Treating stress, anxiety, and insomnia
The first-line treatment for chronic insomnia is cognitive-behavioral therapy for insomnia, but “recent evidence shows that cognitive-behavioral therapy can also serve to treat sudden-onset (acute) insomnia due to rapid stress-causing situation changes,” the authors noted. They also reviewed the key elements of CBT-I: stimulus control, sleep hygiene, relaxation interventions, cognitive reappraisal, paradoxical intention, and sleep restriction.
CBT-I lends very naturally to telemedicine, Dr. Seay, Dr. Sundar, and Ms. Trainor all agreed.
“I actually see this current situation as an opportunity for health care practices and providers to expand the reach of telemedicine – due to necessity – which will hopefully continue after confinement has been lifted worldwide,” Dr. Seay said.
Dr. Sundar pointed to research supporting CBT-I online and several apps that can be used for it, such as SHUTi and Sleepio. Ms. Trainor noted that the Cleveland Clinic offers a basic CBT-I online class for $40.
The authors note that prescribing medication is generally discouraged because it lacks evidence for long-term effectiveness of chronic insomnia, but it might be worth considering as a second-line therapy for acute insomnia from outside stressors, such as home confinement, if CBT-I doesn’t work or isn’t possible. Pharmacologic treatment can include benzodiazepines, hypnotic benzodiazepine receptor agonists, or sedating antidepressants, particularly if used for a comorbid mood disorder.
The authors then offer general recommendations for improving sleep that doctors can pass on to their patients:
- Get up and go to bed at approximately the same times daily.
- Schedule 15-minute breaks during the day to manage stress and reflect on worries and the situation.
- Reserve the bed for sleep and sex only; not for working, watching TV, using the computer, or doing other activities.
- Try to follow your natural sleep rhythm as much as possible.
- Use social media as stress relief, an opportunity to communicate with friends and family, and distraction, especially with uplifting stories or humor.
- Leave devices out of the bedroom.
- Limit your exposure to news about the COVID-19 pandemic.
- Exercise regularly, ideally in daylight.
- Look for ways to stay busy and distracted, including making your home or bedroom more comfortable if possible.
- Get as much daylight during the day as possible, and keep lights dim or dark at night.
- Engage in familiar, comfortable, relaxing activities before bedtime.
- If your daily activity level is lower, eat less as well, ideally at least 2 hours before going to bed.
The authors also offered recommendations specifically for families:
- Divide child care, home maintenance, and chores between adults, being sure not to let the lion’s share fall on women.
- Maintain regular sleep times for children and spend the 30 minutes before their bedtime doing a calming, familiar activity that both the children and parents enjoy.
- “While using computer, smartphones, and watching TV more than usual may be inevitable in confinement, avoid technological devices after dinner or too close to bedtime.”
- Ensure your child has daily physical activity, keep a relatively consistent schedule or routine, expose them to as much daylight or bright light as possible during the day, and try to limit their bed use only to sleeping if possible. “Parents need to be involved in setting schedules for sleep and meal times so that kids do not get into sleep patterns that are difficult to change when school starts back,” Dr. Sundar said. “Limiting screen time is also important especially during nighttime.”
- Reassure children if they wake up anxious at night.
SOURCE: Altena E et al. J Sleep Res. 2020 Apr 4. doi: 10.1111/jsr.13052.