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The COVID-19 pandemic has produced significant stress, anxiety, and worries about health, employment, and financial hardship. This unprecedented crisis has also affected sleep, both in healthcare workers and in the general population, at a time when healthy sleep is critical to build resilience to cope with the casualties of this pandemic. This commentary aims to highlight the critical role of sleep as a public health issue, particularly during a stressful life period such as COVID-19, and provide evidence-based practical guidelines to manage sleep disturbances during this crisis.
How prevalent are sleep problems during this pandemic?
Surveys of healthcare workers since the rise of COVID-19 have shown very high rates of insomnia (34–36%), as well as anxiety (45%) and depressive symptoms (50%), and those symptoms are especially prominent among frontline workers directly involved with patients diagnosed or at risk for COVID-19. Data from the general population also indicate that insomnia, sleep loss, and poor sleep quality are widespread complaints, with rates similar to those associated with other major crises involving, for example, natural disasters such as earthquakes, floods, or wildfires. Not surprisingly, individuals with more severe anxiety and depressive symptoms also report more sleep disturbances during COVID-19. Conversely, those with a stronger social support network and a sense of belonging report less psychological symptoms and better sleep quality.
Why is sleep more disrupted during COVID-19?
Any stressful life event, whether related to one’s personal life or caused by natural disasters that threaten one’s psychological or physical well-being, is likely to precipitate sleep disturbances, and more so among individuals with higher vulnerability. Of course, healthcare workers on the front lines are likely to experience significant stress due to the pressure to organize or provide care to patients, the fear of being infected, and facing death repeatedly, all of which can also disturb sleep when they return home. With the COVID-19 pandemic, at least two factors beyond stress are also involved: the effects of confinement and atypical work schedules. Sleep-wake schedules are regulated by homeostatic pressure (i.e. the need for sleep that accumulates with time spent awake) and the circadian timing system (our biological clock that keeps us awake during the day and makes us sleep at night), the latter being controlled by daylight exposure and several social and environmental timekeepers. Those timekeepers include daily routines such as arising at a specific time with an alarm clock, showing up at work at a fixed time, eating, exercising, and engaging in social and leisure activities at relatively fixed times throughout the day and evening. Under confinement conditions, several of those time cues are altered since there are fewer constraints to perform these activities at fixed times. Furthermore, as daylight exposure is the primary factor regulating the circadian timing system, it is crucial to get some daylight exposure in order to maintain a good signal from the circadian timing system, since time spent outdoors is reduced while in confinement. Research investigating sleep and circadian rhythms under temporal isolation in which participants are isolated from the outside world for several consecutive days (they can sleep and eat at their leisure and use artificial light as needed, but no contact with the outside world) has shown that participants’ sleep schedules quickly become desynchronized with the outside world. The atypical work schedules of many health workers and security agents doing shifts at different times of day are an important risk factor for sleep disturbances and sleep loss, and such problems can be further exacerbated when those workers return home with childcare and family responsibilities.
Why should we pay attention to sleep during this pandemic?
Healthy sleep—that is, adequate sleep duration, quality, and timing—is one of the three pillars of sustainable health, the other two being diet and exercise. Sleep plays a fundamental role for both mental and physical health. For instance, sleep is very much involved in emotion regulation and in immune functions. A single night of sleep deprivation can produce significant mood disturbances and lower immune defenses. Chronic insomnia and prolonged sleep loss increase risks of long-term adverse consequences for mental (depression, substance use), physical (hypertension, diabetes), and occupational health (disability). We also know that insomnia and nightmares triggered by stressful life events can outlast the crisis over a long period. Given these well-established associations, one can safely propose that those individuals who develop significant sleep disturbances during COVID-19 may be at greater risk for long-term negative health outcomes. Thus, protecting sleep during this pandemic is particularly important to build resilience and cope more effectively with the social confinement, distress, and uncertainty produced by this pandemic.
How to manage sleep disturbances during COVID-19?
Several generic strategies can help prevent or minimize sleep problems during this pandemic (see below). Public sleep health education should be the first priority to provide broad-based information about sleep health (e.g., the importance of maintaining regular sleep schedules, staying away from electronics in the bedroom, obtaining a daily dose of day-light exposure) even during a prolonged period of confinement. For those with persistent insomnia, professional help may be required. Evidence-based treatment options for the clinical management of include hypnotic medications (sleeping pills) and cognitive behavioural therapy. Whereas medications may provide rapid relief of insomnia symptoms and may be indicated for acute insomnia (short episodes of situational insomnia), evidence-based systematic reviews, as well as clinical practice guidelines, have all come to the same conclusion that cognitive behavioural therapy should be the first-line treatment for chronic insomnia (that persists over time). Most of these behavioural methods can be adapted to the needs of different individuals during this pandemic. They can also be made more widely accessible through web-based and telehealth platforms.
Strategies to manage sleep disturbances during the COVID-19 pandemic
Conclusion
Healthy sleep plays a critical role for coping physically and psychologically with major life events such as this COVID-19 pandemic. Public health education is essential to keep the general population well informed about the importance of sleep and healthy sleep practices to prevent or minimize long-term adverse outcomes. Evidence-based short-term and long-term interventions are also available, as well as online support strategies.
For more information on Sleep and COVID-19, visit: “Sleep: your ally during the COVID-19 crisis”
Summary
This commentary highlights the critical role of sleep as a public health issue, particularly during a stressful life period such as the COVID-19 pandemic, and provides evidence-based practical guidelines to manage sleep disturbances during this crisis. The COVID-19 pandemic and the imposed social confinement have produced significant stress, anxiety, and worries about health and the fear of being infected, jobs and financial problems, and uncertainty about the future. The incidence of sleep disturbances has also increased dramatically during this period. Aside from stress and anxiety, two other factors are likely to contribute to increased sleep disturbances during this crisis. First, alterations of our daily routines such as arising at a specific time, showing up at work, eating, exercising, and engaging in social and leisure activities at relatively fixed times are all important timekeepers for our sleep-wake cycles to remain synchronized with the day (light) and night (dark) cycles. Alterations of these timekeepers, combined with reduced daylight exposure, also essential to keep our biological clock synchronized, are likely to disrupt sleep and circadian rhythms. Sleep plays a fundamental role for mental and physical health, and adequate sleep duration and quality are essential for coping with major life events such as the COVID-19 pandemic. Public health education is warranted to keep the population well informed about the importance of sleep and healthy sleep practices in order to cope with the pandemic and prevent or minimize long-term adverse outcomes.
Adapted from: Morin, C.M., Carrier, J., Bastien, C. et al. Sleep and circadian rhythm in response to the COVID-19 pandemic. Can J Public Health 111, 654–657 (2020). https://doi.org/10.17269/s41997-020-00382-7 . To access a view-only, full-text version of the original article: https://rdcu.be/b8crX