Advice from a Consultant Psychiatrist in Behavioural Sleep Medicine
This information is sourced from Dr Nicholas Meyer, Consultant Psychiatrist in Behavioural Sleep Medicine
Q. A lot of patients are phoning up complaining of insomnia at the moment. How can we best manage insomnia during the pandemic?
This is an important question. The evidence that is emerging suggests that although some people are experiencing better sleep due to having fewer social commitments (e.g. not having to commute, working from home), there are others who are finding that sleep has deteriorated over this time. This is likely to be related to several factors.
First, the stresses and social isolation related to Covid-19 has increased worry, which people can take to bed with them. Worry, and the hyperarousal associated with it, is a key driver of insomnia. Second, the new ways of living resulting from the pandemic, including being based at home, can affect our circadian system. Many of us are less physically active during the day, get outside less (and therefore have less exposure to light), and might have a tendency to nap during the day. All of these factors can affect night-time sleep.
We have created a video resource, which may be useful to both patients and clinicians, with some simple advice for maintaining healthy sleep and preventing insomnia during this time. The key points are to encourage patients to maintain regular sleep-wake patterns on all days of the week, anchor their wake-time, engage in regular daytime physical activity and exposure to daylight, only go to bed when sleepy, maintain good sleep hygiene (e.g. using the bedroom only for sleep, sex and getting dressed; avoiding naps during the day; avoiding caffeine after 3pm), and instituting a ‘buffer zone’ in the 1.5 – 2 hours before bed, to relax and get the mind and body ready for sleep. These principles are also useful for those who have developed insomnia disorder, or have pre-existing insomnia that has worsened.
Medications play a role: for individuals experiencing acute insomnia over a few weeks, associated with an identifiable stressor, the use of hypnotic medications (zopiclone or zolpidem) taken at bedtime, or melatonin (circadin) taken an hour before bed may be helpful. In patients with chronic insomnia (i.e. insomnia that has gone on for most nights of the week, for 3 months or more), and in those who experience low mood or anxiety, sedative antidepressants at the lower dose range (mirtazapine or trazodone) taken 30 minutes before bed, or zopiclone, taken at bed-time, may be helpful.
However, for those with chronic insomnia, the treatment for which there is the strongest evidence base, and best safety-profile, is cognitive behavioural therapy for insomnia (CBT-I). This is available via online providers, for which some CCGs fund a course of treatment. Alternatively, in-person CBT-I is available through referral to specialist services (e.g. UCLH Insomnia Service). Both digital and in-person CBT-I has been shown to be effective. This approach helps patients to develop their own tool-kit for understanding and managing insomnia, in the long-term. It requires motivation and commitment on the part of the patient.
Finally, perhaps the most important point to remember is to remember that insomnia is a highly distressing and debilitating disorder in and of itself, and often drives psychiatric disorder, including depression and anxiety. Patients with insomnia need to feel that their difficulties are being heard, and reassured that effective treatments do exist.