Speaking of Psychology: COVID-19, insomnia, and the importance of sleep, with Jennifer Martin, PhD

Is your sleep schedule a mess lately? You’re not alone. The stress and disrupted routines of the past year have taken a toll on our sleep. Jennifer Martin, PhD, a professor at the David Geffen School of Medicine at UCLA and spokesperson for the American Academy of Sleep Medicine, discusses how sleep affects our physical and mental health, what the pandemic has done to our sleep patterns, and effective behavioral treatments and advice that can help us get a good night’s rest.

Jennifer Martin, PhD, is a clinical psychologist and professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles. Martin's research and teaching focus on behavioral treatments for insomnia and on how sleep affects health and well-being. She is board-certified in behavioral sleep medicine by the American Board of Sleep Medicine. Martin serves on the board of directors of the American Academy of Sleep Medicine and is a spokesperson for the academy. She was also one of the co-authors of its guidelines on behavioral treatments for insomnia.

Kim Mills: Is your sleep schedule a mess lately? If so, you're not alone. The uncertainty, stress and disrupted routines we've all experienced this past year have, for many of us, taken a toll on our sleep. In March, APA’s Stress in America survey found that two out of three people said that they had been sleeping either more or less than they wanted to since the pandemic began. Some news outlets have even come up with a name for the problem, “coronasomnia”.

So, what effects might these disrupted sleep patterns have on our physical and mental health? Are sleep problems likely to stick around once the pandemic is over? And for those of us who are having trouble with sleep, what are the most effective treatments and advice that can help us get a good night's rest? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills.

Our guest today is Dr. Jennifer Martin, a clinical psychologist and professor of medicine at the University of California, Los Angeles. Dr. Martin's research and teaching focus on behavioral treatments for insomnia and on how sleep affects health and wellbeing. She serves on the board of directors of the American Academy of Sleep Medicine and is a spokesperson for the academy. She was also one of the co-authors of its recent guidelines on behavioral treatments for insomnia. And she's been quoted widely in the media this past year about the pandemic's effects on sleep. 

Thank you for joining us today, Dr. Martin.

Jennifer Martin, PhD: Thanks. I'm really happy to be here with you talking about sleep today.

Mills: Let's start with the number I mentioned a minute ago. In an APA Stress in America survey released earlier this year, two out of three people said they were sleeping either more or less than they wanted to since the pandemic started. About 35% reported less sleep and 31% reported more sleep than they wanted. So, similar proportions in either direction. Has this been borne out in the research you've seen or in anecdotal reports? How has the pandemic been affecting our sleep?

Martin: The results of the APA survey are pretty consistent with what we're seeing, not just in the United States, but worldwide. And that is the changes in our habits and our routines and the levels of stress and anxiety have been having a direct impact on sleep, not just for a few people, but for the majority of people. The early research that we saw was around individuals working in healthcare settings, which as you can imagine was really the epicenter of stress around the COVID pandemic, especially when we knew less than we do now about transmission and risk. And we saw dramatic increases, in addition to a number of other psychological symptoms, in symptoms of insomnia and poor sleep quality.

The other really remarkable statistic to me that's emerged over the past year is that sales of over-the-counter sleep aids and melatonin, which is an herbal supplement often touted as a treatment for insomnia, have tripled or doubled depending on where you look in the last year compared to the year prior. So, not only are people having trouble with their sleep, but they're trying to figure out what to do about it.

Mills: Are there groups of people who have been at higher risk of sleep problems than others in the past year?

Martin: We definitely see that people who, as I mentioned, work in essential jobs or in high-stress occupations have had more disturbed sleep. Another interesting group though is kids and teenagers. So, we have seen a lot of changes because of school at home and sleep. Some kids are actually doing better. They're sleeping more because they don't have to get up so early. And I'm sure some people have heard, there's been a lot of conversation pre-pandemic about what time schools should start, given the biological predisposition of teenagers to have late schedules. But for some of them, there's been a lot of stress and anxiety around this as well. And that's led to trouble sleeping for kids and teens. And for younger kids, I think the lack of social interaction has had a more negative than positive effect on their sleep.

Mills: What are the physical and mental health effects of not getting enough sleep? What happens in the long and short term for people who are not sleeping the recommended number of hours every night?

Martin: Well, let me start with the recommended number of hours every night. That's a question I get asked a lot. And in general, for most people—so, as we know, not everything applies to everyone, but most people need to sleep at least seven hours on a regular basis to stay healthy and to feel well. There are a number of things that can cause people not to get that seven hours. One is insomnia disorder, which we can talk about separately, but sometimes that's associated with getting less sleep. The other thing is that sometimes it's just the habits, routines and choices that people make or out of necessity—so, we know that there are disparities in sleep duration, how many hours people sleep, where people who are lower-income have a tendency to have to work more to make ends meet and therefore sleep less.

So, there are two causes. One, like I said, sleep disorders like insomnia and the other, the behaviors and choices that people make or that they have to make. What can happen as a result of short sleep—I often say that sleep is an event that occurs all over our body and everywhere in our brain. So, insufficient sleep affects metabolism and risk for obesity. It affects cardiovascular disease risk. It affects our mood. It affects our memory. It makes us less able to cope with emotional stressors when they come up. So, the consequences of not sleeping well are pretty widespread. And the good news is there's growing evidence that when we treat sleep disorders or when we extend how much someone is sleeping, that a lot of this gets better. So, we have not just cross-sectional evidence, but some evidence that when we treat sleep issues, that we can see lower blood pressure, we can see improvements in mood, better coping. So, that's kind of the good news story here, I think.

Mills: Can it be harmful to get too much sleep?

Martin: Well, this is a big question because there are some epidemiological studies showing that people who report sleeping nine hours a night or more actually have shorter survival. And it's a little hard to come up with a biologically plausible explanation for why that's true. Sleep is a homeostatic process, so once you're done, you wake up. It's related to metabolism of adenosine in the brain, and once the adenosine is metabolized, there's no more sleep. So, it's not possible to, "sleep too much."

On the other hand, we have this finding about long sleep that's kind of intriguing. And most of the studies have controlled for comorbid conditions and sicknesses that one might think could lead to longer sleep. But one of the things that seldom accounted for in these studies is depression. So, it's possible that this shorter survival in long sleep could be related actually to mood disturbances, but we don't have a good understanding of that. And the other issue is that we can bring people into a sleep laboratory and have them sleep less and study experimentally the effects of shorter sleep, but we can't bring people into a sleep laboratory and make them sleep 11 hours. So, it's a very difficult phenomenon to study, because we have no way of experimentally making it happen, and then measuring the consequences.

Mills: APA's journal, Dreaming, published research last year that found COVID was spurring more anxious and upsetting dreams. Do you have any thoughts on why that might be?

Martin: For me, this is not surprising at all. After we experience something stressful or traumatic, one of the ways that our mind potentially processes those experiences is during REM sleep, and it's not uncommon for people to have disturbing dreams or nightmares about events that happened to them during the day. We see this after all kinds of natural disasters, we see it after people experience individual traumas. And as I'm sure many of your listeners know, disturbing dreams and nightmares are cardinal symptom of post-traumatic stress disorder, which is a chronic reaction to trauma. So, it's not at all surprising to me that people were experiencing more distressing dreams during the pandemic. Some of them are actually funny, so they're not all disturbing. I recall a family member of mine having a dream that he was on a COVID task force with president Trump, but forgot to get dressed and was attending the meeting at the white house in his pajamas. So, some of these are a little—

Mills: That's funny, but it is also a nightmare.

Martin: Exactly. Right. But also about getting up and attending work in your pajamas, which a lot of folks were doing earlier—

Mills: We are doing anyway.

Martin: Right. Exactly. So, it's not at all surprising, and what I'll say is that for a lot of people, as they settle into a new normal routine, or as things in our environment go back to normal, for a lot of people, it will just resolve, but there will be a number of people who continue to experience these disturbing dreams and nightmares on a chronic basis, and at that point, we would think of it as an actual sleep disorder that might require some treatment.

Mills: So, you just said some of the problems that we're having right now will just resolve. What should people expect? If you've been having disturbed sleep over the last year because of COVID and the pandemic gets lifted, we seem to be getting close to feeling a little bit more normal, what should people expect? How long until they really start getting back into a regular rhythm?

Martin: Well, if you think about the things that helped you sleep well in the pre-pandemic era, for most of us, that included things like having a routine to start and end our day. Getting up around the same time in the morning, getting dressed, getting in our car, driving to work, commuting on the subway, whatever your routine might be. And that's a routine that a lot of us have lost this past year. So, in terms of getting sleep back on track, reinstituting some of the routines that provide scaffolding around a healthy night of sleep is important.

There will be a subset of people who will go on to develop chronic sleep problems. We don't know yet what that percentage will be, but what we know in general is that there are some people when they're under an acute stressor, they don't sleep well and when the stressor is gone, they just get right back on track. And then there's a subset of people where that insomnia or poor sleep sort of takes on a life of its own and becomes its own sleep disorder.

So, when we talk about insomnia disorder, it means something very specific. It means you have poor sleep at least three times a week, and then it goes on for at least three months. So, anyone who gets to that point where they say, "Wow, this has been going on for a long time now. I've tried what I can think of in terms of improving my sleep habits and trying to get back into a routine, and I still can't sleep." That's the time to reach out for help. And as you mentioned, in the very beginning, there are clinical practice guidelines about how we treat insomnia disorder without using medications. And the first-line treatment for insomnia is actually a psychological treatment called cognitive behavioral therapy for insomnia. So, that's really that three-month mark, that's kind of the rule of thumb that I suggest people use. If this has been going on for months, it's time to reach out and get some help.

Mills: So, if I came to your clinic and you diagnose me with insomnia, clinical chronic insomnia, what would the CBT treatment entail? What would we do to help me get better?

Martin: CBT for insomnia is a very individualized approach based on what we know about how sleep works. So, for example, we know that everyone's internal clock functions a little differently. So, Kim, let's say that you tell me, "Well, I cannot stand staying up past 10 o'clock at night. And I love getting up early in the morning, but I'm just too tired because of my insomnia." Well, what we will do in CBTI is trying to come up with a routine and a schedule that would allow you to go to bed by 10 and get up and start your day early. By contrast, if my teenage son had insomnia and he came in and said, "I don't have to be at school till 8:30, and I don't like going to bed before midnight." We would work with that too.

So, basically what we do is come up with a package of recommendations based on a person's kind of internal tendencies and external factors that affect their sleep, and we try to set up a schedule and a routine that will help them get good solid sleep. And then we deal with a big giant elephant in the room, which is you can't try your way to sleep. So, the best way to fall asleep is to stop trying. So, I know the paradox. So, we do spend a fair amount of time in CBTI talking about ways to get in bed with the right mindset, so that sleep can come to the surface.

Mills: One of the things that psychologists and other people who do the type of work that you do talk about is sleep hygiene, right? Some recommendations, like keeping a regular sleep schedule, making sure that your bedroom is dark and quiet. Are these useful for people with chronic insomnia?

Martin: I like to use the metaphor of how we take care of our teeth. So, dental hygiene involves things like brushing and flossing every day. And if you don't have any cavities, and you're just sort of walking around through your daily life, that's enough. But if you have a cavity, you need an intervention. So, sleep hygiene is really important for those of us who don't have insomnia. But if you have a cavity, which would be like having chronic insomnia disorder, you need a filling, which in this case would be CBTI. Sleep hygiene on its own doesn't work for the vast majority of people who have chronic insomnia problems. Clinically, my experience is that most people try all of those things on their own before they come and see a psychologist. It takes a lot for someone to reach out to a mental health professional, for help with their sleep.

And most people will come in and tell me, "I already gave up caffeine, even though I love my morning cup of coffee. I quit drinking. I don't do anything fun. All I do is try to sleep. And my room is dark. And I bought an $8,000 organic coconut fiber mattress. And I have these special cooling sheets and whatever. And none of it has fixed my insomnia." And I always tell them, "Well, I'm not surprised," because it usually won't. The insomnia has kind of become its own separate problem and fixing all of those little things doesn't usually help. I always think about it as more like prevention. So having good sleep routines, having a safe, comfortable, nice place to end your day in your bed is all great. But again, once you have a cavity, you need to go see a dentist.

Mills: You mentioned earlier that some of these over-the-counter sleep aids and things like melatonin are on the upswing, that people are using these a lot. They're clearly big business. Are they safe? Are they effective? Are they worth trying?

Martin: Well, I'll say a couple of things. Number one, they are not recommended treatments by the National Institutes of Health, by the American Academy of Sleep Medicine, by the American College of Physicians, by the VA and Department of Defense, none of the clinical practice guidelines out there suggest using over-the-counter sleep aids. Most of which contain antihistamines, and antihistamines have sleepiness as a side effect. So, when I think about it, it's like you're using something for its side effect, not its intended purpose.

Are they safe? Well, that depends too. Some of these medications interact with other medications. Some of them have side effects that we especially worry about in older patients in terms of increasing the risk that they could fall at night. So, they're not all perfectly safe, but there is a very big placebo effect when it comes to treatment of insomnia. So, what happens for a lot of people is they get desperate and then they go to their local pharmacy or health food store, and they buy something that promises them a good night of sleep and they come home and they think, "Finally." And they take the pill and lo and behold, they stopped trying and they fall asleep and they think, "I finally figured it out. This pill is my solution."

But of course, what happens is the active ingredients aren't very effective, so the placebo effect wears out over time, and then they think, "Well, I need to try something else." So, they go back to the health food store, try the next thing, and they have the same experience. So, what's typical for me is that someone comes in and they say, "I tried melatonin. I tried Tylenol PM. I tried Advil PM. I tried this concoction from my chiropractor or my acupuncturist or my herbalist or my sister-in-law," or whatever it might be. "And they all worked for a few nights and then they don't work." And I say, "Well, that means that your brain is exactly how we expect it to be, that once you stop trying because you sort of give up trying to sleep, you give it over to some pill that you took, you're perfectly able to fall asleep, but the active ingredients aren't really very effective."

The challenge is that sometimes it's scary for people to stop using something because that increases their anxiety at bedtime. So, when we have someone who's using an over-the-counter sleep aid or even a prescription sleeping pill, what we usually do is try to do CBTI at the same time that we're discontinuing a medication. So, we're sort of substituting a natural solution for a pharmacologic one.

Mills: So, do you completely recommend against prescription sleeping aids? Is CBTI that effective?

Martin: The clinical practice guidelines in this area suggest that CBTI should be offered to most patients in most circumstances, and prescription sleep aids should be offered to some patients some of the time. So, there are cases where we might do CBTI and for a variety of reasons, the person doesn't improve or they don't improve as much as they're hoping to. And it's reasonable in those instances to add a sleeping pill. I think, unfortunately, the way medicine is practiced right now, people get a prescription, and then when it doesn't work, they get a different prescription, and then when it doesn't work, they get a different prescription and then they get CBTI.

And what we know from some of our own research is this is actually not what patients want. Patients actually prefer behavioral and psychological treatments over medications, but they don't think their doctors have these in their arsenal of what they can offer. So, as providers, I think it falls on us to have a conversation with our patients about what their priorities are, and I think when you do that, you'll find that a lot of them are very open to non-medication approaches. They just don't know that most physicians have them to offer.

Mills: So, if you go to your regular doctor and say, "I'm having trouble sleeping," that doctors will know about psychological interventions, in addition to pharmacological?

Martin: Kim, that's a very optimistic view of the world.

Mills: It's just because we find that about a lot of things—

Martin: It's absolutely—

Mills: Like you go to your physician and you say, "I'm depressed," and you get a drug instead of, "Maybe we could do some cognitive behavioral therapy."

Martin: And so, the suggestion that I usually make is that if somebody's struggling with sleep and they're not happy with the recommendation that their primary care provider makes to them, they should ask to be sent to a sleep specialist. So, most sleep medicine physicians where that's really their specialty, they know this, and they know how to find providers in the community, or there are actually some really nice online or self-directed or app-based programs that are—there are evidence-based CBTI and the research out there supports that they work for patients who are interested in that kind of an approach. So again, I think most sleep specialists know this, and they're much better at helping patients get access to non-medication approaches. Of course, changing practice is hard and it takes time. And it requires those of us in psychology, I think, to do a better job making sure that clinical psychologists are trained and skilled at treating insomnia just like they can treat depression or anxiety.

Insomnia is more common than a lot of the things that we think of as core treatments that all psychologists should be able to provide. And I'm getting a little bit on my soapbox here, but I really think that psychology training needs to include more about how to treat sleep disorders so that we can serve—10% of men and 20% of women before the COVID pandemic had insomnia disorder. So, that's a huge burden, and I think we all need to do our part and making sure that the people that we train are skilled and able to provide these evidence-based approaches.

Mills: A moment ago, you mentioned apps as one way to help people sleep better. How would a consumer find the real evidence-based apps, the ones that actually work?

Martin: Well, there are not a lot of them, but there are a couple that I'll mention because there's research behind them and they were developed by well-known experts, and they're both free. So, I always encourage people to take advantage of resources that are developed and disseminated, for example, by government agencies, where they're funded for the development and the distribution, and they're not charging a subscription or anything like that. So, the first one is called the Insomnia Coach, and it is a self-guided CBTI treatment, which is excellent. There's another one called the CBT-i Coach, which is designed to be used while you're working with a clinician. Again, both of them are evidence-based. There's either published research or ongoing research that shows that they're effective.

One of the things that we looked at in our clinical practice guidelines is does it matter how you get the CBTI? Is it better if it's in person, if it's in groups, if it's online, if it's a clinician-assisted? And of course, different people sign up to be in different kinds of studies. So, somebody who is afraid of their smartphone wouldn't sign up for an app-based treatment study. But the interesting thing is that the treatment is really potent and it works no matter how you get it. So, I think the most important thing is that people are offered some version of CBTI before they get a prescription. We know because there's the most literature in one-on-one treatment with a trained mental health provider.

But again, when we look at some of these other creative methods of improving access like, health educators that are supervised by psychologists or nurses who work in sleep centers, who are trained to do these treatments, all of those approaches work too. So, the most important thing is that people have it as an option. And as I mentioned, I think the Insomnia Coach and the CBT-i Coach provide some options for people that might not have a trained psychologist down the street that they can go see for CBTI.

Mills: Last question, I'm going to ask you to do a little crystal ball gazing here. Do you think that we're likely to learn anything from this pandemic experience about sleep, and the importance of sleep that will be really useful going forward?

Martin: Well, I'm going to answer your question with an anecdote, because I take very good care of my sleep. It's a priority. I have kind of some hard stops, I do not take overnight flights for work ever. I refuse to give up a night of sleep for a job. And when the pandemic first started last year—and I usually don't use an alarm clock. I just go to bed fairly early, I'm a little bit of a morning person, and so I can wake up without an alarm clock. When the pandemic started, I was sleeping more than eight hours a night, every night for many weeks, and I never thought of myself as sleep-deprived.

My children probably increased their sleep time—both of them are teenagers—by at least an hour a night. And I always thought I was a really great parent because I made sure that they get at least eight hours of sleep every night, during the week. And it turns out that my daughter probably needed closer to nine hours, and my son probably needed nine and a half hours of sleep at night. So, one of the things that I learned is that I think we have all been underestimating how much we might actually need to sleep. And I think some of that is going to carry forward. So, I used to always think about protecting those seven hours, and now I'm thinking more about, "I probably need to protect eight hours for myself to get a good night of sleep."

I think the other issue that has come up though, is we've learned a lot about what we need to do to protect that time when we're working at home. We've never had a period in our history when the majority of our workforce, who doesn't have to physically be present, is working in the same building where they sleep at night.

And I think a lot of us had to get creative in how to set up boundaries around our work life so that it doesn't start encroaching on our sleep time. For me, one of the challenges I have is working with people in different time zones, who will say things like, "Well, can we meet at eight?" And I have to remind them that, "Well, for me, that's five o'clock in the morning. I am not my best self at 5:00 AM." So, I think that we have learned a lot about how to successfully work from home, and still protect again, the separation between our home life and our work life.

I do think there will be a significant number of people who develop sleep problems over the past year that are not going to go away on their own and are going to need some help and support in the form of CBT for insomnia. What that number is? We don't know yet, but I'm already starting to see some people who said, "Until a year ago, I was fine." A lot of times, these have been folks who've been personally impacted by COVID, lost people close to them, were very sick themselves, were economically impacted, lost their jobs because of COVID, and now they're sort of trying to regroup and get back on track.

Mills: Well, this has been really interesting. I appreciate your taking the time Dr. Martin, and I hope our listeners, we'll put some links in our show notes so that people know where to go to get some of these apps and other tools that can help them if they're still having sleep issues. Thank you.

Martin: My pleasure. Thanks for having me today.

Mills: You can read more about COVID's effects on sleep in the June issue of APA's magazine, Monitor on Psychology. Go to www.apa.org/monitor. And you can find previous episodes of Speaking of Psychology at speakingofpsychology.org or on Apple, Stitcher, or wherever you get your podcasts. And please leave us a review. If you have comments or ideas for future podcasts, you can email us at speakingofpsychology@apa.org. That's speakingofpsychology, all one word @apa.org. Speaking of Psychology is produced by Lea Winerman. Our sound editor is Chris Condayan.

Thank you for listening. For the American Psychological Association, I'm Kim Mills.