Losing sleep during the pandemic

Citation:

Jindal RD. Losing sleep during the pandemic. J Clin Sleep Med. 2021;17(2):115–116.

In this issue of the Journal of Clinical Sleep Medicine, Zitting and colleagues¹ show that Google searches for the word “insomnia” went up early in the current pandemic. Google Trends has emerged as an important research tool, although as the authors acknowledge, it is difficult to know with certainty the motivations with and context in which someone looks for information. Of all the possibilities, 2 seem the most relevant: More people were using their time to look for help for sleep disturbance that they had previously put off, or the phenomenon reflected a true increase in the incidence of insomnia early in the pandemic. Either way, there was a need to find ways to meet the increased demand. As a clinician, I assist those seeking help in conducting a more adaptive cost-benefit analysis based on their unique circumstances. In my practice of sleep medicine, I try to reconcile the individual’s circumstances with what is known of the roles of the biological drive for sleep and of circadian processes in regulating sleep-wake behaviors, along with the utility and drawbacks of pharmacological interventions. To help sleep medicine practitioners meet the increased demand for help during the pandemic, a task force of the European Academy for Cognitive Behavioral Therapy for Insomnia has identified some broad categories of individual circumstances and has made specific and fairly detailed recommendations for those circumstances and subpopulations.² More recently, the Canadian Sleep and Circadian Network has published briefer yet still useful recommendations.³

As the pandemic has evolved, the risk/cost-benefit ratio of treatment choices may have shifted for individual patients. Usually, I do not prescribe hypnotics or antipsychotic agents to treat sleep disturbances. However, there is considerable literature noting that sleep deprivation can impact decision-making and lead a person to make more risky choices. Now that the end of the pandemic is in sight—given the success thus far of the vaccines being tested—perhaps those needing to make critical decisions for the rest of the pandemic could benefit from a short course of medications to treat their insomnia. Of course, such a consideration needs to be weighed against the well-documented adverse effects of these medications on cognition and next-day alertness.

I practice psychiatry and sleep medicine at the Birmingham VA Medical Center (Birmingham, AL). In March 2020, I started calling my patients to help them make treatment decisions, including whether to come in for face-to-face appointments, based on the accumulating information about the pandemic and on their individual needs. As a salaried employee of the Veterans Health Administration, I did not feel the kind of pressures to generate revenue that my counterparts in the private sector may have felt. Moreover, I am the sole companion for my elderly father and feel fortunate that I received permission to work from home during the pandemic. Given the circumstances, I have found it prudent to share my cell phone number with all of my patients. I have known for some time that my responsibilities as a psychiatrist include “translating” recommendations from other specialists to help patients make informed decisions. During phone calls with patients, I have shared my view that the best minds were working to find solutions and that even if vaccine and therapeutics did not become available right away, doctors and nurses would gain greater knowledge about the virus over time and that it was wise to avoid getting infected for as long as possible, especially for those with greater risk for severe COVID-19-related illness and death. I try to frame restrictions such as mask-wearing and social distancing as trading one set of freedoms with another. I often use the example that seatbelts, brakes on cars, and speed limits are not impediments but actually safeguards that enable us the freedom of driving at the allowable speed and enjoying the rest of our lives.

During my phone calls with patients, sometimes I wish that I had real-time assistance from experts in other fields. My past experience working on the psychiatry consultation-liaison service has taught me that a back-and-forth between experts in different fields can usefully bring out the gradient of risk, which in turn conveys genuine concern rather than an attempt to curtail freedom.⁴

On a personal level, I feel empathy for those who reach different decisions based on their own circumstances. My closest friend—to whom I usually turn for advice—ended up spending more than a week in the basement of his house after accidental exposure treating patients in the hospital. I know that I do not have the option of isolating myself for that long from my father, who has limited language skills in English. Given my experience, I feel that more can be done to heal our national divide over the virus and the economy. Perhaps experts in sleep medicine could help lower the “national temperature” by making the case that some of those flouting the COVID-19-related safety guidelines could be making poor choices because of stress-induced sleep deprivation.

I have found meaning during the pandemic by taking care of patients, spending time with my father, and serving on a committee constituted to provide input regarding allocation of scarce resources in the event of possible surge in demand. Even as I grieve the losses and help others grieve, I try to promote a progressively greater level of psychosocial functioning. For some, it means taking care of themselves and limiting the spread of the virus in the community. For others, it is taking care of people in their community and beyond. At the other end of the spectrum, there are discussions about how to leave useful lessons for the coming generations.

I am fascinated to hear from colleagues who have made their own adjustments given their own set of skills and individual circumstances. I will love to hear more from our readers’ experiences.

DISCLOSURE STATEMENT

The author is an employee of the Veterans Health Administration. The view expressed here reflect the author’s own views and not those of the Veterans Health Administration or any other agency of the U.S. government.