Environmental Science and Pollution Research (2022) 29:28062–28069

https://doi.org/10.1007/s11356-021-18384-4

RESEARCH ARTICLE

Circadian rhythm disorder and anxiety as mental health complications

in post‑COVID‑19
Dmytro I. Boiko1 · Andrii M. Skrypnikov1 · Anastasiia D. Shkodina2,3 · Mohammad Mehedi Hasan4 ·
Ghulam Md. Ashraf5,6 · Md. Habibur Rahman7,8 

Received: 23 November 2021 / Accepted: 24 December 2021 / Published online: 5 January 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
In 2020, the world gained dramatic experience of the development of the 2019 coronavirus disease pandemic (COVID-19)
caused by severe acute respiratory syndrome 2 (SARS-CoV-2). Recent researches notice an increasing prevalence of anxiety
and circadian rhythm disorders during COVID-19 pandemic. The aim of the study was describing clinical features of circa-
dian rhythm disorders and the level of anxiety in persons who have had COVID-19. We have conducted a cohort retrospec-
tive study that included 278 patients who were divided into 2 study groups according to medical history: group 1 includes
patients with a history of COVID-19; group 2 consists of patients who did not have clinically confirmed COVID-19 and are
therefore considered not to have had this disease. To objectify circadian rhythm disorders, they were verified in accordance
with the criteria of the International Classification of Sleep Disorders-3. The level of anxiety was assessed by the State-Trait
Anxiety Inventory. The most common circadian rhythm disorders were sleep phase shifts. We found that COVID-19 in the
anamnesis caused a greater predisposition of patients to the development of circadian rhythm disorders, in particular delayed
sleep phase disorder. In addition, it was found that after COVID-19 patients have increased levels of both trait and state
anxiety. In our study, it was the first time that relationships between post-COVID-19 anxiety and circadian rhythm disorders
had been indicated. Circadian rhythm disorders are associated with increased trait and state anxiety, which may indicate
additional ways to correct post-COVID mental disorders and their comorbidity with sleep disorders.

Keywords  COVID-19 · Circadian rhythm · Anxiety · Mood disorders · Sleep disorders · Cohort retrospective study

Responsible Editor: Lotfi Aleya

3
* Anastasiia D. Shkodina Neurological Department, Municipal Enterprise, “City
ad.shkodina@gmail.com Clinical Hospital of Poltava City Council”, Poltava, Ukraine
4
* Md. Habibur Rahman Department of Biochemistry and Molecular Biology, Faculty
pharmacisthabib@gmail.com of Life Science, MawlanaBhashani Science and Technology
University, Tangail, Bangladesh
Dmytro I. Boiko
5
bojko998@gmail.com Pre‑Clinical Research Unit, King Fahd Medical Research
Center, King Abdulaziz University, Jeddah, Saudi Arabia
Andrii M. Skrypnikov
6
skrypnikovandrii@gmail.com Department of Medical Laboratory Technology, Faculty
of Applied Medical Sciences, King Abdulaziz University,
Mohammad Mehedi Hasan
Jeddah, Saudi Arabia
mehedi.bmb.mbstu@gmail.com
7
Department of Pharmacy, Southeast University, Banani,
Ghulam Md. Ashraf
Dhaka 1213, Bangladesh
ashraf.gm@gmail.com
8
Department of Global Medical Science, Wonju College
1
Department of Psychiatry, Narcology and Medical of Medicine, Yonsei University, Wonju 26426, Gangwon‑do,
Psychology, Poltava State Medical University, Poltava, Korea
Ukraine
2
Department of Neurological Diseases With Neurosurgery
and Medical Genetics, Poltava State Medical University,
Poltava, Ukraine

13
Environmental Science and Pollution Research (2022) 29:28062–28069
Introduction
In 2020, the world gained dramatic experience of the devel-
opment of the 2019 coronavirus disease pandemic (COVID-
19) caused by SARS-CoV-2. Based on previous studies,
SARS-CoV-2 penetrates the blood–brain barrier and can
directly affect the nervous tissue, which causes the develop-
ment of neurological and psychiatric symptoms (Hossain
et al. 2020) (Sharma et al. 2021) (Rahman et al. 2020). At
the same time, quarantine and social distancing have a sig-
nificant impact on the psychological state of the population.
Separation from relatives, loss of freedom, uncertainty about
disease status, and boredom can sometimes have dramatic
effects. Serious socioeconomic losses can be a risk aspect for
signs of mental disorders, in particular anxiety. Fear of infec-
tion, economic hardship, and stigma are important ingredi-
ents that lead to mental health problems during COVID-19
too (Akter et al. 2021)(Kaur et al. 2021). Despite the sig-
nificant amount of research on various aspects of the patho-
genesis and treatment of COVID-19, there are still many
unresolved issues of the effectiveness of the therapy of such
patients, especially the amount of psychosocial interventions
and predictors of long-term prognosis (Ivanova et al. 2020).
Recently, there have been a growing number of reports
of symptoms that persist in the post-COVID period.
Although studies of the classification of long-term effects
remain at an early stage, researchers distinguish, among
others, neurocognitive, psychological, and neurologi-
cal post-COVID syndromes, which are characterized by
involvement of the nervous system (Alsharif and Qurashi
2021; Maltezou et al. 2021).
In a research authored by Fernández-de-las-Peñas et al.
(2021b), the following classification for post-COVID symp-
toms was proposed (Fernández-de-las-Peñas et al. 2021b):
Transition phase: acute COVID-19 (up to 5 weeks);
Phase 1: acute post-COVID symptoms (weeks 5–12);
Phase 2: long post-COVID symptoms (weeks 12–24);
Phase 3: persistent post-COVID symptoms (more than
24 weeks).
Meta-analysis of Xiong et al. (2020) shows an increase
in the incidence of anxiety disorders from 6.3% to 50.9%
after COVID-19 (Xiong et al. 2020). In addition, it is esti-
mated that anxiety symptoms persist in approximately 15%
of patients in the post-COVID period (Rogers et al. 2020),
while 47% COVID-19 patients noticed experiencing anxi-
ety (Deng et al. 2021). It shows a great deal of anxiety in
post-COVID syndrome, but exact range of its prevalence
remains unclear.
According to the definition from the DSM-5, anxiety
is the expectation of a future threat, which differs from
28063
fear in an emotional response to a real or perceived immi-
nent threat. In addition, this term in the DSM-5 includes
an additional component, namely the cognitive aspects of
anxious expectation (Kupfer 2015). In the general popula-
tion, anxiety disorders are usually chronic. To prevent and
control chronic disease, timely treatment and management
of chronic diseases are necessary, which can be achieved
by identifying indicators of risk of chronicity (Ten Have
et al. 2021).
Environmental factors can affect the infectivity and sur-
vival of the coronavirus. Several epidemiological and labo-
ratory studies show that outbreaks of coronavirus disease
and the rate at which it spreads depend on climate, weather
conditions and population density (Doğan et  al. 2020;
Shahzad et al. 2021). The seasons are considered to be a
significant environmental factor influencing the initiation
and further dynamics of mental disorders due to a number of
heliometeorological factors determining biological rhythms
such as the circadian functioning of the human body. It has
been established that there is a multi-vector network between
medico-biological phenomena and biorhythmological fea-
tures of people suffered mental disorders (Zhyvotovska et al.
2017). Circadian rhythm disorders and sleep disorders are
conditions that under normal circumstances rarely attract
the attention of doctors. However, it is important to keep in
mind that circadian rhythms are a factor in the optimization
of the immune system. The most constitutive risk factors are
genetic. The known association of affective disorders with
the functioning of circadian rhythms makes it possible to
study clock genes as predictors of anxiety. Although clock
genes have been implicated in regulating mood, the extent
to which they can influence affective disorders is not well
understood. The PER3 and BMAL1 genes, which influence
daytime mood, may be promising candidates (Landgraf et al.
2016; Liberman et al. 2017).
During the early period of the COVID pandemic, the
attention of researchers was drawn to non-pharmacological
methods of treatment of this disease (Tagde et al., 2021)
(Hussain et  al., 2021). Desynchronization of circadian
rhythm and immune system can lead to increased suscepti-
bility to infectious diseases and affect their course (Bryson
2020). Circadian rhythm disorders and sleep disorders are
closely related to changes in mental status and the devel-
opment of affective disorders, including anxiety syndrome
(Boiko et  al. 2017; Difrancesco et  al. 2019; Silva et  al.
2020). There is evidence of an association between certain
polymorphisms of ‘internal clock’ genes, which are associ-
ated with chronotype features and disorders of the circa-
dian system, with the development of affective disorders,
including anxiety and depression (Partonen 2012; Sipilä
et al. 2010). Animal models indicate circadian changes in
serotonin secretion in rats with anxiety disorders (Bacqué-
Cazenave et al. 2020), which may be one of the common
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links in the pathogenesis between affective disorders and
circadian dysfunction. In addition, circadian rhythms are
reported to play a significant role in the regulation of meta-
bolic processes and the metabolism of neurotransmitters
(Tarianyk et al. 2021). Recent studies indicate a link between
sleep phase shift disorders and high levels of stress and anxi-
ety, which in combination with neurobiological components
may presuppose comorbidity of these conditions (Gradisar
and Crowley 2013; Kivelä et al. 2018).
However, the severity of anxiety in circadian rhythm dis-
orders on the background of COVID-19 has not been studied
yet. The aim of the study was describing the prevalence of
circadian rhythm disorders and its links to the level of anxi-
ety in persons who have had COVID-19.
Materials and methods
Inclusion and exclusion criteria
We have conducted a cohort retrospective study that included
278 patients who consulted a family doctor for a preventive
examination during 2021. This has limited a certain number
of patients in study groups. Criteria for inclusion in the study
were age from 18 to 59 years, complaints of sleep disorders
and anxiety, 5-day work schedule with peak activity in day-
light. Exclusion criteria: age from 60 years, somatic pathol-
ogy in the stages of sub- and decompensation, severe mental
disorders. The age was limited because younger people were
children and were treated in children’s hospitals. People aged
more than 60 years were elderly according to the WHO clas-
sification. It means that they have more accompanying ill-
nesses with a brain injury that can cause anxiety.
Grouping
All patients included in the study gave informed consent.
The study was conducted in compliance with the basic provi-
sions of the ‘Ethical principles of scientific medical research
involving human subjects,’ approved by the Declaration of
Helsinki (1964–2013), guidelines good clinical practice
(ICH GCP) (1996), orders of the Ministry of Health of
Ukraine № 690 dated 23.09.2009, № 944 dated 14.12.2009,
№ 616 dated 03.08.2012.
Patients were divided into 2 study groups:
group 1 (n = 153)—patients with a history of COVID-19;
group 2 (n = 125)—patients who did not have clinically
confirmed COVID-19 and are therefore considered not to
have had this disease.
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Environmental Science and Pollution Research (2022) 29:28062–28069
The study groups were representative by age and sex. The
mean age of patients in group 1 was 39.6 ± 3.8 years, and in
group 2—41.9 ± 4.6 years, which had no statistically signifi-
cant differences (p = 0.643). The gender composition of all
studied groups was equal and comparable without signifi-
cant differences between the groups (χ2 = 3,841, p = 0,504),
namely 82 (53.6 ± 4.03%) men and 71 (46.4 ± 4.03%) women
in group 1 and 72 (57.6 ± 4.42%) and 53 (42.4 ± 4.42%) in
group 2, respectively.
During the examination of the patient, a clinical interview
was conducted detailing the complaints and anamnestic data.
Collection of information on the clinical course of COVID-
19 was performed by analyzing both outpatient cards and
extracts from inpatient cards.
Circadian rhythm disorders
To objectify circadian rhythm disorders, they were verified
in accordance with the criteria of the International Clas-
sification of Sleep Disorders-3, which includes advanced
sleep phase disorder, delayed sleep phase disorder, irregular
sleep phase disorder, non-24-h sleep–wake disorder, jet lag,
and shift work sleep disorders, others (not classified in other
headings) (Berry 2012; Sateia 2014).
To assess the function of the circadian rhythm, we used
a sleep diary, which was filled in by the patient for 7 days
before the first visit, and data from daily thermometry, which
was performed by the patient every 3 h.
The following criteria were used to confirm circadian
rhythm disorders:
a) persistent or recurring because of:
damage to the circadian rhythm system;
mismatch of internal rhythm and external factors;
b) lead to insomnia and/or excessive daytime sleepiness;
c) related to the disturbances in social, professional, and
other spheres of activity;
d) cannot be better explained by another sleep disorder,
neurological or mental disorder, medication and substance
use.
Level of anxiety measurement
The level of anxiety was assessed by the State-Trait Anxi-
ety Inventory (STAI). It consists of 40 questions divided
into two blocks, the first of which is responsible for trait
anxiety, and the second—for state. The scale of trait anxi-
ety describes anxiety as a characteristic permanent behav-
ioral trait, due to which a person perceives objectively safe
things as a source of danger. At the same time, the state scale
characterizes the emotional reaction to the current situation.
Each of the 40 questions contains a Likert-scale answer in
Environmental Science and Pollution Research (2022) 29:28062–28069 28065

the form of a statement from 1 point (never) to 4 points
(very often). A separate sum of points is calculated for each
block, which can vary from 20 to 80 points, whereby a larger
amount corresponds to a higher intensity of anxiety. It is
considered that < 30 points are a low level of anxiety, 31–45
points—moderate, > 45 points—high (Julian 2011).
Statistical analysis
Statistical analysis was performed using EZR Statistics
v.1.13 and Microsoft Office Excel 2019. Qualitative vari-
ables were presented in the form of absolute values (abs.)
and relative value (P) with the calculation of relative error
(p). To compare qualitative data, χ2-Pearson with Yates
correction was used. To analyze the risk of comorbidity
of nosologies, the calculation of the risk ratio with a 95%
confidence interval was used. The results were considered
statistically significant at p < 0.05.
Results and discussion
The mean period until the COVID-19 clinical onset from the
time of examination in group 1 patients was 7.6 ± 1.1 weeks.
Among them, 113 (73.8 ± 3.6%) people reported the pres-
ence of respiratory system symptoms, 96 (57.0 ± 4.01%)—
nervous system symptoms, 67 (43.8 ± 4.02%)—hemato-
logical abnormalities, 26 (16.9 ± 3.04%)—cardiovascular
symptoms, 14 (9.15 ± 2.5%)—gastrointestinal disorders,
and 4 (2.6 ± 1.3%)—urinary system disorders. Regarding the
nervous system issues in particular, in accordance with med-
ical records in patients with COVID-19 there were olfactory
disorders in 71 (73.9 ± 4.5%) patients, taste disturbances in
64 (66.7 ± 4.8%) patients, ataxia in 11 (11.5 ± 3.3%) patients
and peripheral nerve damage in 9 (9.4 ± 2.9%) patients.
Among patients who have had COVID-19, only 44
(28.8 ± 3.7%) patients considered themselves to be in
contact with carriers and assumed the possibility of the
disease development, another 48 (31.4 ± 3.7%) patients
considered having had no prior contact with infected per-
sons, however, admitted the possibility of COVID onset,
and 61 (39.9 ± 3.9%) patients were sure that they would
not get sick.
According to the results of daily thermometry and entries
in sleep diaries, we identified 118 (77.1 ± 3.39%) cases of
circadian rhythm disorders among patients of group 1 and
67 (53.6 ± 4.46%) among patients of group 2, which are
shown in Table 1. It was found that the presence of circa-
dian rhythm disorders is more typical for persons of group
1 (χ2 = 16.06, p < 0.001). Among circadian rhythm disor-
ders in group 1, advanced sleep phase disorder was found
in 28 (23.7 ± 3.9%) patients, delayed sleep phase disorder
in 61 (51.7 ± 4.6%), irregular sleep phase disorders—in 18
(15.3 ± 3.3%), non-24-h rhythm—in 8 (6.7 ± 2.3%), others—
in 3 (2.5 ± 1.4%) patients.
Among the latter, 1 jetlag syndrome and 2 shift works
sleep disorders were identified. In group 2, advanced sleep
phase disorder was found in 19 (28.4 ± 5.5%) patients,
delayed sleep phase disorder—in 24 (35.8 ± 5.9%), irreg-
ular sleep phase disorder—in 17 (25.4 ± 5.3%), non-24-h
rhythm—in 3 (4.5 ± 2.5%), others (shift work sleep disor-
der)—in 2 patients.
We found that the history of COVID-19 was not associ-
ated with the risk of developing advanced sleep phase dis-
order (RR = 0.84, 95% CI 0.51–1.38), irregular sleep phase
disorders (RR = 0.61, 95% CI 0.33–1.09) and non-24-h cir-
cadian rhythm (RR = 1.51, 95% CI 0.42–5.52). At the same
time, the presence of a history of COVID-19 increased the
risk of developing delayed sleep phase disorders by 1.5 times
(RR = 1.44, 95% CI 1.01–2.08). Other circadian rhythm dis-
orders were relatively isolated, so they are not subject to
statistical analysis due to the lack of data.
In group 1, low levels of trait anxiety were found in 64
patients, moderate—in 65, and high—in 24, while in group

Table 1  Distribution of levels Circadian rhythm disorder Level of trait anxiety

of trait anxiety depending on
different types of circadian Group 1 (n = 153) Group 2 (n = 125)
rhythm disorders, taking
into account the presence of Type Yes/No Low Middle High Low Middle High
COVID-19 in the anamnesis,
DSPD Yes 9 (5.9%) 35 (22.9%) 17 (11.1%) 3 (2.4%) 5 (4.0%) 16 (12.8%)
abs. (P%)
No 55 (29.4%) 30 (19.6%) 7 (4.6%) 69 (55.2%) 29 (23.2%) 3 (2.4%)
ASPD Yes 9 (5.9%) 16 (5.9%) 3 (2.0%) 8 (6.4%) 6 (4.8%) 5 (4.0%)
No 55 (29.4%) 49 (32.0%) 21 (13.7%) 64 (51.2%) 28 (22.4%) 14 (11.2%)
ISPD Yes 4 (2.6%) 11 (7.2%) 3 (2.0%) 10 (8.0%) 4 (3.2%) 3 (2.4%)
No 61 (39.9%) 54 (35.3%) 21 (13.7%) 62 (49.6%) 30 (24.0%) 16 (12.8%)
Non-24-h rhythm Yes 1 (0.65%) 1 (0.65%) 6 (3.9%) 0 (0%) 2 (1.6%) 1 (0.8%)
No 63 (41.2%) 64 (41.8%) 18 (11.8%) 72 (57.6%) 32 (25.6%) 18 (14.4%)

Note. DSPD—delayed sleep phase disorder, ASPD—advanced sleep phase disorder, ISPD—irregular sleep
phase disorder

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Fig. 1  Level of trait anxiety in
patients who either have had
(group 1) or haven’t had (group
2) COVID-19
2, low levels were found in 72 people, moderate—in 34, and
high—in 19, which is presented in Fig. 1.
It was found that in the group of patients with COVID-
19 in the anamnesis, a moderate level of trait anxiety pre-
vailed, compared to the group 2, where a low level prevailed
(χ2 = 8.02, p = 0.019).
The level of state anxiety in group 1 was low in 46 people,
moderate—in 48, and high—in 59, and in group 2 54 people
had low levels, 47—moderate and in 24—high, which is
presented in Fig. 2.
It was determined that in patients who have had COVID-
19, there is statistically significant higher intensity of state
anxiety and its high level prevails, while in patients haven’t
had COVID-19 low and moderate levels of anxiety were the
most common (χ2 = 12, 72, p = 0.002).
Fig. 2  Level of state anxiety in
patients who either have had
(group 1) or haven’t had (group
2) COVID-19
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Environmental Science and Pollution Research (2022) 29:28062–28069
The levels of trait anxiety in patients with various forms
of circadian rhythm disorders, taking into account the
presence of COVID-19 in the anamnesis, are presented in
Table 1.
In group 1, the increase in the level of trait anxiety was
associated with the presence of a delayed sleep phase dis-
order (χ2 = 32.67, p < 0.001), non-24-h rhythm (χ2 = 7.21,
p = 0.021) and a disorder of the irregular phase of sleep
(χ2 = 22.46, p < 0.001). At the same time, patients in group 1
who were diagnosed with advanced sleep phase disorder, no
significant differences (χ2 = 5.87, p = 0.0542) in the severity
of personal anxiety compared with those who did not have
this disorder.
Group 2 was characterized by an increase in per-
sonal anxiety with the concurrent delayed sleep phase
Environmental Science and Pollution Research (2022) 29:28062–28069 28067

disorder (χ2 = 62.69, p < 0.001), but no differences were
found between the level of anxiety while detecting disor-
ders of early (χ2 = 2.91, p = 0.234) and irregular (χ2 = 0.180,
p = 0.091) phases of sleep or non-24-h rhythm (χ2 = 4.19,
p = 0.122).
The distribution of levels of state anxiety in patients
with various forms of circadian rhythm disorders, taking
into account the presence of COVID-19 in the anamnesis,
is presented in Table 2.
An increase in state anxiety in group 1 and group 2
was found in patients with delayed sleep phase disorder
(χ2 = 34.46, p < 0.001 and χ2 = 66.53, p < 0.001, respec-
tively), irregular sleep phase disorders (χ2 = 31,89, p < 0.001
and χ2 = 18.71, p < 0.001, respectively) and non-24-h
rhythm (χ 2 = 31.85, p < 0.001 and χ2 = 20.79, p < 0.001,
respectively). The presence of advanced sleep phase disorder
was not associated with more pronounced state anxiety in
both group 1 (χ2 = 0.72, p = 0.712) and group 2 (χ2 = 0.26,
p = 0.881). It was not possible to estimate the differences
in the intensity of trait and state anxiety in patients with
jet lag and shift work disorder due to the small number of
observations.
Symptoms of respiratory and nervous system damage
predominated in patients who had COVID-19. Among the
latter, there were disturbances of smell and taste, ataxia and
damage to peripheral nerves, which, in turn, may indicate
the neurotoxicity of the SARS-CoV-2 virus.
On the other hand, the fact of coronavirus infection
itself could act as a psycho-traumatic factor that caused
changes in the mental state of patients, as most of them
considered themselves protected and insensitive to the
disease, i.e., did not expect the onset of COVID. In addi-
tion, the long-term quarantine measures that have been
introduced due to the pandemic have affected both the
mental and physical conditions of people. A high preva-
lence of anxiety disorders has been reported both in the
acute period of COVID-19 and within 6–7 months after it.
There are a variety of data on the frequency of their occur-
rence, which ranges from 16 to 45% (Chen et al. 2021;
Fernández-de-las-Peñas et al. 2021a).
The most common circadian rhythm disorders were
sleep phase shifts. We found that COVID-19 in the anam-
nesis caused a greater predisposition of patients to the
development of circadian rhythm disorders, in particular
delayed sleep phase disorder. In addition, it was found that
after COVID-19 patients have increased levels of both trait
and state anxiety. The prevalence of delayed sleep phase
disorder may be due to both the neurotropic nature of the
SARS-CoV-2 and the quarantine associated with COVID-
19 pandemic. Thus, the effect of a change in light expo-
sure under lockdown conditions on daily functioning was
observed, namely a shift of the rhythm by 3 or more hours
ahead. This has led to a decrease in exposure to natural
light, which affects the central circadian oscillator, which
can also affect physical and nutritional activity (Bertrand
et al. 2021; Leone et al. 2020). It was also noted that the
delay in sleep during a pandemic is associated with a
worse quality of sleep and the psychological state of the
respondents, and as a result, reduces the quality of their
life and the degree of disability (Robillard et al. 2021).
Some limitations of our study should be considered. In
particular, it was conducted within one hospital. It will be
useful to conduct similar studies in different countries in
order to accumulate sufficient data. In addition, we were
limited by clinical interviews without neurophysiological
study of sleep structure or analysis of circadian biomark-
ers. The study of these features may play an important role
in establishing a link between post-COVID-19 anxiety and
circadian rhythm disorders. Furthermore, investigating of
the chronotype of patients may be useful, which is usu-
ally considered as the middle of a sleep time on the free
day. It is intriguing in further research to study the role of
chronotype in the formation of circadian rhythm disorders
and increased post-COVID-19 anxiety.

Table 2  Distribution of levels Circadian rhythm disorder Level of state anxiety

of state anxiety depending on
different types of circadian Group 1 (n = 153) Group 2 (n = 125)
rhythm disorders, taking
into account the presence of Type Yes\No Low Middle High Low Middle High
COVID-19 in the anamnesis,
DSPD Yes 9 (5.9%) 33 (21.6%) 19 (12.4%) 1 (0.8%) 7 (5.6%) 16 (12.8%)
abs. (P%)
No 55 (29.4%) 32 (20.9%) 5 (3.3%) 71 (56.8%) 27 (21.6%) 3 (2.4%)
ASPD Yes 13 (8.5%) 12 (7.8%) 3 (2.0%) 10 (8.0%) 6 (4.8%) 3 (2.4%)
No 51 (33.3%) 53 (34.6%) 21 (13.7%) 62 (49.6%) 28 (22.4%) 16 (12.8%)
ISPD Yes 3 (2.0%) 4 (2.6%) 11 (7.2%) 4 (3.2%) 12 (9.6%) 1 (0.8%)
No 61 (39.9%) 61 (39.9%) 13 (8.5%) 68 (54.4%) 22 (17.6%) 18 (14.4%)
Non-24-h rhythm Yes 0 (0%) 3 (2.0%) 5 (3.3%) 0 (0%) 0 (0%) 3 (2.4%)
No 64 (41.8%) 62 (40.5%) 19 (12.4%) 72 (57.6%) 34 (27.2%) 16 (12.8%)

Note. DSPD—delayed sleep phase disorder, ASPD—advanced sleep phase disorder, ISPD—irregular sleep
phase disorder

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28068
The relationship between the severity of anxiety syn-
drome and circadian rhythm disorders in the post-COVID
period has been established. Delayed sleep phase disor-
der, irregular sleep phase disorder, and non-24-h rhythm
had the most pronounced link to the increased levels of
anxiety. These conditions are accompanied by a process
of maladaptation due to an imbalance between the socially
acceptable work schedule and the daily functioning of the
patient.
Concluding Remarks
The post-COVID period is characterized by complications
in the form of mental disorders, in particular anxiety disor-
ders. An equally important symptoms of the post-COVID
period are circadian rhythm disorders, which can enhance
the level of affective disorders. Among the circadian
rhythm disorders, delayed sleep phase disorder occurs most
frequently in the post-COVID period, which is associated
with a higher level of anxiety in these patients. These links
may indicate possible ways to optimize approaches to the
treatment of post-COVID syndrome, for example, reducing
affective symptoms by correcting circadian dysfunction. It
was the first time that links between post-COVID anxiety
and circadian rhythm disorders, which should be taken into
account when planning the rehabilitation after COVID-19
and may even change the approach to the organization of
the working time and schedule of such employees in the
first six months after the disease. A significant innovation
could be the implementation of psychological care ser-
vices for those who have suffered from COVID-19 whose
approach will include psychotherapeutic methods taking
into account the biological rhythms.
Acknowledgements  This paper is supported by Poltava State Medical
University (Research project 0121U108235 «Clinical-psychopatholog-
ical and paraclinical examinations and optimization of medical and
rehabilitation measures at the common forms of mental and comorbid
disorders»).
Author contributions  Anastasiia D. Shkodina and Md. Habibur Rah-
man performed conceptualization, methodology, and supervision;
Dmytro I. Boiko and Andrii M. Skrypnikov were involved in writ-
ing the original draft and methodology, validation, supervision, and
collecting data; Mohammad Mehedi Hasan and Ghulam Md Ashraf
contributed to data curation, review, and editing.
Funding  This work was supported by the Deanship of Scientific
Research (DSR), King Abdulaziz University, Jeddah, under Grant No.
(DF-538–141-1441). The authors, therefore, gratefully acknowledge
the DSR technical and financial support.
Data availability  Not Applicable.
13
Environmental Science and Pollution Research (2022) 29:28062–28069
Declarations 
Ethical approval  Not applicable.
Consent to participate  Not Applicable.
Consent to publish  Not Applicable.
Competing interest  Not Applicable.
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