What’s Keeping You Up at Night?

Breaking the Cycle of Anxiety, Insomnia and Sleep Anxiety

A good night’s sleep does more than refresh and revitalize. It’s essential to your health, so make it a priority to understand what’s keeping you up at night.

“Healthy sleep is as important as proper nutrition and regular exercise for our physical and mental well-being,” says Kannan Ramar, MD, sleep medicine physician at the Mayo Clinic’s Center for Sleep Medicine and immediate past president of the American Academy of Sleep Medicine. “Lack of sufficient sleep is associated with increased risks of type 2 diabetes, high blood pressure, cardiovascular disease, depression and anxiety.”

The sleepless nights and drowsy days previously experienced by one out of three Americans with insomnia rose to pandemic highs of almost 60% in 2021, sounding a wake-up call to address this treatable condition which profoundly impacts both mental and physical well-being.

Sleep disturbance is intricately interconnected with the presence of issues such as anxiety and depression, each influencing the others, so it’s not always possible to determine which came first. Behavioral changes that result from chronic insomnia include feelings of being overwhelmed, inability to concentrate, irritability, nervousness, restlessness, and a sense of impending danger or doom.

Of adults diagnosed with depression, 75% experience insomnia and 20% have obstructive sleep apnea. Similarly, anxiety can make it harder for the body to relax and fall asleep.

Research suggests that anxiety can also affect rapid eye movement (REM) during slumber and trigger vivid, disturbing dreams that wake the sleeper.

Completing the loop is sleep anxiety — apprehension or fear about going to sleep — which is commonly seen in those with insomnia, narcolepsy, sleep apnea or restless legs syndrome.

While insomnia can seem never-ending, a number of strategies can effectively break the cycle.

The Basics:

• Set boundaries for blue light exposure by turning off tv, tablets and phones at least 30 minutes before bedtime.
• Limit large meals, caffeine and alcohol within 3 to 4 hours of bedtime, which can disrupt sleep. Alcohol allows you to fall asleep quickly but not stay asleep throughout the night.
• Establish a consistent wake-up time seven days a week.
• Ensure your bedroom is a designated place of sleep by keeping it dark, cool and quiet. And turn around your clock so you can’t see the time if you’re tossing and turning in the middle of the night.
• Pursue support if you are experiencing chronic insomnia, defined as difficulty sleeping three or more times per week for at least three months. “We know that the longer insomnia lasts, the more difficult it is to treat,” says Dr. Ramar.

Support can include:

• Cognitive behavioral therapy for insomnia (CBTI), a form of talk therapy focused on learning how to create an optimal sleep environment with positive bedtime routines and avoidance of factors that trigger anxiety and negative thinking. Requiring up to 12 weeks to see results, the key is shifting from “trying hard to sleep” to “allowing sleep to happen,” according to Stanford Health.
• Prescription sleep hypnotics, such as Ambien or Lunesta. Hypnotics can be considered in conjunction with CBTI, but patients must be closely monitored for adverse effects and a buildup of tolerance to the medication’s effects. Low doses of Trazodone, an antidepressant, are sometimes used, as it causes drowsiness.
• Light therapy, which is especially helpful for those who need to reset their circadian rhythms; e.g., a night owl who wants to function better with an early morning rising time.

If you are experiencing too many wakeful nights, please let your healthcare provider know. It may be helpful to keep a sleep diary for several weeks to help pinpoint the habits affecting your ability to fall and stay asleep. In some cases, we may recommend a polysomnography (sleep study), where you’ll be monitored for blood oxygen levels, body position, breathing, electrical activity in the brain, eye and leg movements, heart rates and rhythms, sleep stages and snoring during an overnight stay in a sleep lab.

Finally, keep in mind that the amount of sleep needed per night – typically 7 or 8 hours on average – varies by individual. “If you function well and are fully alert during the day, you can be confident your sleep needs are being met,” says Dr. Ramar.

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Pandemic Stress Likely Compounded by Seasonal Affective Disorder

Coping With Sad This Winter

As we continue to weather the storm of COVID-19, seasonal affective disorder, or SAD, is once again on our radar. More subtle than an arctic blast, SAD is just as real, with just as much potential to have a chilling effect on our mood, productivity and wellness. Similar to last winter, the emotional stress and ongoing uncertainty that come with a global pandemic is unfortunately creating an ideal climate for SAD. Not surprisingly, mental health experts are expecting to diagnose and treat an increased number of people with SAD in 2022.

First discovered in the 1840s, SAD was not officially recognized as a disorder until the early 1980s, when Dr. Norman Rosenthal coined the term and categorized it as a form of clinical depression. We now know that SAD affects at least 5% of Americans; is more likely to affect women than men, those with other forms of depression or family members with the condition; and is far more common in northern regions, due to reduced natural sunlight. New research has advanced several theories as to why some people develop SAD, including: sluggish transmission of serotonin (which helps regulate mood and the body’s circadian rhythms; reduced sensitivity of the eyes to environmental light; a combination of these factors; or other reasons yet to be uncovered).

A deeper understanding of what triggers SAD and its impact on mental health has inspired a growing number of clinical treatments that can effectively neutralize its effects.

Chief among them:
Healing light.
Sitting in front of a bright light box for 30 to 45 minutes daily has been a treatment of choice for more than three decades, helping SAD patients with either 10,000 lux of white fluorescent or full spectrum light that shines 20 times brighter than ordinary indoor illumination. Dawn simulation, another form of light therapy, begins in early morning before patients awake by emitting a low level of light that gradually increases over 30 to 90 minutes to recommended room light level (approximately 250 lux). Enhancing indoor lighting with regular lamps and fixtures is also recommended).

Talk therapy.
Newer studies from the University of Vermont suggest that cognitive behavioral therapy (CBT), a psychological treatment aimed at providing patients with tools to change negative thoughts and behaviors, may be as effective as light therapy for treating SAD. According to the National Institute for Mental Health (NIMH), CBT adapted for SAD focuses on behavioral activation, helping SAD sufferers identify and engage in enjoyable seasonal activities to combat the ennui and fatigue they typically experience in winter.

Sleep hygiene.
Creating a consistent light-dark, sleep-wake cycle is important for SAD patients, who often experience hypersomnia (excessive daytime sleepiness) and insomnia (trouble falling or staying asleep).
Antidepressant medications. Because SAD is associated with disturbances in serotonin activity, antidepressant medications have been effectively used to treat symptoms.
Active days. Keep moving with daily walks outside, even on cloudy days, and aerobic exercise. Both can help alleviate symptoms of SAD.

Winterize your mental health
Be proactive in safeguarding your mental wellness over the coming months. Most importantly, know the symptoms of SAD and call our office for help if you’re experiencing:

• Diminished interest in things that were once enjoyable
• Low energy or overwhelming fatigue
• Difficulty with concentration or focus
• Worthless or helpless feeling
• Sleep issues: too much sleep, or not enough
• Changes in appetite or weight; increases in carbohydrate and sugar cravings
• Agitation

Experts advise those who’ve previously experienced episodes of seasonal depression to try to get in front of it this year. Call our office for guidance regarding medications or CBT sessions. For many, reprogramming their mindset can help restore proper circadian rhythms and eliminate the psychological dread of winter. Try enrolling in an online class, taking up a new hobby or creating a new routine to optimize daylight exposure. Or keep it even simpler. As Dr. Rosenthal told the New York Times, “A 20-minute early morning walk in the sun can be as good as commercial light therapy.”

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COVID-19 and The Road Ahead

From Boosters & Breakthroughs to Vaccines & Variants: Where Do We Go From Here?

The following reflects an 8/24/2021 discussion; please check the CDC website for real-time updates as the situation continues to evolve.

Their answers may not land lightly, but epidemiologist Jodie Guest, PhD, and drug development expert Michael Kinch, PhD, have been immersed in examining COVID-19 since its first stirrings in early 2020. They share an informed look at the road ahead for us all.

State of Concern

Noting more than 39 million COVID-19 cases nationwide, (as of 9/2/21) Guest projects this will continue to rise rapidly and eclipse one million a week. While “hot spots” for outbreaks clearly correspond to the country’s most lightly vaccinated locales, the impact of the delta variant is being felt in virtually every state. “There’s almost nowhere you can go in the U.S. that you don’t need to be masked indoors, even if vaccinated,” she says. The progressive increase in vaccinated patients with COVID-19 in European hospitals is also troubling, says Kinch, a potential harbinger of what is to come for the U.S.

However, what’s driving the surge is not cases among the vaccinated, known as “breakthroughs.” It’s a term Guest would like to eliminate permanently, given its negative connotation regarding vaccine efficacy. “These type of infections are still rare. More than 90% of those hospitalized with COVID-19 are unvaccinated.” She points out that while viral loads in patients with COVID-19 are the same for vaccinated and unvaccinated patients in the first few days of illness, they drop much faster and further in the vaccinated.

The vaccine, contends Kinch, was never intended to eliminate all possibility of getting COVID-19. “It’s not a suit of armor,” he says, “because no vaccine ever provides 100% protection. But we know they work incredibly well to prevent you from getting very sick or dying.”

The FDA’s recent approval of the Pfizer mRNA vaccine, with Moderna approval expected to follow soon, is pivotal, says Guest, in helping launch vaccination requirements at businesses, schools and other locations. “Don’t underestimate the importance of this approval in providing support for mandates that will protect all of us,” she says. “Recognize that in the entire history of vaccines, there has never been a set more studied than the ones we have now.”
Adds Kinch, “With the enormous amount of data gathered on the vaccines’ efficacy and safety, those who think of themselves as vaccine hesitant may more accurately be described as vaccine resistant.”

Third Doses and Boosters

The recent approval of a third dose of Pfizer or Moderna for immunosuppressed patients who didn’t build sufficient immunity from the first two doses applies to just 3% of the adult population. For everyone else (with the exception of pregnant women), a booster shot six to eight months after the initial series is being considered for approval.

“Right now, that’s how long we believe we can go without significantly diminished immunity,” says Guest. Antibody tests are not proven to be an accurate measure of protection from COVID-19, says Kinch, because the antibody levels vary by individual.

If you received Pfizer or Moderna initially, choose the same for a booster. Notes Kinch: “There’s no difference between these two vaccines—one is not better than the other.” In fact, some studies show no impact on efficacy from switching brands, he says; Johnson & Johnson data is yet to come.

And where does the flu shot fit in this fall? Absolutely essential, both agree, with the only caution that a two-week separation between the two vaccines may be recommended by some healthcare providers to avoid triggering a hyperactive immune response.

Protecting our Children

The best way to keep youngsters under 12 safe is ensuring that everyone around them is vaccinated, says Guest.
“Teachers, caregivers, babysitters and others should be vaccinated, or fully masked whenever they’re with children,” she advises. A different dose is being tested for 5- to 12-year-olds, with approval possible later this year.

The Next Wave of Variants?

While not identified by the Centers for Disease Control (CDC) as a “high concern,” Kinch admits that the lambda variant worries him primarily because not enough is known about its ability to resist vaccines. “One view is that the COVID-19 spike protein can only mutate to a certain point, and if that’s true, lambda could be the end of the virus. The other view is that we don’t know if it stopped mutating,” he says.
“We’re not defenseless, though,” counters Guest, “because we can keep it from getting here by having COVID-19 not circulating in communities. Greater numbers of vaccinated people will prevent us from getting whatever variant might follow delta.”

Stay Safe and Well

One of last year’s most popular signoff lines takes on new resonance as our experts advise on what that now means for the vaccinated in fall 2021.

Mask Up, Indoors and Out.

Masks are increasingly needed outside in crowded areas. Indoors, remember that while a soft, comfortable cloth mask protects others from you, if you need extra protection in certain settings, use a KN95 or N95 mask.

Pass on Indoor Dining, Movies, Concerts and Sporting Events.

Also reconsider full-capacity outdoor events with no masking/distancing/vaccine requirements. (As an alternative, order take-out and support virtual events offered by local venues). And avoid getting together in person with those who are not vaccinated.

Reach out to Every Unvaccinated Person you Know.

“The best action we can take is to keep encouraging every unvaccinated person we know to get the shot, now,” advises Guest. “We’re all in the race against variants and need to work together to defeat them as quickly as possible.” Adds Kinch, “It’s unfortunate that the motivations behind much of the messaging has messed up the message itself. Be completely honest about what is known and not known about the vaccine.”

The Swiss Cheese Respiratory Pandemic Defense.

“Layering prevention messages is crucial because the delta variant has made the holes in the Swiss cheese slice of the vaccine just a bit bigger,” says Guest. “Now masks are more crucial than ever before.”

Dr. Jodie Guest is professor and vice chair of the Department of Epidemiology, Emory University, Atlanta, and award-winning leader of Emory’s Outbreak Response Team for COVID-19.

Dr. Michael Kinch is associate vice chancellor and founder/director of the Center for Research Innovation in Biotechnology and the Center for Drug Discovery at Washington University, St. Louis.

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