A sleep psychologist’s take on sleep during COVID-19

In a recent cross-account, national consumer study conducted by a U.S. PR agency, Kickstand, uncovering some profound data on COVID-19’s impact on stress, mental health, and access to resources.

Among the findings:

• 69% of Americans agree COVID-19 has negatively impacted their mental health, with 80% agreeing it has increased their stress and anxiety levels
• At the same time, half of Americans also say they’re having a harder time accessing the resources (medication, therapy, etc.) that they typically rely on to manage their anxiety
• 62% of Americans say they would benefit from tools and resources for managing stress during the COVID-19 crisis, with nearly half saying they’ve tried meditation

We know that stress, isolation, and a lack of access to resources plays a huge role in the increasing concerns over new-found sleep disruptions and issues. In recognition of Mental Health Awareness Month, the following article was written by Muse meditation teacher Dr. Shelby Harris, PsyD, CBSM who is a licensed psychologist and Board Certified Behavioral Sleep Medicine specialist. Dr. Harris is also a Clinical Associate Professor in the Departments of Neurology and Psychiatry at the Albert Einstein College of Medicine.

Why are people finding it harder to sleep during COVID-19?

As a clinical psychologist and specialist in Behavioral Sleep Medicine, a recent article from April 17 in Medscape, entitled “Sleep in the Time of COVID-19” caught my eye.

I’ve been seeing more and more sleep disruption in my patients as the weeks in social isolation have progressed, and I am glad to hear that the media and researchers are taking note of this issue as well… especially during Mental Health Awareness Month!

In the piece mentioned above, they discuss a review article in the Journal of Sleep Research from early April 2020 that summarizes European recommendations for dealing with sleep problems during home confinement during COVID-19.

There are several reasons that can explain why some individuals are having sleep issues. Increases in daytime stress, anxiety, disruption are all obvious causes for sleep disruption, but other factors such as:

• Limited light exposure
• Less exercise
• Homeschooling
• Changing sleep schedules and daytime routines
• Poor diet and increased childcare demands

…all act to further worsen the ability to obtain a solid night’s rest.

Potential effects of social distancing during COVID-19:

Posttraumatic Stress Disorder (PTSD) is likely to be an issue as well in the longer term, with stress, anxiety, and chronic poor sleep putting one at a greater risk of developing PTSD. Although many people seem to be struggling with sleep issues due to anxiety and depression, some are actually sleeping better because life is simply just not as busy for them.

They’re not forced to get up super early for an early morning commute, and a naturally later sleep-wake pattern works for them. Some find that they’re less stressed about the next day, and as a result, sleep better as well.

What we do know is that even though the initial stressor of COVID-19 is there (but admittedly growing old), there are things we can do to improve our sleep during times of stress. Cognitive Behavior Therapy for Insomnia (CBT-I) is a nonpharmacologic treatment for insomnia that’s evidence-based and the gold standard for insomnia treatment. It is widely recognized as the initial preferred treatment for insomnia, before medication should even be started, as it can be just as effective as medication in many cases…and often more effective in the long term.

CBT-I is a package of various treatment techniques developed to target behaviors that worsen sleep and teaches ways to challenge negative thoughts about sleep. It often also incorporates meditation into daily practice to help one recognize the noisy brain at night and be able to focus better on quieting the brain at bedtime.

CBT-I can be delivered in many formats, in person, telehealth (I’m doing this with my patients now, and it works nicely!), books (e.g. my book The Women’s Guide to Overcoming Insomnia: Get a Good Night’s Sleep without Relying on Medication is one example), or on various apps (CBT-I Coach, Sleepio, Cleveland Clinic).

Basic tenants of CBT-I that you can try at home:

1. Keep a routine bed and wake-time 7 days a week. Our bodies have an internal clock, and that clock craves routine.
   
   
2. The bed is solely for sleep and sex. If you cannot sleep, don’t lay in bed trying to force sleep to happen. Instead, get up, go sit somewhere else and do something quiet, calm and relaxing in dim light (without a screen!) until you are sleepy. Examples include meditation, reading a book, listening to music, doing a puzzle, knitting, adult coloring books. Return to bed only when you’re sleepy – and if you get in bed and don’t fall back to sleep, get up and repeat. Give yourself approximately 20 minutes to fall asleep in bed, then get up… just guesstimate- don’t look at the clock as clock-watching can worsen sleep.
   
   
3. Limit your exposure to the news to once per day, ideally earlier in the day for no more than 15-30 minutes.
   
   
4. Exercise regularly. If your usual methods for exercise are now limited (e.g. gym is closed), be creative. There are apps and websites online, many of which are free, that offer excellent workouts. It’s important to be OK with the idea that you might not get the same workout you once got – what’s key is to make sure you’re moving during the day. Sleep at night is a battery that needs recharging. If you don’t use it during the day, it won’t need to charge as much at night. Make sure though not to exercise strenuously within 3 hours of bed.
   
   
5. Get as much daylight during the day as possible, and dim the lights at least an hour before bed. Limit screens an hour before bed and no screens during sleep hours. Get up in the morning and lift your shades and bathe your brain and eyes in light – even if it is a cloudy day outside.
   
   
6. Find a quiet, calm and relaxing pre-bedtime wind-down routine that does not include screens.
   
   
7. Use social media as a way to reduce stress and connect with the world. However, if you find it makes you more anxious due to certain headlines or friend’s posts, limit your use of it or use it earlier in the day.
   
   
8. Avoid alcohol and nicotine within 3 hours of bedtime as they can worsen sleep quality.
   
   
9. Take moments during the day, even 3 minutes here and there, where you can practice a mindful breath or engage in some self-care. Acknowledging your stress during the day helps diffuse it as night grows closer. I’m a huge fan of using meditation during the day to improve sleep and quiet the brain overall. Find a meditation that speaks to you, and practice daily. There’s no one right way to do it, just actually doing it, is what works.
   
   
10. Make sure to be kind to yourself. There’s no rulebook for how to live during a pandemic, and we’re all just trying to do the best we can and figure it out. Some days will be better than others, but the more consistent you can be the better off you’ll be in the long run.

As I just noted, consistency is key here. If you try the above strategies and are still struggling, consider talking with your doctor about more in-depth strategies to help you sleep. Help is available, and medication is not always indicated (in fact we try not to use it initially!).

A good night’s sleep will help give you the solid emotional and cognitive foundation to help tackle the stressors of each new day in this COVID-19 world.

More about Dr. Shelby Harris PsyD, CBSM:

She is board certified in Behavioral Sleep Medicine (BSM) by the American Academy of Sleep Medicine and treats a wide variety of sleep issues using evidence-based, non-medication treatments. Before going into private practice, Dr. Harris was the longstanding director of the Director of Behavioral Sleep Medicine Program at the Sleep-Wake Disorders Center at Montefiore Medical Center.

Dr. Harris obtained her BA in psychology and music from Brown in 2000 and her PsyD in Clinical Psychology from Yeshiva University in 2006. She is frequently invited by hospitals, companies and organizations to give grand round lectures and sleep health workshops. Dr. Harris has been an invited columnist for the NYT “Consults Blog,” and is frequently quoted in the media, including the NYT, Huffington Post, New Yorker, Wall Street Journal, and O Magazine.

She has appeared on the Today Show, World News with Diane Sawyer and Good Morning America. Her self-help book The Women’s Guide to Overcoming Insomnia: Get a Good Night’s Sleep Without Relying on Medication was published by W.W. Norton books in 2019.