Insomnia

Clarissa Chan, PharmD

As we do our best to navigate the unprecedented strain COVID-19 has imposed worldwide, many people are unaware of the growing public health issue of insomnia.

The SleepFoundation.org’s Guidelines During the COVID-19 Pandemic cite that sleep is essential in the consolidation of memories, mood regulation, and maintenance of a healthy immune system—all important in our mental and physical well-being—especially during these difficult times.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines insomnia as not sleeping well three nights a week for more than 3 months. Historically, major stressful events such as natural disasters or wartime have been documented to disrupt sleep, according to a 2001 New England Journal of Medicine article by Peretz Lavie, PhD.

Dramatic increases in the inability to sleep well during this pandemic has been coined “COVID-somnia.” The main causes of COVID-somnia are stress, changes to daily routines, fear, and isolation.

“All our patients are suffering from shifts in their sleep patterns due to their fears about getting the virus, concerns about loved ones, not being able to go to work, not having social contact with others,” said Rachel Marie E. Salas, MD, FAAN, associate professor of neurology at the Johns Hopkins Center for Sleep. Stressors and changes during this time are multifactorial and are not only hindering treatment for patients with short-term sleep problems but are also worrying health care providers that the pandemic may push patients into chronic insomnia the longer it continues.

Sleep medications and other therapies

According to Express Scripts, between February 16 and March 15 of this year—prior to the initial outbreak of the coronavirus and the stay-at-home orders enacted in many states—the number of sleep disorder medications filled was up 14.8%.

Sleep-promoting medications are generally more effective for patients with acute sleep disturbances for no more than 14 days. Beyond that, they could have negative effects. “In the long-term, they affect your sleep quality and your cognition. They also reduce slow-wave sleep [which is important in memory consolidation],” said Mark Boulos, MD, assistant professor of neurology at the University of Toronto. Typically, sleep medications are controlled substances, which have the potential to be addictive or easily misused. Health care providers should prescribe these medications carefully.

Alon Y. Avidan, MD, MPH, FAAN, professor and vice chair in the department of neurology at the David Geffen School of Medicine at UCLA and director of the UCLA Sleep Disorders Center, said cognitive behavioral therapy for insomnia (CBTi) is the first-line intervention providers recommend to patients.

“[Patients] can easily be treated by a cognitive behavior therapist who can focus on sleep retraining, relaxation techniques, and modifying their fears and worries about the inability to sleep. Many folks with insomnia have developed poor habits, associations, misconceptions, and behavioral patterns that are amenable to CBTi,” said Avidan.

According to a New York Times September 2019 article by Natasha Singer, pharmacies like CVS Health are making CBTi more widely available through digital and telehealth platforms as a possible benefit for their employees. This allows the therapy to be more accessible and affordable than arranging office visits with mental health providers.

What to do to help patients avoid sleepless nights?

Pharmacists can advise patients to look first at their sleep hygiene habits. Patients should sleep in a cool, dark, and quiet room. It is important to find a good transition from wakefulness to sleep, which typically takes about 30 minutes. For example, encourage patients to relax and not engage with the news—especially news related to COVID-19—before going to bed.

Patients should avoid blue light exposure from backlit screens on their computer or phone close to bedtime because it reduces the body’s production of melatonin, a hormone that helps regulate sleep through the body’s circadian rhythm. Outside of the home, they should expose themselves to daylight and sun.

Patients should also try to maintain a regular sleep-wake schedule with a conscious effort to avoid naps during the day. A healthy diet and regular exercise at least 2 hours before bed are also important for maintaining healthy sleep habits, according to an April 2020 article by Ronda Wendler posted on the University of Texas MD Anderson Cancer Center’s website.

If these interventions are not successful in helping patients manage insomnia, medications, when used short-term, can help patients temporarily recover from sleep debt. Interventions with medications can help patients with acute insomnia, which can prevent chronic insomnia disturbances that lead to psychiatric disorders.