Summary The coronavirus disease 2019 (COVID‐19) pandemic resulted in significant increases in insomnia, with up to 60% of people reporting increased insomnia. However, it is unclear whether exposure to risk factors for the virus or worries about COVID‐19 are more strongly associated with insomnia. Using a three‐part survey over the course of the first 6 months of the pandemic, we evaluated associations between COVID‐19 exposures, COVID‐19 worries, and insomnia. We hypothesised that COVID‐19‐related worries and exposure to risk of COVID‐19 would predict increases in insomnia. Participants ( N = 3,560) completed a survey at three time‐points indicating their exposures to COVID‐19 risk factors, COVID‐19‐related worries, and insomnia. COVID‐19 worry variables were consistently associated with greater insomnia severity, whereas COVID‐19 exposure variables were not. COVID‐19 worries decreased significantly over time, and there were significant interactions between change in COVID‐19 worries and change in insomnia severity over time. Individuals who experienced increases in COVID‐19 worries also experienced increases in insomnia severity. Changes in worry during the COVID‐19 pandemic were associated with changes in insomnia; worries about COVID‐19 were a more consistent predictor of insomnia than COVID‐19 exposures. Evidence‐based treatments targeting virus‐related worries may improve insomnia during this and future calamities.

IMPORTANCESerotonin reuptake inhibitors (SRIs) are the only medications approved for obsessive-compulsive disorder (OCD), yet most patients taking SRIs exhibit significant symptoms. Adding exposure/response prevention (EX/RP) therapy improves symptoms, but it is unknown whether patients maintain wellness after discontinuing SRIs. OBJECTIVE To assess whether patients with OCD who are taking SRIs and have attained wellness after EX/RP augmentation can discontinue their SRI with noninferior outcomes compared with those who continue their SRI therapy. DESIGN, SETTING, AND PARTICIPANTSA 24-week, double-blind, randomized clinical trial was performed from May 3, 2013, to June 25, 2018. The trial took place at US academic medical centers. Participants included 137 adults with a principal diagnosis of OCD (Ն1 year) who were taking an SRI (Ն12 weeks), had at least moderate symptoms (defined as Yale-Brown Obsessive-Compulsive Scale [Y-BOCS] score Ն18 points), and received as many as 25 sessions of EX/RP therapy. Those who attained wellness (Y-BOCS score Յ14 points; 103 patients [75.2%]) were study eligible. Data were analyzed from June 29, 2019, to October 2, 2021.INTERVENTION Participants were randomly assigned either to receive taper to placebo (taper group) or to continue their SRI (continuation group) and monitored for 24 weeks. MAIN OUTCOME AND MEASURESThe Y-BOCS score (range, 0-40 points) was the primary outcome; the Hamilton Depression Rating Scale (HDRS; range, 0-52 points) and the Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF; range, 0%-100%) scores were secondary outcomes. Outcomes were assessed at 8 time points by independent evaluators who were blinded to randomization. The taper regimen was hypothesized to be noninferior to continuation at 24 weeks using a 1-sided α value of .05. RESULTS A total of 101 patients (mean [SD] age, 31.0 [11.2] years; 55 women [54.5%]) participated in the trial: 51 patients (50.5%) in the taper group and 50 patients (49.5%) in the continuation group. At 24 weeks, patients in the taper group had noninferior results compared with patients in the continuation group (mean [SD] Y-BOCS score: taper group, 11.47 [6.56] points; continuation group: 11.51 [5.97] points; difference, −0.04 points; 1-sided 95% CI, −ϱ to 2.09 points [below the noninferiority margin of 3.0 points]; mean [SD] HDRS score: taper group, 5.69 [3.84] points; continuation group, 4.61 [3.46] points; difference, 1.08 points; 1-sided 95% CI, −ϱ to 2.28 points [below the noninferiority margin of 2.5 points]; mean [SD] Q-LES-Q-SF score: taper group, 68.01% [15.28%]; continuation group, 70.01% [15.59%]; difference, 2.00%; 1-sided 95% CI, −ϱ to 6.83 [below the noninferiority margin of 7.75]). However, the taper group had higher rates of clinical worsening (23 of 51 [45%] vs 12 of 50 [24%]; P = .04).CONCLUSIONS AND RELEVANCE Results of this randomized clinical trial show that patients with OCD who achieve wellness after EX/RP therapy could, on average, discontinue their SRI with noninferior outco...

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The COVID-19 pandemic was associated with significant increases in sleep disorder symptoms and chronic worry. We previously demonstrated that worry about the pandemic was more strongly associated with subsequent insomnia than the converse during the acute (first 6 months) phase of the pandemic. In this report, we evaluated whether that association held over one year of the pandemic. Participants (n = 3560) completed self-reported surveys of worries about the pandemic, exposure to virus risk factors, and the Insomnia Severity Index on five occasions throughout the course of one year. In cross-sectional analyses, insomnia was more consistently associated with worries about the pandemic than exposure to COVID-19 risk factors. In mixed-effects models, changes in worries predicted changes in insomnia and vice versa. This bidirectional relationship was further confirmed in cross-lagged panel models. Clinically, these findings suggest that during a global disaster, patients who report elevations in either worry or insomnia should be considered for evidence-based treatments for these symptoms to prevent secondary symptoms in the future. Future research should evaluate the extent to which dissemination of evidence-based practices for chronic worry (a core feature of generalized anxiety disorder or illness anxiety disorder) or insomnia reduces the development of co-occurring symptoms during a global disaster.