Association of Prior COVID-19 Infection with Restorative Sleep Quality Using REST-Q Scores: Findings from the COPE Initiative

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Objectives: The COVID-19 pandemic has disrupted sleep health globally. However, the relationship between prior SARS-CoV-2 infection and subjective restorative sleep, measured using validated instruments, remains underexplored. This study evaluated the association between prior SARS-CoV-2 infection and restorative sleep quality using Restorative Sleep Questionnaire (REST-Q) scores in a large, nationally representative U.S. sample. Methods: Data were obtained from the September-October 2022 wave of the COVID-19 Outbreak Public Evaluation (COPE) Initiative, a cross-sectional online survey of 4,982 adults approximating the U.S. population by age, sex, race, and ethnicity. Restorative sleep was measured using the 9-item REST-Q. COVID-19 infection status was self-reported and categorized as never infected, one infection, or ≥ 2 infections. General linear models and ordinal logistic regression assessed associations between infection status and REST-Q scores, adjusting for demographic, socioeconomic, comorbidity, sleep-related, and mental health variables (Patient Health Questionnaire-4). Results: Participants with prior COVID-19 infection had significantly lower REST-Q scores compared with those without infection (52.1±22.5 vs. 57.9±24.4, p<0.001). Prior COVID-19 infection was also associated with higher odds of reporting low restorative sleep (adjusted OR=1.15, 95% CI: 1.02-1.30, p=0.019). REST-Q scores decreased with increasing number of infections. In fully adjusted models including anxiety and depression, the association attenuated (p=0.078) but remained significant in sensitivity analyses accounting for infection recency. Conclusions: Prior COVID-19 infection is associated with reduced restorative sleep quality as measured by REST-Q scores, independent of multiple confounders. The association persists although is partly attenuated when adjusted for anxiety and depression. These findings suggest a potential long-term impact of COVID-19 on self-reported restorative sleep and highlight the need for mechanistic and interventional research to address post-COVID sleep impairment. Brief Significance Statement: This study is the first to examine the association between prior COVID-19 infection and restorative sleep using the validated Restorative Sleep Questionnaire (REST-Q) in a large, nationally representative U.S. sample. Findings demonstrate that individuals with a history of COVID-19 report significantly poorer restorative sleep, independent of multiple demographic, socioeconomic, and sleep-related factors, underscoring the need for targeted post-COVID sleep interventions.

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