol (P-F: “I truly feel as though there are very few people that are going to be extremely honest about their actual alcoholic consumption.”). Ideas to improve this care included providing education on the connection between drinking and long COVID symptoms and suggestions that the larger VA system make alcohol care more of a priority, as they did with suicide prevention, P-D: “So I think the more visibility there is, the more comfortable not only would staff have in bringing up that topic, but probably the more comfortable the veteran or patient would be. . .” (see Table 1 for more representative quotes).

Discussion

This preliminary, mixed-methods study is one of few to explore subjective sleep-wake experiences and unhealthy alcohol use behaviors among Veterans with long COVID; we not only examined this from the perspective of patients but also explored healthcare providers’ perceptions on delivery of care for these conditions within a VA COVID-19 Recovery Clinic. These findings were considered alongside chart review data on a larger sample from the clinic. Initial results suggest that Veterans and providers considered sleep problems to have worsened after an acute COVID infection and that incorporating targeted sleep interventions within the clinic would be beneficial and acceptable to both. Conversely, discussion about alcohol use occurred less frequently between patients and providers, both systematically (ie, no universal screening in the clinic) and sporadically (eg, few patients self-disclosing concerns about drinking). Results also indicated that many long COVID patients had a sleep diagnosis prior to seeking care at the COVID-19 Recovery Clinic; in contrast, a minority of patients had prior AUD.

Findings align with existing literature indicating that sleep disturbance is common among people living with long COVID. Across the chart review sample, insomnia symptom severity scores were suggestive of mild insomnia symptoms. Further, approximately 40% of the chart review sample had a current or historical diagnosis of sleep apnea and/or insomnia disorder. Four of 5 Veterans interviewed endorsed symptoms suggestive of a sleep disorder. Notably, the number of presumed sleep disorders ranged from 0 to 3 per person, with 2 of 5 interviewees endorsing symptoms of 2 to 3 sleep disorders. This highlights that some individuals living with long COVID are plausibly also living with multiple sleep disorders; however, studies with larger samples are needed to corroborate this finding. If, in fact, larger scale work reveals this to be the norm, interventions that target multiple dimensions of sleep health (eg, the Transdiagnostic Intervention for Sleep and Circadian Dysfunction [TranS-C])³⁸; may be particularly useful.

Our interview data provide new insights into subjective sleep disturbances experienced by people living with long COVID. In line with prior research, participants identified sleep problems including: difficulties initiating sleep, frequent awakenings, changes in sleep timing, not getting restful sleep, and daytime tiredness that impacts daily routines and functioning. Most reported having sleep problems prior to COVID-19 infection, yet also endorsed changes post-COVID-19. Two patient-identified contributors to sleep disturbance that have not, to our knowledge, been reported in this patient population included coughing spells and a fear of dying during sleep. Overall, these reported sleep disturbances bear some resemblance to sleep disturbances observed following hospitalization for critical illness and in the context of other chronic conditions (eg, chronic obstructive pulmonary disease, chronic pain, and cardiovascular disease).^39
-42 Sleep interventions that are effective for individuals living with those co-occurring conditions may also have value for those living with long COVID, however this has yet to be empirically tested. Future research should focus on clarifying the etiology of subjective sleep disturbance among people living with long COVID using prospective research methods in which all participants undergo gold-standard diagnostic approaches (eg, data from structured and/or semi-structured interviews, polysomnography, etc.); results from such observational and experimental studies would help to inform subsequent intervention efficacy and effectiveness studies in this group.

The percentage of long COVID patients with an alcohol-related diagnosis in the chart review sample was similar to prevalence rates of AUD found in national samples.^43,44 Most patients with an alcohol-related diagnosis appeared to have stopped or reduced their drinking by the time they were seen in the COVID-19 Recovery Clinic; only a minority reported interest in seeking treatment to help reduce use. AUDIT-C data corroborated this finding, revealing that most patients had reported minimal alcohol use in the previous 1 to 2 years. Given chart review findings, it is possible that individuals with long COVID are not more or less likely to have an alcohol-related diagnosis. However, future studies designed to evaluate the longitudinal relationship between long COVID and alcohol-related diagnoses is needed to explore this hypothesis.⁴⁵

Qualitative interviews provided a deeper understanding on the interplay between long COVID and unhealthy alcohol use. Patients reported that, overall, their drinking behavior was not impacted by long COVID symptoms; many were not regular drinkers before COVID and most continued not drinking or drinking socially on occasion after contracting COVID. Providers agreed that, in general, unhealthy alcohol use is detrimental to one’s health, but were not confident that there was a direct relationship between alcohol use/AUD and long COVID. There was an acknowledgement by all that alcohol use was not systematically screened for in the COVID-19 Recovery Clinic, yet some providers routinely inquired about alcohol use during intakes. Others reported talking with all patients about the harmful effects alcohol use has on cognition, given the cognitive difficulties long COVID patients report. Given this, it may be useful for clinics to move toward implementing a standardized process for alcohol screening.

In the general population, sleep disturbance and unhealthy alcohol use commonly co-occur and can perpetuate one another.²¹ Our semi-structured interviews did not explicitly inquire about the co-occurrence of sleep disturbance and unhealthy alcohol use and Veterans did not spontaneously report this co-occurrence as a significant issue in the context of long COVID. Several providers did comment on the known negative associations between alcohol use and sleep disturbance but most chart review patients with a documented sleep disorder did not have co-occurring unhealthy alcohol use or a documented alcohol-related disorder (and the association between sleep disorder and alcohol-related disorder was not statistically significant). This lack of association may be related to an underreporting of alcohol use by patients or a lack of awareness regarding the reciprocal impact of alcohol consumption on sleep quality and disease prevention, which is especially pertinent in the context of infectious diseases such as COVID-19. However, it is noteworthy that over half of patients diagnosed with an alcohol-related disorder within the chart review sample also had a sleep-related diagnosis. Future work would benefit by looking at longitudinal incidence rates and co-occurrence of alcohol-related disorders and sleep disorders in larger long COVID samples (eg, using national VA electronic health record data). It will be important for providers to not only recognize the potential diagnostic co-occurrence of unhealthy alcohol use/alcohol-related disorders and sleep disorders but also to engage in discussions with their patients about the adverse effects of alcohol on sleep health and how alcohol may exacerbate sleep disorders such as insomnia and obstructive sleep apnea.^45,46

Qualitative interviews also highlighted potential opportunities for implementing evidence-based sleep and/or alcohol-related care in VA COVID-19 Recovery Clinics. All patients interviewed were receptive to receiving sleep and alcohol-related interventions during their appointments. Providers were enthused about the possibility of delivering sleep-related interventions in the COVID-19 Recovery Clinic, conveying this would likely be beneficial to, and well-received by, patients. They were less confident about delivering alcohol-related care; some were very open while others were less so. However, many noted that providers may be receptive if they had more time and confidence in delivering this care. Given VA’s investment in annual alcohol screening in primary care and the requirement for primary care clinicians to deliver brief alcohol interventions when a patient screens positive for unhealthy alcohol use, COVID-19 Recovery Clinic providers could leverage VA alcohol-related training and educational materials to reduce barriers. In addition, the COVID-19 Recovery Clinic team often includes a psychologist who could train other providers as well as triage, evaluate, and treat patients with unhealthy alcohol use. This may address barriers of knowledge, confidence, and time.

Findings should be interpreted with consideration of several limitations. Our focus was on Veterans and providers from 1 hospital within the VA network; therefore, we must be cautious generalizing our findings to non-Veterans living with long COVID, to other VA clinics, and to healthcare systems outside the VA. Further, though qualitative interviews provided a more in-depth understanding of the subjective sleep and alcohol-related experiences of Veterans, our sample size was limited. Additionally, descriptive data from chart reviews had to be coarsened to protect patient privacy, and exact rates and sample sizes for certain findings could not be reported. Finally, we evaluated rates of sleep disturbance and unhealthy alcohol use of long COVID patients during a 1-year timeframe; this provides an informative – albeit a time-limited – glimpse into the experiences of people living with long COVID. However, our understanding of long COVID remains nascent and, as we learn more about these conditions, the treatment landscape for long COVID will continue to rapidly evolve. It will be important to continue monitoring sleep- and alcohol-related experiences to determine whether and how they change over time.

In conclusion, this mixed-methods study found that sleep disturbance is common among people living with long COVID, while AUD less so. The nature of sleep disturbance is likely multifactorial; for some, COVID-19 may precipitate new experiences of sleep disturbance and for others it may exacerbate existing sleep disturbance. Patients and providers both believed alcohol use negatively impacted health, but reactions to incorporating alcohol-related care in the clinic were mixed. Future work investigating long COVID in an AUD population may provide more insight into how to deliver AUD care to these patients feasibly. In contrast, patients and providers expressed consistent openness to the idea of intervening on sleep as part of their long COVID care. This sentiment reinforces future efforts to evaluate the efficacy and effectiveness of sleep health interventions in the context of long COVID.

Footnotes

Acknowledgements

This material is partially the result of work supported with resources and the use of facilities at the VISN 4 Mental Illness Research, Education, and Clinical Center at the VA Pittsburgh Healthcare System. The contents of this work do not represent the views of the Department of Veterans Affairs, Department of Defense, or the U.S. Government. We thank the COVID-19 Recovery Clinic and Veterans who volunteered their time for this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This material is the result of work supported by a 2022 Gerald Goldstein Early Career Mental Health Research Award (Veterans Health Foundation, Pittsburgh, PA; mPIs: Tighe & Bachrach). Dr. Bachrach is supported by a VA Career Development Award funded by Health Systems Research (CDA 20-057 / IK2HX003087). Dr. Tighe was supported by a VA Career Development /Capacity Building Award funded by Rehabilitation Research & Development (IK2RX003393) from 2020-2023.

ORCID iD

Rachel L. Bachrach

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Sleep and Alcohol Use Among Veterans Living With Long COVID

Abstract

Objectives:

Methods:

Results:

Conclusions:

Keywords

Introduction

Method

Procedures and Sample

Chart review

Patient interviews

Provider interviews

Recruitment strategy

Measures

Patient interviews

Provider interviews

Data Analysis

Results

Sample

Chart review

Patient interviews

Provider interviews

Patient and Provider Perspectives on Sleep

Chart reviews: Sleep

Patient interviews: Sleep

Provider interviews: Sleep

Patient and Provider Perspectives on Alcohol

Chart reviews: Alcohol

Patient interviews: Alcohol

Provider interviews: Alcohol

Discussion

Footnotes

Acknowledgements

Declaration of Conflicting Interests

Funding

ORCID iD

References