Since the pandemic began, researchers around the world have documented a surge in sleep disorders, with 2 in 3 Americans reporting they are now sleeping either more or less than desired (Partinen, M., The Lancet Neurologyopens in new window, Vol. 20, No. 1, 2021; Stress in America 2021, APA).
Upended routines, more screen time, increased alcohol consumption, and dissolving boundaries between work and private life are just a few of the factors contributing to problems with sleep. And given the crucial role sleep plays in both physical and mental health, psychologists say it’s important to be proactive in addressing any issues.
“Once sleep is disrupted, it can impact mental and physical health, which may in turn cause further sleep disruption,” said Athena Akrami, PhD, a neuroscientist at University College London who is studying cognitive dysfunction in COVID-19, including sleep disturbances. “A vicious cycle may form that is very difficult to diagnose and treat properly.”
Psychologists are finding a range of sleep changes associated with the pandemic. Some people are sleeping more than ever, while others face shortened schedules, delayed schedules, or insomnia. Those suffering from post-acute sequelae of SARS-CoV-2 infection (PASC), or “long COVID syndrome,” where post-infection symptoms persist for months, are also reporting insomnia, sleep apnea, night sweats, and other problems (“An Analysis of the Prolonged COVID-19 Symptoms Surveyopens in new window,” Patient-Led Research Collaborative, 2020).
Even after a stressful experience ends, sleep disturbances may continue—so experts say problems with sleep could persist into the coming months as life begins to normalize.
“The good news is there are treatments that work,” said psychologist James Maas, PhD, a retired professor at Cornell University and an international consultant on sleep. “For many of us spending time at home, this is a wonderful opportunity to regularize our sleep patterns and reap all the benefits that stem from a good night’s rest.”
How sleep went awry
Even before the pandemic, more than 50 million Americans suffered from a sleep disorder, most commonly insomnia, which can involve trouble falling or staying asleep, waking early or throughout the night, or poor sleep quality (“Sleep and Sleep Disorder Statisticsopens in new window,” American Sleep Association).
Decades of research have linked chronic sleep deprivation to an increased risk for obesity, heart disease, Type 2 diabetes, and problems with immune function (“Sleep and Sleep Disordersopens in new window,” Centers for Disease Control and Prevention). Sleeping more or less than recommended—typically 7 to 9 hours a night—is a significant predictor of death by any cause (Cappuccio, F. P., et al., Sleepopens in new window, Vol. 33, No. 5, 2010). Sleep disturbances also hinder social, motor, and cognitive skills and predict suicide risk, depression, and other mental health problems (Bernert, R. A., et al., Current Psychiatry Reportsopens in new window, Vol. 17, 2015; Fang, Y., et al., npj Digital Medicineopens in new window, Vol. 4, 2021; “Mental health and sleepopens in new window,” Sleep Foundation).
The link between sleep and mental health is just as strong—and just as important—as ever, said Rébecca Robillard, PhD, an assistant professor of psychology at the University of Ottawa, who leads clinical sleep research at the Royal Ottawa Institute of Mental Health Research. In a survey of 5,525 Canadian adults conducted between April and June 2020, she and her colleagues found that sleep problems rose from 36% before the pandemic to more than 50%. Those facing difficulties fell into three categories: less time in bed, more time in bed, or delayed sleep schedule (Journal of Sleep Researchopens in new window, Vol. 30, No. 1, 2021).
“It makes perfect sense that sleep complaints are on the rise right now, because all of the stay-at-home conditions we experience throughout the day are exactly the factors that we know can affect sleep,” said Susan Rubman, PhD, a behavioral sleep psychologist and assistant professor of clinical psychiatry at the Yale School of Medicine.
People are working, exercising, and socializing inside their homes and even in their bedrooms, which can weaken the cognitive and behavioral associations between those areas and rest or relaxation, Rubman said. We are also facing more stressful situations, limited social support, and disrupted routines, all of which are known to trigger sleep problems (Kutana, S., & Lau, P. H., Canadian Psychologyopens in new window, Vol. 62, No. 1, 2021).
“Aside from being a major life event, living in stay-at-home conditions also increases our exposure to minor hassles and frustrations, which are known to reduce sleep quality,” said Rubman (Lee, S. A., et al., Innovation in Agingopens in new window, Vol. 4, Supp. 1, 2020).
In addition, less sunlight exposure, more screen time, irregular mealtimes, and increased alcohol use—all of which can interfere with circadian rhythm—are likely to exacerbate sleep problems in people working or learning from home. Rubman said her clients report everything from trouble falling asleep or staying asleep to early wake-up times, poor sleep quality, disrupted sleep cycles, and vivid dreams or nightmares.
Robillard’s findings echo those accounts. Adults who reported higher stress levels, more alcohol use, and more TV exposure were more likely to face new problems with sleep during the pandemic. Women and people with family responsibilities also had more trouble with sleep. Those results build on studies showing high rates of insomnia and other sleep issues among frontline workers early in the pandemic (Herrero-San Martín, A., et al., Sleep Medicineopens in new window, Vol. 75, 2020; Huang, Y., & Zhao, N., Psychiatry Researchopens in new window, Vol. 288, 2020).
“This points to potential behavioral solutions and also suggests that there are identifiable subgroups of the population that might benefit from additional support right now,” Robillard said.
Establishing healthy routines
Though many Americans have turned to over-the-counter sleep aids such as melatonin—sales of which rose 42% in 2020opens in new window, according to the market research firm Nielsen—Maas said the best defense against insomnia is to improve sleep hygiene or participate in cognitive behavioral therapy.
Good sleep hygiene practices start with establishing a regular sleep-wake cycle, said Maas. Go to bed around the same time each night, but not until you feel sleepy, and wake up at the same time each day. Establishing a daytime routine that includes exercise, regular mealtimes, and exposure to sunlight also helps calibrate the body’s circadian rhythm—as does avoiding caffeine within 10 hours and alcohol within 3 hours of bedtime.
Psychologists also recommend reserving the bedroom for sleep and sex but acknowledge that this may not be possible throughout the pandemic.
“As we’re forced to spend more time at home, spaces in our homes have become multipurpose activity centers,” Rubman said.
In such cases, leave the bedroom for extended breaks when possible and avoid working, television, or other digital entertainment in bed, which can lead to a cognitive and behavioral association between bed and wakefulness.
At night, the bedroom should be quiet, dark, and cool, Maas said. He recommends setting the thermostat between 65 and 67 degrees and using a white noise machine or room-darkening shades if needed. Ideally, don’t use electronic devices such as smartphones or laptops in bed, because the light they generate can delay sleep onset.
“If your insomnia lasts for more than 3 weeks, it’s time to go see a trained clinician,” ideally someone who is accredited by the American Academy of Sleep Medicine, Maas said.
Sleep specialists can administer cognitive behavioral therapy for insomnia (CBT-I), which has proven effective in numerous randomized controlled trials (van der Zweerde, T., et al., Sleep Medicine Reviews,opens in new window Vol. 48, 2019; de Bruin, E. J., et al., Sleepopens in new window, Vol. 38, No. 12, 2015). CBT-I helps patients improve sleep hygiene and addresses cognitive and behavioral barriers to sleep, for instance by restricting the amount of time spent awake in bed and teaching patients to avoid ruminating. The evidence for CBT-I is so strong that some psychologists say it’s time to shift the focus from additional research testing toward improving public access to such care.
“We know people are struggling with sleep during the pandemic, and we know what works,” Robillard said. “This is now a public health concern that needs to be addressed with large-scale interventions and increased access to CBT-I.”
COVID sleep loss
Patients recovering from COVID-19 are facing their own set of challenges. Though long COVID syndrome is still something of a mystery, researchers are starting to document its symptoms and speculate about its mechanisms.
“Debilitating fatigue, difficulty breathing, and sleep disturbances are some of the main complaints we’re hearing from these individuals,” said Marishka Brown, PhD, director of the National Center on Sleep Disorders Researchopens in new window, part of the National Institutes of Health (NIH).
In a study of 1,733 COVID-19 patients discharged from a Wuhan, China, hospital, 63% experienced fatigue and 26% had problems with sleep (Huang, C., et al., The Lancetopens in new window, Vol. 397, No. 10270, 2021). Akrami, who is part of the Patient-Led Research Collaborative, a self-organized group of researchers from neuroscience, public policy, and various health disciplines who have all suffered from long COVID, coauthored another study of the syndrome, which is currently under reviewopens in new window. She and her colleagues tracked symptoms in more than 3,700 COVID-19 patients for 7 months, finding high rates of fatigue and cognitive dysfunction. More than three-quarters of respondents also had difficulties with sleep, including insomnia, sleep apnea, night sweats, and other issues.
Akrami and her colleagues say the enduring problems with sleep and cognition may be related to inflammation in the brain. Neuroinflammation, which is known to be linked to sleep disorders (Clark, I. A., & Vissel, B., Journal of Neuroinflammationopens in new window, Vol. 11, 2014), is one symptom of COVID-19. It may be a direct result of damage to the brainstem, or an indirect effect of a dysregulated immune response (Yong, S. J., ACS Chemical Neuroscienceopens in new window, Vol. 12, No. 4, 2021).
“The relationship between long COVID and sleep is a very interesting and important one, but much of what we’ve heard so far is anecdotal,” Akrami said. “We’re working to turn anecdote into rigorous science.”
Other research has shown that melatonin supplements may improve outcomes for COVID-19 patients, possibly by boosting the immune system or simply by enhancing sleep quality, which in turn bolsters health (Zhou, Y., et al., Cell Discoveryopens in new window, Vol. 6, 2020).
Several clinical trialsopens in new window are underway to further investigate melatonin’s efficacy in treating or preventing COVID-19 infection, and NIH has launched the PASC Initiativeopens in new window to study the prolonged health consequences of long COVID, including how it impacts sleep. Akrami and her colleagues are conducting longitudinal studies of cognitive symptoms associated with long COVID and plan to compare the syndrome’s effects with other chronic conditions, such as Alzheimer’s disease, Parkinson’s disease, and lupus. They are also investigating how symptoms of long COVID might change if patients are later vaccinated.
“Sleep needs to be understood as a behavior but also as biology,” Brown said. “By studying sleep quality, timing, and duration—and how they relate to our physical and mental health—sleep researchers have a key role to play in enhancing quality of life during the COVID era.”
