Contributor: Coping With Insomnia During COVID-19

December 18, 2020
Manoj Malhotra, MD
Manoj Malhotra, MD

Manoj Malhotra, MD, is the vice president of US Medical Affairs for the Neurology Business Group at Eisai Inc. He joined Eisai in October 2016, and since then, has been responsible for Medical Affairs activities for the Americas as well as the Global Medical lead for Epilepsy.

It is no surprise that sleep problems are on the rise due to life changes caused by the coronavirus disease 2019 (COVID-19) pandemic. Based on my experience, the current environment, with myriad of shifts in our day-to-day lives, is a perfect storm for sleep challenges.1 Insomnia, an inability to fall and/or stay asleep, can be influenced by many things. Some may include your lifestyle, sleep routine and habits, and the environment around you. They may also include factors inside the body such as the ability to turn up or down wake signals in the brain.

Between mid-February and mid-March, there was a 14.8% increase in sleep medication prescriptions in the United States, according to data from Express Scripts. This evidence suggests more people are struggling with sleep during the pandemic than were previously.

Most people have experienced the negative impact of a poor night’s sleep, often characterized as “waking up on the wrong side of the bed,” but the impact of chronic insomnia is potentially greater than that. Sleeping well is essential for good health. Studies suggest an optimal sleep duration between 7 and 8 hours. Also, people with chronic insomnia may present with other comorbid medical conditions at increased rates versus those without chronic insomnia.2

Diagnostic criteria for insomnia disorder include difficulty falling asleep or staying asleep for 3 out of 7 nights each week for a period of 3 months that results in clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. Individuals who struggle with insomnia disorder should consider having an in-person or virtual conversation with their primary care physician. There are a variety of approaches to treating chronic insomnia and there is no single ideal solution that will work for everyone.

Clinicians seeking to help individuals achieve optimal sleep will start with the least invasive, or lowest risk, treatment approach, which is cognitive behavioral therapy for insomnia, known as CBT-I. This typically includes “sleep restriction,” or limiting the amount of time people spend in bed when they are unable to sleep, and “stimulus control,” which means keeping the bedroom dedicated to sleep and sex, as well as getting out of bed when you can’t sleep.

For individuals with chronic insomnia who are still experiencing symptoms despite their best effort at managing their symptoms through behavioral and/or environmental changes, there are several pharmacological treatment options which may be considered.

There are 4 main classes of prescription medications used to treat sleep issues: sedatives, antidepressants, melatonin agonists, and orexin receptor antagonists. Each class has a different mechanism of action that affects the central nervous system in a specific way. It is important for patients to speak with their health care professional to determine which treatment approach is best for them.All prescription medications should be used as directed by the prescribing health care professional.

  • Sedatives are medications that increase brain activity of GABA, a substance in the brain, to sedate and promote sleepiness.
  • Antidepressants are primarily tested to treat depression, but some studies report that certain antidepressants may be used as a hypnotic and can be considered for short-term use.
  • Melatonin agonist is a medication that activates melatonin, a natural substance in the brain that is needed for sleep.
  • Orexin receptor antagonists (blockers) are the most recent class of insomnia medications that inhibit the effect of orexin, a chemical in the brain that plays an important role in keeping people awake. In individuals with normal daily sleep-wake rhythms, orexin signaling is believed to promote periods of wakefulness. In individuals with insomnia, it is possible that orexin signaling regulating wakefulness is not functioning normally.

Given up to 30% of adults worldwide reported insomnia symptoms before the pandemic and the deleterious effects of the COVID-19 environment on sleep, it is important to prioritize sleep as we seek to navigate these challenging times. People struggling with sleep should speak to a health care professional to identify the treatment options that are best suited to help them with their insomnia symptoms.


References

1) Sher L. COVID-19, anxiety, sleep disturbances and suicide. Sleep Med. Published online April 25, 2020. doi:10.1016/j.sleep.2020.04.019

2) Taylor DJ, Mallory LJ, Lichstein KL, Durrence HH, Riedel BW, Bush AJ. Comorbidity of chronic insomnia with medical problems. Sleep. Published February 30, 2007. doi:10.1093/sleep/30.2.213

3) Lie JD, Tu KN, Shen DD, Wong BM. Pharmacological treatment of insomnia. P T. Nov 2015; 40(11): 759–771.