Health x Wellness

Sleep disturbances during the COVID-19 pandemic

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It cannot be overstated that a good night’s rest is crucial in maintaining our health. Conversely, a lack of sleep or poor-quality sleep can harm our health. Sleep is essential for our immune systems to work effectively and it also improves our overall well being. As such, being aware of this and addressing sleep disturbances is of the utmost importance to weathering this pandemic well.

Not having to attend school during the recent circuit breaker period is a dream come true for many teenagers, but that dream did not quite pan out for Damien*, a 17-year old patient of mine. He slept a lot, but still awoke exhausted the next day.

During the circuit breaker period, he began delaying his bedtime gradually. He enjoyed being awake at night as it was quieter and more peaceful, plus in those wee hours of the night, his parents would not be awake to nag at him. He would surf the Internet and play computer games until 5am and wake up very late the next day, often around two to three in the afternoon. He complained that he felt tired despite having slept for 10 hours. He also complained that he could not fall asleep even when he felt tired.

Feeling exhausted even after having slept for more than eight hours is not uncommon, and with our routines disrupted dramatically over the last few months due to pandemic control measures, many of us will be faced with this reality. According to a survey by the World Economic Forum, 22% of respondents said that their sleep quality had suffered as a result of the pandemic.

Getting the body and mind back on track

So, what was going wrong for Damien? Should he have slept less or was it just a mistaken perception that he was always tired? Following an assessment, I found that he had Delayed Sleep Phase Syndrome, a type of Circadian Rhythm Sleep-wake Disorder, whereby sleep times are delayed with an inability to fall asleep and awaken at a desired or conventionally acceptable time. It is a body clock disorder where the internal clock delays sleep even if an individual is tired. This is different from being a “night owl” who can intentionally stay up late, but can adjust the sleep schedule when required.

He was counselled on good sleep hygiene practices, and his sleep patterns were adjusted gradually by having his mother wake him up an hour earlier and him trying to sleep an hour earlier each day. The use of melatonin was also considered, but he preferred to tackle this without the use of medication. After about eight weeks, Damien was eventually able to adhere to a good routine and saw the benefits of waking up early in the morning, exercising and having a productive day.

Too little sleep or untreated insomnia leads to significant daytime distress and impaired functioning, poor alertness, negative mood, fatigue, cognitive (thinking, learning, concentration and memory) impairment and slows performance on tasks, and increases the risk of falls and accidents. A lack of sleep can also make a person irritable, and cause or worsen feelings of depression, putting them at a greater risk of developing depression and anxiety disorders.

What are sleep disorders?

Damien’s case is not uncommon. Have you stayed up late working on a project for school or work, or just to unwind in front of the TV only to wake up the next day feeling groggy and grumpy? This situation presents itself occasionally for some, or is part of the routine for others who have simply resigned themselves to the fate of, “I am always tired”. Sometimes, these are sleep disorders.

Sleep disorders can be divided into three major categories, based on the symptoms present: insomnias (not enough sleep or poor-quality sleep), hypersomnias (excessive daytime sleepiness) and parasomnias (unusual happenings in the night).

Patients with insomnia disorder report dissatisfaction with sleep quantity or quality, associated with one (or more) of the following: difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening with the inability to return to sleep.

Insomnia is a common sleep disorder in Singapore, with a local reported rate of 15.3%. A local study also found that 13.7% of older adults aged 60 and above, were reported to experience insomnia.

Hypersomnia often results in individuals suffering from excessive daytime sleepiness, and can be caused by depression, neurological disorders, and side effects from medication. It can also be caused by obstructive sleep apnoea, narcolepsy, hypersomnolence disorder, and circadian rhythm sleep-wake disorder.

Parasomnias include unusual behaviours that occur during sleep and include sleepwalking, night terrors, nightmare disorder, sleep paralysis, restless legs syndrome and rapid eye movement (REM) sleep behaviour disorder. They can be associated with anxiety and depression.

Could the pandemic situation be affecting my sleep quality?

Sleep disturbances have become more prevalent during the COVID-19 period, as there have been many changes and disruptions to our everyday lives. Working-from-home, school closures (home-based learning) and quarantine measures disrupt our daily routines. Moreover, the underlying fear of contracting the virus weighs on many of us.

Mary*, a 39-year old lady developed severe anxiety and fear of being infected by COVID-19. She felt breathless constantly and fearing that she had contracted the virus, she sought help at the A&E, but no physical abnormalities were found. Her breathlessness was a psychosomatic symptom. She had difficulty sleeping as a result of her constant fear and anxiety; she also developed depressed mood, loss of interests and poor concentration. My impression was that she was suffering from mixed anxiety and depressive disorder. We started her on an antidepressant medication with sedative properties, and her condition has improved with medication and counselling.

Home, no longer a place of rest for many

People who are unemployed or those working from home may sleep very late and oversleep the next day, since there is no need to wake up for an early commute. Students who do not need to report online to their teachers in the morning can sleep in late as well. Conversely, on days when people need to attend online meetings early in the morning, they may face difficulty falling asleep the night before and waking on time the next day. Their sleep pattern has become erratic.

Watching the news, conducting online meetings or surfing the Internet with few breaks can lead to fatigue and over-stimulation of the brain, making it difficult to wind down. The blue light from screens can suppress the production of melatonin, a hormone that the body makes to help us sleep.

In addition, some people find working from home stressful, especially those who lack a conducive working environment. The responsibility of having to supervise their children’s home-based learning and work at the same time can also add to the stress. Some family relationships have also become more strained due to conflicts arising from the increased time spent together. This also leads to more stress and sleep issues.

How can you get a good night’s sleep?

Adults are recommended to have at least seven hours of sleep per night. Beyond sleep duration, people can improve their quality of sleep by practicing good sleep hygiene. Sleep hygiene refers to the performance of activities consistent with the maintenance of good quality nocturnal sleep and daytime alertness.

Here are some things you can do to help maintain good sleep hygiene:

  • Have a conducive sleep environment, ensuring that it is dark, cool and quiet
  • Keep a regular bedtime and wake time
  • Go to bed only for sleep and get out of bed when you are unable to fall asleep after trying for 20 minutes. For instance, you could try some light reading and attempt to sleep again
  • Do not work or watch TV in your bedroom, use your bedroom only for sleep
  • Avoid naps during the day if possible, or limit daytime naps to 1 hour in duration
  • Get regular exercise while maintaining a safe distance from others during the day but avoid excessive exercise in the evening hours (at least 4 hours before bedtime)
  • Limit caffeine intake, avoid in the afternoon and evenings
  • Avoid smoking in the evening and while awake at night
  • Avoid heavy meals within 3-4 hours before bedtime
  • Avoid alcohol intake within 3-4 hours before bedtime
  • Develop relaxing bedtime routines to wind-down (e.g., deep breathing and progressive muscle relaxation, light reading, calming music and meditation, etc), avoid stimulating activities before sleep

Now more so than ever, we need to tend to our physical and mental health – and sleep is a critical piece of this equation.

*Names have been changed for confidentiality purposes

Article contributed by Dr Seng Kok Han, Consultant Psychiatrist at Nobel Psychological Wellness Clinic



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