Aaron B. Holley, MD
June 24, 2020
The coronavirus pandemic has touched all of our lives. Those who haven't gotten sick are affected by the economic, social, and occupational changes required for physical distancing. Paradoxically, while some are stuck at home, others work long hours contributing to the COVID-19 response. Add that to the inevitable worry that comes from having an invisible pathogen in our midst, and you're left with lots of stress. A simple PubMed search using the terms "stress" AND "anxiety" AND "COVID" produces 109 references. With stress comes poor-quality sleep.
So what mitigation strategies can be used to improve sleep? While over-the-counter and prescription pharmaceuticals are available, it's important to note that the majority of sleep disorders are behavioral in nature. If your patients are having difficulties sleeping since the pandemic began, it's unlikely that they have suddenly developed an organic disorder like obstructive sleep apnea or narcolepsy.
The first step in improving sleep is evaluating daytime behaviors. This is good news—you don't want your patients to have an organic illness. The bad news? Sustained behavior change is hard work.
Behaviors That Affect Your Sleep
The first behavior to assess is simple, at least conceptually. You have to figure out how much sleep your patient is getting per night. Is it less than 8 hours? I bet it is. Data from the United States show a large percentage of adults sleep less than 6 hours per night. If they make up part of that percentage, they need to consider getting more sleep. Remember, I didn't say behavior change would be easy.
I've been a sleep physician for almost 15 years, so I've heard it all: "My body doesn't need that much sleep." "I wake up at the same time no matter when I go to sleep." "Doc, I've never needed that much sleep." "How can I sleep that much? I don't have time."
I understand, but the data are compelling. We in the sleep community have studied this every which way. The closer you get to 8 hours, the better your reaction time, moral and abstract reasoning, memory, weight, overall health, and mortality.
The next two behaviors to consider are easier to deal with. With respect to daytime function and sleep efficiency (ie, how quickly you fall asleep), synchronizing sleep and wake times reaps dividends. Your patients don't have to go to bed and wake up at the exact time every night and day, but they should come close. If they vary sleep and wake times by more than an hour from one day to the next, they're doing themselves a disservice. Their body will help them; we're biologically wired to go to sleep and wake up at the same time every day.
Lastly, develop a nighttime routine. Some people are gifted—they're able to work on a computer doing complex, stressful, work-related tasks right up until their bedtime. From there, they simply turn out the light, and they're able to fall asleep. For most of us, this isn't possible. Having a choreographed routine that includes a transition from something active (eg, work, emails, video games, physical activity) to something more passive (eg, reading in dim light, relaxing with a spouse) is key. If your patient continues this "passive" routine at about the same time each night, it'll trigger their brain to prepare for sleep.
Medications and Sleep Aids
I want to be clear: There is no such thing as a free lunch. Sleep aids and wake-promoting agents are best used in three specific scenarios:
- Behavioral sleep change is actively being instituted, and medications are being used to assist with the process.
- The patient has a coexisting behavioral health disorder that is actively being treated, and medications are being used to assist or temporize until the behavioral health condition improves.
- Behavior change is not possible because of occupational requirements (eg, a healthcare worker battling COVID-19, a deployed soldier) for a finite period of time.
Medications can improve symptoms, at least temporarily, but they do not replace sleep debt. No medicine can replicate the physiologic and psychologic restoration that occurs with sleep. This is an immutable fact that is not governed by your schedule.
Okay, enough with the disclaimers. Let's talk sleep pharmacology.
I'd be remiss if I didn't start by addressing alcohol and antihistamines, the two most common products that patients use to assist with sleep. The list of reasons why alcohol is a poor choice is long and includes dependence, sleep fragmentation, hangover effects, and distorted sleep architecture. Over-the-counter antihistamines (eg, diphenhydramine) are generally discouraged for similar reasons. So, if you're avoiding prescription sleep medications and using alcohol or antihistamines instead, you aren't doing yourself any favors.
Melatonin is another option, but it's not a very good insomnia drug. It isn't regulated by the US Food and Drug Administration (FDA), so the potency of the product you're using is unknown. It also doesn't have much effect on sleep onset latency. There is no shortage of people who swear by it, and I find people are reassured because it's "organic." For those who take it before bed and insist it helps, I don't get in their way. They're almost certainly experiencing placebo effect, though.
Personally, I prescribe nonbenzodiazepine sedative hypnotics (NBSHs), such as zolpidem or eszopiclone, for improving sleep latency and efficiency. Zolpidem is available as a generic and is inexpensive. This FDA-approved drug is without adverse breathing effects, and it does not disrupt sleep architecture.
NBSHs, and zolpidem in particular, are associated with cognitive changes, complex sleep-related behaviors, and falls. Precise frequency is difficult to quantify owing to data coming from individual patient reports or observational studies. Data from prospective trials estimate that 1%-2% of patients will experience these effects, and in my experience, these complications are mild and rare. Proper counseling can reduce potential harm, and for patients who are treatment-naïve, starting at low doses (5 mg for zolpidem and 1 mg for eszopiclone) will help.
Many general practitioners are hesitant to prescribe NBSHs. Although the side effects are real, they must be weighed against alternatives. Alcohol, antihistamines, and sedating antidepressants cause their own, often more serious adverse effects. Doing nothing may prolong sleep deprivation and the harms that come with it. In some cases, NBSHs are the "least bad" option.
In summary, behavior change, although difficult, is the best treatment. Sleep aids can help and have their role, but they are best used as a bridging therapy while change is implemented.
Aaron B. Holley, MD, is an associate professor of medicine at Uniformed Services University and program director of pulmonary and critical care medicine at Walter Reed National Military Medical Center. He covers a wide range of topics in pulmonary, critical care, and sleep medicine.
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