I can’t sleep

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I always slept well – pre-pandemic. During the initial phase of pandemic planning, I had long days so I would collapse exhausted and wake the next day to go again. But, I slept ok. As things progressed, I realized that I was not sleeping even though I was tired. I lay awake at night praying for sleep and only managed two or three hours that were certainly not restorative. As a doctor, I was aware of medications commonly prescribed for sleep. I also knew some persons might have a glass of wine to relax. I did not want to try those options. My nightly routine was to have a warm shower and watch Netflix usually until 11:00 pm or midnight hoping to drift off.  I made my room comfortably cool and ensured the blackout curtains were closed. Still, no good sleep. I had stopped exercising during the pandemic. Now vaccinated I felt able to return to my gym, and I felt this was important to re-establish a healthy sleep cycle.

I was aware that I had a persistent feeling of tightness in my chest, especially noticeable at night. My breathing was fine and my COVID test was negative. I recognized that I was in a spiral of stress-causing insomnia with worsening sleep deprivation causing fatigue which was limiting my capacity to cope with the inescapable stress of COVID-19 management. I had to break the cycle.

Insomnia

Insomnia is a common problem. It is experienced by most persons at some point in their life. For some, it is chronic, for others it occurs episodically often at times of stress.

There are five stages to the normal healthy sleep cycle. In stage 1, which lasts about 10-15 minutes, there is drowsiness. Stage 2, 3 and 4 sleep progresses from light to moderate to deep and then enter stage 5, rapid eye movement or REM sleep. This is the phase of sleep that is restorative. Babies spend about 50 percent of their sleep time in REM sleep. Adults and children achieve REM sleep for 20 percent of their sleep cycle.

Acute insomnia refers to a disturbance of sleep due to a stressful life event. Chronic insomnia is present if there is difficulty sleeping for three or more nights per week for three months or more. It is generally tied to stressful situations. It may also be related to irregular sleep schedules, poor sleep hygiene, persistent nightmares, mental health disorders, underlying physical or neurological problems, medications, a bed partner, and certain other sleep disorders.

Sleep deprivation has serious health consequences. These include decreased alertness, daytime sleepiness, impaired memory and crankiness. Additionally, there is increased risk of accidents due to impaired reaction time and inattention. Chronic sleep deprivation has been shown to contribute to high blood pressure, diabetes, heart failure, stroke, obesity, impaired immunity, lower sex drive and depression. Lack of sleep also promotes wrinkles, bags and dark circles under the eyes and makes the affected person look older!

It is important to recognize where mental or chronic medical issues are causing insomnia, and address these in partnership with your doctor. Simple options can be tried to address insomnia.

Behavioural and dietary changes

Behavioural changes include creating an environment conducive to sleep. A dark, quiet room with no devices. No TV! It is better to read a book before bedtime. Devices with lighted screens interfere with melatonin production. Establish a healthy bedtime routine which might include a shower before bed and make the room cool if possible (not cold). A ritual like prayer or meditation at bedtime calms the mind.

Drinking warm milk with cinnamon is a long touted home remedy. Cinnamon is known to have a wide range of positive health benefits but its effect on sleep is less well established in scientific literature. The effect may be post-prandial due to a full, warm tummy. One cup of milk is about 165 calories, and the cinnamon evens out blood sugar levels so it is a great bedtime snack for diabetics who have issues with late-night hypoglycemia (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4466762/). After drinking warm milk with cinnamon, I would drift off within 30 minutes. However, I would wake up at about 1:00 to 2:00 am many nights.

If you have a lot on your mind, it is best to clear your head. Write it out. Make a to do list. Journal. Talk with a friend or counselor. Getting it out may not solve the issues at hand but will allow you to settle your mind to get the rest you need to find the best strategies for coping.

Sleep stories and white noise

A friend introduced me to sleep stories. They can be found on some apps and there are some on YouTube. Essentially these are bedtime stories for adults! The cadence of the narrator’s voice and background sounds are soothing and relaxing and can be very effective. White noise can have a similar effect. Reading work or school documents at bedtime often does the trick for me.

Herbal remedies

Melatonin is a hormone that is secreted by the pineal gland in a circadian fashion based on the body’s internal clock. Its secretion is enhanced by darkness and reduced by light. The variation in melatonin levels controls the sleep-wake cycle. A dark sleep environment promotes melatonin release and helps sleep. Daylight inhibits melatonin release. The light from devices such as televisions, laptops and cell phones also reduce melatonin release prompting most sleep experts to recommend no use of these devices for two hours before bedtime. Melatonin is available as a tablet. The 3 mg dose taken sublingually seems most effective at inducing sleep. It should be taken 30-60 minutes before bedtime.

Valerian Root is a another herbal remedy that induces sleep by its action on the brain. It may also have anti-anxiety properties making it very useful where stress is a factor. Studies suggest that 500mg is often effective though most manufacturers recommend 1000mg as the nightly dose. It is metabolized by the liver and increases the action of other drugs metabolized by the liver by reducing the rate at which those drugs are metabolized. Please consult your doctor if you take medication or have any liver issues before trying this option.

Pharmacological options

Benzodiazepines decrease anxiety and cause sleep. They shorten the deeper stages (3 and 4) of the sleep cycle, but do not affect REM sleep.

Non benzodiazepine sedative hypnotics, unlike the benzodiazepines do not affect stages 3 and 4 of the sleep cycle.

My progress

My sleep has improved greatly, and I am catching up on my deficit. I find warm milk to be helpful, but only with cinnamon added. I have tried Melatonin and Valerian at different times. Both were effective but the Valerian seemed to produce a nice deep natural sleep. A relative of mine with chronic insomnia is also finding it helpful. I did try the sleep stories and they worked, but I had to play them on my phone. I avoid alcohol as it is known to reduce REM sleep. I drink coffee before midday. One cup only. It is best to eliminate coffee altogether. I am reintroducing meditation into my morning routine as it just makes my day go better. I hope that those of you struggling to sleep find these suggestions helpful. Please speak with your doctor to determine what is best for you.

Dr. Simone French is a consultant emergency physician, and the medical director at the Emergency Medicine Division of the UHWI. She is the physician owner of Imara Medical Centre where she practices general and urgent care medicine.