Addressing the Complex Relationship Between Mental Health and Sleep

The COVID-19 pandemic has affected everyday life in a number of ways, including some that many consider positive. From telehealth appointments to more work-from-home arrangements, lifestyle shifts serve as frequent reminders about how much has changed during the last 2 years.

However, the negative impacts cannot be overstated. One that has received more focus is declining sleep quality, both for health care workers and the wider public. Research has tied poor sleep quality to the mental health of the world at large, and attacking these problems in tandem is an approach worth considering, according to experts in the field, given the cyclic, intertwined nature of these 2 problems.

Sleep Quality Worsened for Health Care Workers

The sleep quality of health care workers has declined since the start of the pandemic in March 2020, with the horrors of the day spilling into sleep. According to one systematic review published just over a year after the pandemic began, 31% of health care workers reported poor sleep quality related to stress, anxiety, and depression.

“Nurses, in their waking hours, just see their dead patients sitting across from them at the dinner table, and in their sleeping hours, they wake up from nightmares,” noted Rebecca Love, chief clinical officer of intelligence at IntelyCare, an on-demand health care staffing company, describing what nurses she’s talked to have expressed about post-traumatic stress and their sleep. “What we’re seeing is that the mental wellness of our health care workers who have experienced post-traumatic stress or moral injury is affecting all aspects of their waking and sleeping hours.”

Health care workers also have been reporting correlations between mental health problems and poor sleep quality. A systematic review evaluating 414 studies found that 44.0% of health care workers reported having a sleep disorder and 31.4% reported post-traumatic stress.

In the same review, 3 studies that evaluated the relationship between insomnia and mental health diagnosis found that 26.2% of health care workers had insomnia and moderate to severe signs of acute stress, 14.3% had insomnia and mild to severe systems of depression, and 10.8% had insomnia and mild to severe systems of anxiety.

The lack of sleep brought on by mental health issues has implications beyond just leaving health care workers groggy in the mornings, however. Doctors, nurses, and other health care professionals are tasked with being the last line of defense for patients suffering from severe COVID-19. One wrong move due to an exhausted brain can spell the difference between life and death for the patients they’re treating.

There also can be long-lasting consequences for health care professionals who come to work after a poor night's sleep.

“Nobody talks about the impact to your life if you make a mistake. It’s not like you’re going to get slapped on the hand or potentially fired; it means that they can take your entire livelihood from you,” said Love. “That’s what we all fear. That we’re going to make some mistake, that our nursing license could be ripped from us…from circumstances that we have little control over.”

The ongoing mental health stress on health care workers can often cause a cyclical pattern that encompasses lack of sleep because of a mental health disorder and that mental health disorder becoming more relevant due to lack of sleep.

Sleep Problems Expand Beyond the Health Care Workforce

Sleep disorders during the pandemic have not only affected health care workers but also the general population, as activity and sleep schedules changed, whether because of remote work or other reasons.

Those other reasons include higher levels of stress, said Michelle Drerup, PsyD, DBSM, director of behavioral sleep medicine at Cleveland Clinic, which saw an increase in patients with insomnia and irregular sleep problems.

“Specific to sleep during the pandemic, things that were sleep disruptors for many people were kind of just a decrease in typical activity levels,” she said. “If I’m working remotely and not needing to leave the house, often I’m not getting light exposure that can impact sleep.”

Flexible sleep schedules, such as going to sleep later and waking up much later than usual, could benefit some, but for others, going off regular routines could disrupt future sleep.

A systematic review reported that 18.0% of the general population not affected by COVID-19 and 57.0% of patients with diagnosed COVID-19 had some form of sleeping disorder during the pandemic. A separate systematic review found that 36.7% of the general population had sleep problems during the pandemic,and that sleep disturbances were higher during lockdown compared with no lockdown. In addition, 4 of 10 individuals reported a sleep problem from November 1, 2019, to July 15, 2021.

Drerup said that sleep was often thought of as a consequence of depression and anxiety, but now there’s recognition that sleep can also have a causal role in developing and maintaining mental health issues.

“I think that if people started having more disrupted sleep on top of higher stress that led to the development of one of these more long-term mental health issues, then that might be more of a lasting impact on the general population] because then when someone has an anxiety disorder, sleep further deteriorates because it becomes this very vicious cycle,” she said.

Addressing Sleep, Mental Health Together

With connections evident among sleep disorders, depression, and anxiety, this effect of the pandemic is a problem worth addressing.

A lack of high-quality sleep in both health care workers and society at large could have lasting impacts on both the quality of care that health care workers can deliver, as well as community mental health.

Drerup said that cognitive behavioral therapy (CBT) has been used to effectively help people overcome patterns of thinking that prevent them from getting the quality of sleep they need. A recent survey found 23% of Americans fall asleep watching television and 29% use alternative sleep aids such as aromatherapy, both of which are unhealthy habits to take to bed. Doctors have been using CBT over sleep medication due to overall results.

“Long-term CBT is much more effective, because it addresses whatever’s kind of the root cause or what’s maintaining sleep difficulties,” Drerup said. “The idea behind a medication is, ‘Okay, you’re going to kind of reset, and you’ll take it for a short time and then you are able to discontinue.’ For most people, that’s not what happens…. So, when they don’t take it, their sleep is even worse.”

She said that CBT should be the first line of treatment for any adult with chronic insomnia. A silver lining of the pandemic is that telehealth has facilitated CBT access, which has been a benefit due to the influx of patients with insomnia.

Love said she thinks that there’s been an effort to address the underlying mental health issues in the health care community that could have a positive impact on sleep quality. She recommends writing as a way for health care workers to work through their trauma and said that individual workplaces are addressing the mental health issues underlying poor sleep quality in different ways.

“For our own business, our nurses have access to an app called TaskHuman, [where] real life coaches who are nurses can call and talk and [the conversations are] completely confidential,” she said. TaskHuman is a third-party app offered by IntelyCare.

Dreup stressed the interconnectedness of sleep and mental health. “It used to be thought that [if] someone has depression and sleep issues, if we treat the depression, the sleep issues will go away. We know that isn’t always the case,” she said.

Love said that she wants other health care workers to know that they’re not alone in their trauma keeping them from sleep.

“Many of us on the frontlines have been broken by this pandemic. And sometimes just by admitting that we’re broken, it means we can actually start to fix it,” she said.

References

1. Alimoradi Z, Brostrom A, Tsang HWH, et al. Sleep problems during COVID-19 pandemic and its association to psychological distress: a systematic review and meta-analysis. EClinicalMedicine. 2021;36:100916. doi:10.1016/j.eclinm.2021.100916
2. Marvaldi M, Mallet J, Dubertret C, Moro MR, Guessoum SB. Anxiety, depression, trauma-related, and sleep disorders among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2021;126:252-264. doi:10.1016/j.neubiorev.2021.03.024.
3. Jahrami HA, Allhaj OA, Humood AM, et al. Sleep disturbances during the COVID-19 pandemic: a systematic review, meta-analysis, and meta-regression. Sleep Med Rev. 2022;62:101591. doi:10.1016/j.smrv.2022.101591.
4. ResMed’s global sleep surveys reveal what’s keeping us up at night; aim to bring awareness to the state of sleep health for world sleep day. News release. ResMed; March 14, 2022. Date accessed March 22, 2022. https://newsroom.resmed.com/news-releases/news-details/2022/ResMeds-Global-Sleep-Surveys-Reveal-Whats-Keeping-Us-Up-at-Night-Aim-to-Bring-Awareness-to-the-State-of-Sleep-Health-for-World-Sleep-Day/default.aspx