Mass social distancing and social isolation to prevent the spread of a deadly disease, along with technological tools that allow social communication and continued work and school, is an unprecedented situation.
The current reality of most people's lives during the COVID-19 pandemic has the potential to induce or exacerbate sleep problems, though it may also present some with an opportunity to improve sleep, wrote Ellemarije Altena, PhD, of the University of Bordeaux (France), and her colleagues in a recent research review in the Journal of Sleep Research.
The review was conducted by a task force of the European Academy for Cognitive Behavioural Therapy for Insomnia. The European CBT-I Academy is an initiative of the European Insomnia Network to promote implementation and dissemination of treatment.
After discussing the known effects of stress, confinement, and altered schedules on sleep, the authors present recommendations on ways to manage sleep problems such as insomnia in the general public and potentially encourage people to take advantage of the opportunity to align their schedules with their natural circadian rhythms. Physicians may find the recommendations helpful in advising patients with sleep problems related to the COVID-19 emergency.
"Being forced to stay at home, work from home, do homeschooling with children, drastically minimize outings, reduce social interaction or work many more hours under stressful circumstances, and in parallel manage the attendant health risks, can have a major impact on daily functioning and nighttime sleep," Dr. Altena and colleagues wrote.
There may also be a lag time in physicians hearing about changes in sleep or sleeping problems from patients, said Krishna M. Sundar, MD, FCCP, medical director of the Sleep-Wake Center at the University of Utah in Salt Lake City. "There may actually be some improvement in sleep durations given that most folks are working from home with more time with family and less work- related stress," he said in an interview. "In terms of sleep or other effects on worsening of psychiatric problems, it is still not clear what the overall effects are going to be."
Although daylight has the biggest impact on regulating circadian rhythms, artificial light, meal times, diet, and amount of physical activity can also have an influence. Negative effects on sleep can result from both excessively high activity levels, such as stress and work overload, or excessively low levels, such as from depression or confinement, the authors note.
The current situation also opens the door to interactions between stress, sleep, anxiety, and risk of PTSD. "Those sensitive to stress-related sleep disruption are more likely to develop chronic insomnia," which, in combination with a major stressor, is a risk factor for PTSD, the authors write. They note that 7% of Wuhan residents, the city in China where the virus appears to have originated, particularly women, reported PTSD symptoms after the COVID-19 outbreak, and anxiety was highest in those under age 35 years and those who followed news about the disease for more than 3 hours a day.
Better sleep quality and fewer early morning awakenings, however, appeared to be protective against PTSD symptoms. The authors note the value of physical exercise, cognitive interventions, and relaxation techniques, including meditation, for reducing stress and milder symptoms of PTSD.
"Some patients are sleeping a bit better because of the pace of things has slowed down a bit," said Anne C. Trainor, a nurse practitioner and instructor in the neurology department's sleep disorders program at Oregon Health & Science University in Portland, who was not involved in the study. "Keeping a regular schedule for sleeping and eating, getting exercise daily — preferably in sunlight and not just before bedtime — and using relaxation or mindfulness practice and cognitive interventions to help manage anxiety" were the key takeaways from this review, Ms. Trainor said in an interview.
Home Confinement, Stressors and Sleep
A wide range of stressors could affect sleep during COVID-19 social distancing interventions, including "major changes in routines, living with uncertainty," and anxiety about health, the economic situation, and how long this situation will last, the authors write.
Parents must juggle work, homeschooling, and ordinary household errands and management. Meanwhile, entrepreneurs, small business owners ,and workers in entertainment, hospitality and food service must contend with anxiety about job uncertainty and financial security. For anyone working from home, disruptions to work and home routines can make it difficult to associate being home with relaxation — and sleep.
"The more regular our sleep schedule is the better quality our sleep tends to be, but it is a struggle when we don't have separate spaces to work and parent in," Ms. Trainor said.
At the same time, "confinement-related stress may be caused by an inability to engage in rewarding activities, such as visiting friends and family, shopping, attending cultural and sports events, and visiting bars or restaurants," the authors write. "Spending more time with family in a limited space can also induce stress, particularly in situations where there are preexisting family difficulties."
Being stuck at home may lead to less daylight exposure than usual, reduced physical activity, and increased eating, which can contribute to weight gain and other health risks. However, "the effect of stress from confinement, loss of work, and health concerns needs to be individualized and may be difficult to generalize," Dr. Sundar said.
The authors of the review note the established associations between too little social interaction, increased stress, and poor sleep quality, though loneliness mediates this relationship. Loneliness is also a risk during this time, with or without online social interaction.
Children and teens may also have difficulty sleeping, which can affect their behavioral and emotional regulation, and primary caregivers experience more stress while juggling childcare, household duties, and work.
"While many parents share childcare and household responsibilities, in most families these tasks are still predominantly managed by mothers," the authors added.
"Sharing responsibilities between parents and not overworking just one parent is key," said Brandon M. Seay, MD, a pediatric pulmonologist and sleep specialist at Children's Healthcare of Atlanta. He also recommended trying to incorporate work into the day while kids are doing online learning.
Ms. Trainor agreed that trading off responsibilities between parents is ideal, though the challenge is greater for single parents. It may be possible for some to take family leave, but not all families have that option, she said.
The study authors also point out a Catch-22 for many people: The blurred boundary between home life and work life can undermine work productivity and efficiency, thereby increasing stress. "Healthy sleep may be a key protective factor to cope positively with these challenges, although adequate opportunity to sleep may be affected by increased time pressure of work, childcare, and household requirements."
Dr. Seay advises adults to try to get at least 6-8 hours of sleep each night, even taking advantage of a later waking time — if the kids also sleep in — to help. "If anything, the ability to sleep later and wake up later is of benefit for a lot of my teenage patients," he said in an interview.
In fact, the study authors also address possible positive effects on sleep for some people during the current situation. Since social support can improve sleep quality, social media interaction might provide some social support, though it's not the same as meeting people in person and "screen exposure may hamper sleep quality when used close to bedtime."
Some people may actually have an opportunity to get more daylight exposure or exercise, which can improve sleep, and some, especially night owls and teenagers, may be able to align their daily schedules more closely to their natural circadian rhythms.
"Given that we are not bound by usual work or social schedules, there may be a tendency to drift to our sleep chronotypes," especially for teenagers, Dr. Sundar said.
For some, this may be their first opportunity to learn what their chronotype is, Dr. Seay said.
"It is always advantageous to 'obey' your natural sleep timing, [although] it simply isn't always the most efficient outside of our current situation," he said. "Use this as a time to figure out your natural sleep timing if you constantly have issues being able to wake up in the morning. Now that you don't have to be up for work or school, you can figure out what time works for you."
At the same time, if you have an extreme circadian rhythm disorder, especially an irregular one, it may still be best to try to keep a regular sleep schedule to avoid feeling isolated if others are socializing while you're asleep, Ms. Trainor said.
The authors similarly note the limits of potential benefits during this time, noting that they "may not be enough to counteract the negative effects of the increased work and family requirements, as well as the overwhelming levels of stress and anxiety about the well-being of oneself and others, and the negative effects of confinement for family social reactions."
Treating Stress, Anxiety, and Insomnia
The first-line treatment for chronic insomnia is cognitive-behavioral therapy for insomnia, but "recent evidence shows that cognitive-behavioral therapy can also serve to treat sudden-onset (acute) insomnia due to rapid stress-causing situation changes," the authors noted. They also reviewed the key elements of CBT-I: stimulus control, sleep hygiene, relaxation interventions, cognitive reappraisal, paradoxical intention, and sleep restriction.
CBT-I lends very naturally to telemedicine, Dr. Seay, Dr. Sundar, and Ms. Trainor all agreed.
"I actually see this current situation as an opportunity for health care practices and providers to expand the reach of telemedicine — due to necessity — which will hopefully continue after confinement has been lifted worldwide," Dr. Seay said.
Dr. Sundar pointed to research supporting CBT-I online and several apps that can be used for it, such as SHUTi and Sleepio. Ms. Trainor noted that the Cleveland Clinic offers a basic CBT-I online class for $40.
The authors note that prescribing medication is generally discouraged because it lacks evidence for long-term effectiveness of chronic insomnia, but it might be worth considering as a second-line therapy for acute insomnia from outside stressors, such as home confinement, if CBT-I doesn't work or isn't possible. Pharmacologic treatment can include benzodiazepines, hypnotic benzodiazepine receptor agonists, or sedating antidepressants, particularly if used for a comorbid mood disorder.
The authors then offer general recommendations for improving sleep that doctors can pass on to their patients:
- Get up and go to bed at approximately the same times daily.
- Schedule 15-minute breaks during the day to manage stress and reflect on worries and the situation.
- Reserve the bed for sleep and sex only; not for working, watching TV, using the computer, or doing other activities. Try to follow your natural sleep rhythm as much as possible.
- Use social media as stress relief, an opportunity to communicate with friends and family, and distraction, especially with uplifting stories or humor.
- Leave devices out of the bedroom.
- Limit your exposure to news about the COVID-19 pandemic. Exercise regularly, ideally in daylight.
- Look for ways to stay busy and distracted, including making your home or bedroom more comfortable if possible.
- Get as much daylight during the day as possible, and keep lights dim or dark at night. Engage in familiar, comfortable, relaxing activities before bedtime.
- If your daily activity level is lower, eat less as well, ideally at least 2 hours before going to bed.
- Divide child care, home maintenance, and chores between adults, being sure not to let the lion's share fall on one person, if possible.
- Maintain regular sleep times for children and spend the 30 minutes before their bedtime doing a calming, familiar activity that both the children and parents enjoy.
- "While using computer, smartphones, and watching TV more than usual may be inevitable in confinement, avoid technological devices after dinner or too close to bedtime."
- Ensure your child has daily physical activity, keep a relatively consistent schedule or routine, expose them to as much daylight or bright light as possible during the day, and try to limit their bed use only to sleeping if possible. "Parents need to be involved in setting schedules for sleep and meal times so that kids do not get into sleep patterns that are difficult to change when school starts back," Dr. Sundar said. "Limiting screen time is also important especially during nighttime."
- Reassure children if they wake up anxious at night.
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Tara Haelle. Sleep in the Time of COVID-19 - Medscape - Apr 17, 2020.
J Sleep Res. Published online April 4, 2020. Abstract