Insomnia in the Time of COVID

My Sleep Pattern Pre-COVID:

I used to be a great sleeper. As a child, I remember there once was a severe storm that caused a lot of structural damage, including blowing down several chimneys in Glasgow tenements. I slept right through it! None of the stresses and strains of my professional life ever led me to lose much sleep, although, to be fair, until I went part-time in my last 2 years of work, I think exhaustion was a great help in leading me to the Land of Nod!

I thought that I would sleep well when I retired, but unfortunately my retirement coincided with the final stages of the Brexit fiasco. During the political upheaval of 2019 I found myself often waking around 04.00 to 05.00. After a spell out of bed, I would sometimes, but not always, get a bit more sleep, but overall I felt my sleep quality on these nights was poor. I remain firmly opposed to Brexit, but after the disastrous general election result I think I accepted that Brexit was going to happen, and my sleep improved. Then, along came COVID.

COVID and Insomnia:

SARS-CoV-2

Since the pandemic began, I have again started to notice frequent waking around 04.00-05.00. It seems, however, that I am not alone. According to a recent report from Express Scripts, a prescription benefit plan provider, the use of anti-insomnia, anti-anxiety, and antidepressant medications have spiked, with filled prescriptions increasing by 21% between February and March 2020. This is against a background of use decreasing between 2015 and 2019. Those numbers peaked during the week of March 15, which is the same week the World Health Organization declared COVID-19 a pandemic, and the USA declared a national emergency in response to the crisis.

COVID and Anxiety:

There are many reasons for increased anxiety, and insomnia related to the pandemic. People may be socially isolated due to quarantine. They may be worried about their own health, their financial situation, or their employment. They may be anxious about their children, or their elderly relatives. They may be overwhelmed by the national, and global effects of the virus.

Prevalence and Effects of Insomnia:

Even in normal times, around 30-35% of people have short-term insomnia. In more than 72% of cases this acute insomnia resolves completely. Recovery is, however, sometimes incomplete and approximately 7% develop chronic insomnia. This is defined as having sleep problems at least 3 times per week for at least 3 months. Apart from causing inability to focus and irritability, chronic insomnia is associated with an increased risk of obesity, diabetes, hypertension and cardiovascular disease. It may also be associated with an increased risk of Alzheimer’s Disease, and other forms of dementia.

Patterns of Sleep Disturbance:

Effects of stress and anxiety on sleep include difficulty in getting to sleep, and early morning wakening. There may be sleep fragmentation, with multiple arousals throughout the night. Vivid, disturbing dreams are closely related to this. The relationship between stress and sleep problems is complex. Effects on neurotransmitters have been demonstrated, and an increase in the level of cortisol in the blood of those with insomnia.

Alcohol, COVID and Insomnia:

Preliminary evidence suggests that some people have increased their alcohol intake during lockdown. It may be thought by these folk that alcohol will help them get to sleep, but, in fact alcohol is the enemy of restful sleep. It can make you sleepy, but you are likely to spend more time in deep sleep as a result. However, that is not what you want: it is the restorative rapid eye movement (REM) stage of sleep which helps you feel most rested when you wake.

Alcohol particularly affects your ‘sleep architecture’ early in the night, leading to disrupted sleep later in the night. In addition, alcohol, like caffeine, has a diuretic effect. This means you are more likely to wake early needing the toilet, and you may then struggle to get back to sleep.

Finally, if you drink alcohol regularly, any beneficial effect of the drug on your sleepiness levels tends to wear off quickly.

Approaches to Sleep Disturbance:

1. Stick to a sleep routine:

Have regular sleep and wake times. Don’t lie in at the weekends. Remember that your quarantine routine may be different from your work-based one. There are also variations for different age groups: for example, adolescents need about 10 hours of sleep per night, compared with adults’ 7-9 hours.

2. Avoid, or at least limit, napping:

Napping for longer than 20 mins, or late in the day, can severely reduce “appetite” for sleep.

3. Consider other lifestyle factors:

Keep a regular schedule for meals. Avoid caffeine, nicotine, and alcohol for several hours before bed.

4. Limit news exposure:

This is especially important at bedtime. Possibly, designate time to catch up on news earlier in the day.

5. Have wind-down time before bed:

Perhaps watch a distracting movie, or read an enjoyable book.

6. Decrease screen time before bed:

This is because of the effects of blue light on melatonin production.

7. Exercise during day:

This should ideally be done in the afternoon.

8. Try to get some sunlight, either by walking or by sitting by a window:

Try to get 15-30 minutes of sunlight exposure upon wakening.

9. Talk about how you are feeling to relatives and/or friends:

Those on their own could perhaps consider journaling to offload negative emotions (or blogging?).

10. Consider non-drug techniques that help anxiety:

Examples include breathing exercises, mindfulness meditation +/- app, cognitive behavioural therapy.

11. Consider a mask +/- earplugs.

12. Keep your bedroom as place of sanctuary:

Avoid activities in the room other than sleep (and sex). Don’t have a TV in the room, and don’t have the room too hot or too cold.

13. If sleep proves impossible, get out of bed and do something relaxing eg reading, doing a puzzle.

14. Try not to worry about insomnia:

This will only make matters worse.

Obviously, not all of these approaches are suitable for everyone, but hopefully, if COVID is affecting your sleep, you will find some of them helpful. Any other suggestions would be gratefully received!

Medicine

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