MANKATO — Lost income. Unemployment. Incessant worry of losing a loved one to COVID-19. An uncertain future. Racing thoughts about when and if there will ever be a return to normalcy.
These are just some of the reasons behind the stress-related sleep problems patients are increasingly reporting to their doctors at Mankato Clinic and Mayo Clinic Health System in recent months.
“I would say there’s more insomnia, secondary to just worrying about the virus itself and all the other things that have happened like losing jobs, finances, how people are going to afford their rent,” said Darla Theobald, a certified nurse practitioner at Mayo.
Dr. Nidal Alkurdy, a doctor at the J. Scott Sanders Center for Sleep Medicine at Mankato Clinic, also has noticed a connection between current events and insomnia.
“We can definitely say that stress, anxiety and worrying about health and financial issues have significantly increased in the past few months with COVID, unemployment and the economic situation,” he said.
Not only are people having trouble falling asleep, but the sleep they’re getting is more restless, which is further aggravated by increased alcohol and caffeine intake, lack of exercise and the 24-hour news cycle.
“Obviously with the riots, that definitely put a lot of unrest into people’s minds as well,” Theobald said.
About 3,000 patients report sleep issues at the nine locations in Mayo’s southwest region annually, which include Mankato, New Prague, Fairmont and Waseca; and of those, about 1,100 require a sleep study, where doctors monitor patients while they’re sleeping for heart rate, breathing, brain waves and leg movements.
But sleep studies are usually conducted when a doctor suspects the patient is suffering from sleep apnea, a condition usually associated with snoring, when the person wakes up repeatedly throughout the night as breathing stops and starts.
While sleep apnea is a physical condition treated with a breathing device, insomnia — especially the kind brought on by stress — can sometimes be trickier to treat, especially when there are underlying issues.
Dr. David Dare, a sleep medicine physician at Mayo, said stress and anxiety are often the main culprits behind a patient’s inability to fall asleep. Determining the source of those stressors is one of the first steps in treating a new patient.
He said cognitive behavioral therapy, improving sleep hygiene and establishing a routine are some of the treatments for insomnia, the latter of which is especially useful for patients whose schedules have been upended from COVID-19.
“We especially want to make sure that if we’re struggling with alterations in our daily schedule due to unemployment or underemployment, that we do things that keep our sleep in a good pattern,” Dare said. “We don’t want to have three different sleep schedules, going to bed at varying times.”
Doing that, he said, is akin to socially imposed jet lag, which hinders the production of melatonin, a hormone released by the brain that supports relaxation, telling the body and brain when it is time to go to sleep. Going to bed and waking up at the same time every day helps to boost melatonin in the brain.
“If we adhere to a healthy sleep schedule, then we are helping this hormone,” Alkurdy said, adding that it’s especially important to avoid exposure to bright lights a few hours before bedtime, whether it’s watching TV, staring at a computer monitor or using a cellphone.
“That can sometimes suppress the production of melatonin when they are exposing their eyes to light,” he said.
Theobald suspects higher rates of unemployment and the shelter-in-place order through the spring might have led to coping mechanisms that actually hinder sleep.
“I’ve heard stories where people don’t really even have a sleep schedule anymore because they don’t have to get up and go to work,” Theobald said. “So, they might be watching movies until 4 a.m. and then sleep during the day, so really trying to keep a regular bedtime routine and time, as well as getting up at the same time every day.”
She said it’s not just a coincidence that stress-related insomnia has increased along with alcohol sales in recent months.
“Most people know the sale of alcohol skyrocketed during COVID,” she said. “We know that does not help you sleep better. It actually makes sleep worse, so try to avoid those coping mechanisms.”
While alcohol acts as a sedative and may help you fall asleep initially, it can wake a person up in the middle of the night after it’s metabolized. Alcohol also interferes with the quality of sleep, reducing the two most important stages: stage three, or deep sleep, and REM sleep, or rapid eye movement, the stage most associated with dreams.
“Stage three and REM are where people get the good quality sleep,” Theobald said. “So, if you have people that aren’t getting into those stages of sleep, those people are going to be extremely fatigued and tired during the day.”
Alkurdy said underlying conditions such as depression and anxiety brought on by current events may require psychotherapy and medications, although medications that induce sleep are the last resort. One of the most important factors, he said, is associating the bedroom with sleep and relaxation. Going to bed while ruminating is not a recipe for a good night’s sleep.
“Stress is frequently associated with anxiety and worry, when our brains keep thinking,” he said. “The first most important rule to fall asleep is the need to relax, unwind and stop thinking about things. If they’re stressed and anxious, that’s not going to happen.”
Relaxation techniques like meditation, exercising during the day or curling up with a good book are all coping mechanisms that increase the chances of a quiet mind before bed, but attitudes about sleep itself are especially important, Dare said.
“As a society, we traditionally have a strong work ethic and often fall into the trap of underestimating the value and the need for sleep,” he said. “We do it for approximately one-third of our lives and it affects everything from mood, cognitive function, cardiovascular health, pulmonary health — even from dermatology to GI symptoms. As sleep effects so much, I encourage patients to prioritize sleep in their lives.”