Why the pandemic is keeping us awake,
It’s called Covidsomnia, a state of constant, stressed-out wakefulness caused by the changes forced on our lifestyles by the pandemic, making us exhausted by the bad news and unable to find rest. Now find out how to cope...
Given the list of anxieties that came with this devastating global crisis; worries about health, the economic impact, isolation — it was not entirely unpredictable that insomnia has become another malaise triggered by the pandemic.
Since last spring when the world turned on its axis, sleep clinics, GPs and psychologists have been flooded with consultation requests from people suffering from the condition.
Many of us blessed with the ability to drift off easily in normal times are reporting that sleep has become elusive and otherwise troubled, swelling the ranks of the regular army of insomniacs who, for whatever reason, can’t get any shuteye at all.
Terms like Coronosomnia or Covid-somnia have been coined for the surge in sleep problems brought on by the pandemic and according to experts the effects are being felt right across the generations.
Students forced by lockdown to return to their family home and the strangely solitary world of online learning are spending more time in their bedrooms than ever. Similarly, apartment dwellers who have no choice but to run a makeshift office from their bedroom find that the normal sanitypreserving boundary between their private and working lives has been blurred.
EPIDEMIC OF SLEEPLESSNESS
The golden rule for successful sleeping, that beds and bedrooms should be used for nothing but sleeping and sex, is being violated right left and centre ; its corollary of a strict routine to anchor the body clock that controls the circadian rhythm regulating the sleep and wake process has been demolished by school closures, job losses and the ceasing of normal activities during successive lockdowns.
Add to that the trauma wrought by lives turned upside down, the threat of illness, the problems of isolation and confinement and the pervasive use of electronics hostile to sleep and you have the perfect storm, the foolproof recipe for an epidemic of sleeplessness of global proportions.
Just as worrying, this epidemic appears here to stay, certainly for years after the vaccine is widely distributed and life returns to normal.
‘I see people in my clinic who have suffered trauma or stressful events maybe 40 years ago but the legacy of it is the sleep disorder,” says sleep physiologist Breege Leddy, director of the Insomnia Clinic and one of the few practitioners of CBT-I (Cognitive Behaviour Therapy for Insomnia) in this country.
‘When the situation with Covid resolves itself, and let’s hope that’s soon, the problem of sleep disturbance owing to the upheaval it created in society will remain. I suspect that all we are seeing now is the tip of the iceberg.’
The effects of sleep deprivation on mind and body trip off Leddy’s tongue. After a bad night’s sleep we may feel irritable and cranky, colloquially known as ‘getting out the wrong side of the bed’.
But several nights of tossing and turning leads to more crippling effects like loss of memory, poor concentration and judgement. Single car accidents are often caused by members of the socalled Wide-Awake Club. Mental health problems like depression and anxiety are other symptoms, while the medical risks include obesity, cardiovascular disease, and Type 2 diabetes.
Chronic insomnia is diagnosed when a patient is unable to fall asleep within 30 minutes more than three times a week for more than three months.
Once a patient falls into its clutches, they might stop wanting to do normal things like going away for the night because people with insomnia are often consumed by it and always thinking about how any change at all will affect their sleep.
The good news is that many sleep disorders are treatable, or would be with more Government investment in sleep services and psychological supports.
There is no one-size-fits-all when it comes to sleep and the old adage about a full eight hours being essential to a healthy lifestyle comes from an old wives’ myth and the lucrative wellness industry which rightly posits sleep as the third pillar of good health — after diet and exercise — but more dubiously flogs a range of pseudo-scientific sleeping aids as well as acres of misinformation in its pursuit. ‘The body can adapt to a certain amount of sleep deprivation. The whole idea that we need eight hours sleep is not accurate. There is no set rule about of eight hours. The important thing is to get good quality consolidated sleep. The number of hours of sleep we need is as individual as the colour of our eyes,’ says Breege Leddy.
HOW COVID HAS AFFECTED SLEEP
International reports of increased sales of sleep medications and overthe-counter sleeping aids from special pillows to ‘dream’ lights hint at the prevalence of insomnia since the world took a dark and uncertain turn. Last spring there was a 14.8 per cent increase in sleep medication prescriptions in the United States, according to data from Express Scripts. Psychologists in the US claim that Covid-19 has reignited the recurring nightmares of survivors of 9/11 and other catastrophes.
The sleep tracking wearable company Zepp polled 2,000 respondents in the UK, Europe, the US and Thailand about their sleeping patterns during the pandemic. They found that 38% of Germans, 37% of British and 37.8% of Americans felt they were sleep-deprived owing to money, work and other anxieties created by
Covid -19.
Thirty-three per cent of respondents said that they went to bed later than usual and 20% claimed that they found it harder to sleep. Respondents believed that they were losing an average of 2.7 hours of sleep per night due to pandemic induced worries. In an online survey run by international sleep expert Jason Ellis in conjunction with the British Sleep Society, of 843 adults living through the pandemic almost 70% showed a change in their sleeping pattern.
According to Dr John Garvey, director of the Sleep Laboratory at St Vincent’s Hospital, while there is no hard data here about the effect of the pandemic , it’s a ‘reasonable assumption that we will see an increase in sleep problems over time with all the consequences that has for our sleep and mental health services.’
Sleep disruption and anxiety are a chicken and egg situation, he says.
‘There’s about a 50 per cent crossover between stress or anxiety and insomnia,’ he says.
DISORDERS CAN BE FATAL
Dr Garvey, a board member of the Irish Sleep Society and a prominent critic of the patchy funding for our ‘overwhelmed’ sleep services, works with patients suffering from obstructive sleep apnoea, a respiratory condition sometimes brought on by obesity that causes patients to hold their breath and literally choke themselves during sleep.
Sleep apnoea, which affects about one billion people on the planet, is only one of a suite of conditions that can cause us to toss and turn at night when we should be recharging our batteries and enjoying the restorative balm of sleep.
‘There are different categories of sleep disorders; there are patients who have difficulty falling asleep and staying asleep which is insomnia and there are people who do unusual things when they are asleep, like sleep walking,’ says Dr Garvey.
REM Behaviour Disorders describes a condition which allows
people to act out their dreams when they are sleeping. They still have their muscle tone so they can perform physical acts, including violent acts, but the memory part of their brain is asleep so they have no recollection of the episode afterwards.
Fatal Familial Insomnia is extremely rare, characterised by an inability to sleep that may be initially mild but progressively worsens, leading to significant mental and physical deterioration and even death.
But in the main, sleep problems are more prosaic, affecting many of us over the course of our lives. ‘We can all run into problems with our sleep ,’ says Dr Garvey. ‘The most important thing with respect to sleep is to get up at the same time every morning as the exposure to bright light in the morning entrenches our body clock in the time zone.
‘It doesn’t matter so much what time you get up at as long as you get up at the same time every day, regardless of how long you have slept or what time you have gone to bed or what you have to do that day.
‘Technology has allowed a 24hour society to evolve. We can buy a book on our Kindle now at 2am whereas 30 years ago the only latenight entertainment to be had was the national anthem on the TV. As mammals though, we haven’t changed and a lot of problems with sleep is to do with our ignoring the gulf between those needs and the 24-hour society that is available to us.’
SCREENS VS SUNLIGHT
Lockdown has stopped many of us leaving our homes and unless we make a concerted effort to get out, our daily exposure to sunlight in the morning — which is essential for regulating our body clock — is reduced.
Sunlight is our biggest zeitgeber, literally ‘time giver’, and its cues along with those from social interaction and alarm clocks help ground humans to a 24-hour cycle.
But while the pandemic has wreaked havoc on our daily routine, it has also led to a greater dependence on technology.
Zoom calls and classes, social media and streaming services have become the mainstay of our new social lives, our working day and our educational system, helping to fill the void left by the retreat of face-to-face interaction from our lives. But electronics are a doubleedged sword, as can be seen in the longer hours we are spending staring at our screens, propelled by the reality of working from home.
The greater exposure to the blue wave light of our screens also interferes with our sleep process by blocking the release of melatonin, the hormone which tells us when it is time to go to bed.
Each night as darkness falls, melatonin shoots out of our brain’s pineal glands and into our blood, inducing sleep. But that natural process is prevented by our abnormal exposure to electronics at night.
Psychologist Nicole Paulie of Spectrum Mental Health, which offers online counselling sessions, believes that working from home is something of a misnomer, particularly when space is tight.
‘What I’m seeing is that people are often living in work instead of working from home. They might close their laptop in the evening but it’s a constant trigger for stress and what must be done. If the boundary around work is poor then you are more likely to struggle to get to sleep.’
Paulie suggests that people make a conscious effort to relax before bedtime, by keeping a journal or exercising, and switching off the screens about 30 minutes beforehand.
‘The pandemic has exacerbated our dependence on screens and digital tools. We do pilates on Zoom and family quizzes, you name it. We have to counterbalance that with screen-free time and microbreaks,’ she maintains.
LACK OF SERVICES FOR HELP
The medical route may seem to be the only treatment option in severe cases of insomnia, even if the system is under strain in this country.
Sleep services developed here in an ad-hoc fashion fall behind countries like Australia that are at the vanguard of managing sleep disorders, giving patients ready access to psychology services and other supports.
Up until recently the standard response of GPs to insomnia was prescribing sleeping pills but once sleep medication became linked to problems with addiction and side effects that practise became frowned upon except for very limited periods.
Natural remedies like melatonin supplements and more significantly the rise in popularity of CBT-I, a psychological approach to insomnia, are among the alternatives.
Our main hospitals, including the children’s hospitals, all have sleep clinics but they have waiting lists spanning three years.
According to Dr Garvey, the failure to harness the primary care service and invest in our network of GPs to deal with the most prevalent sleep disorders or to recruit psychologists and specialists dealing with pure sleep disorders like insomnia has created an overreliance on the hospital services and respiratory consultants.
‘Our sleep service is under huge pressure but while we do provide treatment and diagnosis for sleep apnoea, patients with insomnia are really badly served,’ he says.
‘Public patients with insomnia, for instance, do not get access to CBT-I. Online platforms may be their only support, while for private patients, off the top of my head I can only think of three practitioners of CBT-I in Ireland.’
KEEP A SLEEP DIARY
Most of the sleep labs deal with respiratory sleep disorders, the exceptions being Dr Elaine Purcell’s sleep clinic in the Mater Private which deals with the entire range of sleep disorders and St James’s Hospital which also deals with narcolepsy.
Most sleep clinics only host a handful of beds. Patients are hooked into a tangle of wires to monitor their every bodily activity. Electrodes are glued to the head for measuring brain activity, an electrode under the nose monitors airflow, an ECG on the chest looks at the heart while one on the ankle looks at limb movement.
There’s even an attachment on the eye for measuring REM (rapid
eye movement). The readings are recorded over the course of the patient’s sleep, generating a wealth of detailed information about heart rate, breathing, twitching muscles , the structure of sleep and so forth.
Results often show that patients suffer from sleep apnoea, which often causes insomnia and can be treated with a Continuous Positive Airwave Pressure device (CPAP), a little portable machine with a hose which drives air into the upper airwaves and gives relief.
The emotional toll of sleep apnoea on sufferers and those within their orbit can be considerable. ‘It causes a lot of marriage splits,’ says Dan Smyth, founder of the Sleep Disorder Support Foundation.
‘The snoring is a turn-off but sufferers can be volatile and abusive if they are long-term sleep deprived. I dealt with a guy who was on the verge of losing his job as his colleagues couldn’t stand his mood swings. I advised him to tell his employers he had a problem and they were very understanding.
‘They gave him time off to deal with it and eventually he returned to the workplace and was promoted.’
For treatment of insomnia, CBT-I is now held up as the gold standard. But whatever the source of the sleep difficulty, Dan Smyth advises people to keep a sleep diary for weeks before their consultation.
‘It means that you have that step covered when you get into the system and you can save some time. It will also make consultants treat you more seriously,’ explains
Dan, whose organisation began life in 2000 as a support group for apnoea, from which he suffers.
‘Sleep is a very disciplined process and there are various stages and sleep cycles you go through before you get to the quality sleep that is essential.’
CBT FOR INSOMNIA
The subtle nuances of the sleep process, its ever-repeating cycles and stages is a subject of passionate interest for Breege Leddy who also reports a deluge of referrals from the sleep deprived since Covid changed our lives.
‘The pandemic is a transient event and it is leading to high levels of acute insomnia where patients have disturbed sleep or are wakening up early in the morning or finding it difficult to go asleep at night. About 80 per cent of these cases will develop into chronic insomnia,’ she explains.
After 15 years as a senior sleep physiologist in a variety of hospitals where she was exposed to nearly all of the 80 sleep disorders in existence, Breege came across the work of Professor Colin Espie, professor of sleep medicine at Oxford University and a pioneer of a new insomnia treatment.
‘He showed how Cognitive Behavioural Therapy was having brilliant results in treating insomnia and I decided to get trained in it,’ says Breege about the epiphany that set her on the road to offering a non-medicated but structured treatment to insomnia. Leddy gives patients four treatment sessions where she analyses their thoughts and feelings about sleep to see if they are accurate, while behaviours are examined to see if they promote sleep. ‘Chronic insomnia means that the sleep and wake cycle which is regulated by your circadian
rhythm have become out of sync,’ she explains.
‘The body has lost its sense of time as bad habits may have crept in like daytime napping, lie-ins and so forth.
‘The body starts to recognise that there is no pattern of sleep, the mind finds it difficult to switch off and sleep becomes erratic and unpredictable, generating even more frustration and anxiety for sufferers.
‘Sleep is not just a night-time disorder, it’s a 24-hour cycle because our homeostatic, or sleep, drive which also regulates sleep is built up over the course of the day and is diluted by daytime napping and other changes to our normal routine,’ Leddy continues .
‘The flexibility of working from home or unemployment caused by the pandemic has obviously interfered with that.
‘But it has also upended the circadian system in that a lot of the signals we normally have to give the body a sense of time, from a strict lunchtime or an early commute, have vanished, cutting adrift our body clock.’ Given how the foundations of good sleep are laid down long before we hit the proverbial hay, it’s a bit of no brainer how the disruption caused to our lives by Covid makes embracing a pro-sleep lifestyle so difficult.
For that reason many doctors recommend that people try to preserve their normal routines, even if they work remotely. Some say we should go as far as waking at the same time, dressing as if going to work, eat breakfast and begin working at the same time as we did before the pandemic.
Ideally we should also preserve time for exercise and have dinner at the same time we used to.
‘People should avoid watching anxiety-provoking news programmes before bedtime as this would heighten anxiety and perpetuate insomnia, while the blue light from the screen would stimulate the circadian clock delaying sleep,’ says a sleep specialist.
‘The best , thing is to maintain normal daily routines, maximise activities that promote alertness during the daytime and avoid behaviours that promote arousal at bedtime.’
It may seem counterintuitive that discipline and an unnecessarily rigid routine may be one of the keys to our switching off successfully at night.
But ten months into a global pandemic, anything that helps us access the soothing balm of sleep at the end of another gruelling and monotonous day is well worth a try. ww