Physician, Heal Thyself With Sleep

With the demands of the COVID-19 pandemic, sleep deprivation among health care professionals (HCPs) has become a major concern. Are they functioning well enough at work? Do they show signs of stress? Several reviews and surveys have attempted to evaluate and quantify the effects of these unrelenting stressors on the mental and physical health of HCPs treating patients with COVID-19.^1,2

An Unprecedented Problem

The impact of the pandemic and subsequent lockdowns on sleep has been universal, according to Michael Grandner, PhD, MTR, CBSM, FAASM, director of the Sleep and Health Research Program and the Behavioral Sleep Medicine Clinic at the University of Arizona College of Medicine in Tucson. “There is not one person anywhere whose sleep has not been affected at all by the pandemic. It’s a foundation of our biology. Paradoxically, everyone’s sleep is affected differently,” he said in an interview.

Lack of sleep among HCPs became a critical problem as frontline clinicians struggled to cope with the personal aspects of COVID-19 while treating those who were sick. A meta-analysis of 53 studies reported a pooled prevalence of poor sleep quality in up to 61% of nurses in general,¹ whereas a 2020 survey in China showed that more than one-third of all medical staff experienced symptoms of insomnia associated with the COVID-19 pandemic.²

“Health care workers, in particular, have had to work long hours with limited resources and in close proximity to COVID-19 patients during the pandemic,” William D. Killgore, PhD, director of the Social, Cognitive, and Affective Neuroscience (SCAN) Lab in the Department of Psychiatry at the University of Arizona, said in an interview. The SCAN Lab uses advanced technologies to map neurological processes and responses. “As the hospitalization rates continue to surge again, many health care workers are experiencing high levels of stress, anxiety, depression, burnout, and insomnia,” he added.

Many Sleep Domains Affected

Sleep parameters affected include sleep latency, duration, and efficiency.³ Some study results suggested that insomnia, or difficulty falling asleep or remaining asleep, is reported by more than half of health care workers who worked with patients with COVID-19, Killgore said. “Many health care workers are showing signs of posttraumatic stress, which is often associated with nightmares and disturbed sleep. Unfortunately, sleep is important for the ability to process through emotional experiences, so sleep disruption due to anxiety, long hours, and stress can lead to a vicious circle that maintains sleep problems and the emotional effects of traumatic experiences.”

Issues in Sleep Loss and Insomnia

Clinicians on the front lines experienced greater sleep deprivation as a result of increased sleep restriction from extended work schedules, coupled with various insomnias once they returned home. Jessica Dietch, PhD, of the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in California, explained that prior to the pandemic, shift work, particularly involving rotating shifts, was associated with worse sleep across the domains (latency, duration, and efficiency), which were exacerbated with the changing shift demands.

Additional stressors included extreme variability in sleep duration along with increased work and family demands, each of which may limit clinician’s sleep opportunities by restricting the amount of sleep to less than needed. “Decreased sleep duration, particularly that occurring over multiple days or weeks in a row, can lead to the accumulation of sleep debt,” Dietch explained in an interview. “We know that increases in stressors, which abound for HCPs during the COVID-19 pandemic, can precipitate new insomnia, such as difficulty falling or staying asleep, or exacerbate existing insomnia.”

“Insomnia occurs when there is a decreased ability to detach at night,” Grandner added. This causes sleep to become more fragmented and more shallow, although he noted that in laboratory studies, impairments after a night or 2 of sleep deprivation tend to be less than expected. “Impairments accumulate after a few days or nights of sleep deprivation,” he explained. “Your body will entrain arousal when you’re up night after night, leading to a pattern of chronic insomnia.”

The physiological and psychological impact after sleep loss over multiple nights is significant. According to Killgore, “Sleep loss has been associated with reduced functional connectivity, ie, communication, between the emotional regions of the brain and the regions that normally regulate those areas, potentially leading to an increased tendency to view experiences from an emotionally skewed—usually negative—perspective.”

Impact on Cognition

Sleep deficits begin to lead to pronounced alterations of cognition, Killgore added, with potentially serious consequences. “When a person is lacking restorative sleep, they build up a biological ‘pressure’ to fall asleep, which eventually starts to intrude upon their waking performance in the form of brief attentional lapses,” he said. “These are momentary glitches, often less than a second in duration, in ongoing cognitive processing where mental activity just seems to stop for a moment. The problem is that these lapses are uncontrollable and occur without warning.” He added lapses can be life-threatening, happening while driving or working.

The most significant impacts on job performance show up not as much in routine, repetitive tasks, according to Grandner, but “when someone has to make a novel judgment call, like when driving home and the light changes or an animal darts into the road.” This results from cognitive slowing, in which processing critical information and solving problems take longer; it potentially represents the most catastrophic effect of continued sleep loss. Killgore explained that “a sleep-deprived health care provider may not see a simple solution to a simple problem that just takes a different perspective. [Sleep deprivation] also affects judgment and willingness to take risks and how [someone] makes moral decisions. So a health care worker who is lacking sleep may make very different life-or-death decisions than they would if they were well rested.”

Clinicians and HCPs who do shift work—ie, working at times that are biologically out of alignment with their normal day-night rhythm—also seem to be at greater risk for insomnia and other psychological problems during the pandemic.

Negative Psychiatric Sequelae

Sleep deprivation also alters mood and emotional processing. Without sufficient sleep, individuals are prone to emotional and physical burnout, and normally manageable tasks can easily become overwhelming.

Killgore et al found that lack of sleep leads to an increase in implicit biases, such as those against individuals of different races or ethnicities.⁴ “In our study, when sleep was restricted to 4 hours per night for 3 weeks, implicit biases against Arab Muslims were high, but when the same people got 8 hours of sleep a night for 3 weeks, these biases against others completely disappeared,” he said.

Lack of sleep has been associated with poor memory and difficulty with attention and concentration, Killgore added. Although causality is not conclusive, nearly every major psychiatric disorder is associated with sleep problems, he said.

Other Health Risks

Long-term sleep restriction can have many adverse health effects, Killgore explained. “Most notably, long-term insufficient sleep is associated with increased metabolic disturbances, weight gain, obesity, hypertension, diabetes, and greater risk of heart attacks and stroke, as well as weakened immune function,” he said.

Not surprisingly, continued sleep deprivation also presents a higher risk of acquiring the COVID-19 virus. “There’s a potential indirect pathway, in that poor sleep can exacerbate conditions that may be associated with increased risk of infection or complications from COVID-19, like cardiovascular disease,” Dietch said. “Good sleep health is important to support physical and mental health broadly during the COVID-19 pandemic.”

Killgore added, “Our own research has shown that getting more and better quality sleep is associated with greater resilience during the COVID-19 pandemic.”⁵

Addressing Impairments

Killgore pointed out that a sleep-deprived individual, even one who is normally very wise and judicious, very often will not realize that they are sleepy and prone to making mistakes. Many individuals with chronic sleep problems can get extremely tired and may even fall asleep frequently throughout the day without knowing it. Killgore suggested that it is important to take any errors in performance, even minor ones, as serious indicators of impairment. “The best option is to simply follow the science and assume that if you are sleep restricted, you are probably impaired without knowing it,” he explained. “Most people will start to show performance deficits after they have been awake longer than 18 hours straight. Performance declines rapidly overnight, from about 11 PM to about 8 AM the following morning.”

Killgore suggested that individuals probably show impairment if they are awake at a time when they would normally be sleeping. Chronic sleep restriction down to even 6 hours a night for 2 weeks causes nearly as much impairment as a single night without any sleep, he said. Killgore encourages clinicians to “take it seriously if [they] are dozing off or making simple mistakes at times when [they] should be awake and alert. These are clear signs that [they] are not getting enough sleep.”

Grandner observed that paradoxically, “one of the best clues to impairment is the feeling that you’re starting to adjust to the stress.” Another is the recognition of heightened emotional status— feeling unusually annoyed, sad, or anxious, for instance. “Feeling indecisive or defensive about decisions [is another sign] that you may be sleep impaired,” he added.

“Unfortunately,” Killgore stated, “there is no substitute for sleep. Sleep is an absolute need, and the body will start grabbing it wherever it can, even at the most inopportune moments, if you are not getting enough. The solution isn’t to swing the pendulum in the other direction—it’s to find balance.” He suggested that one of the most important things to do after work is to try to disengage from the day. Also, a number of psychological and behavioral treatments exist for insomnia (Table 1).^6,7

Finding Short-Term Solutions

Individuals can employ strategies to remain more alert, at least until they can catch up on sleep. The experts agreed that in the short term, caffeine can help maintain alertness—but they also noted that it should be used judiciously, as it remains in the body and can cause sleeplessness 6 to 12 hours after ingestion. “Although caffeine is very effective at sustaining immediate alertness and vigilance performance, it often produces no measurable improvements in judgment and decision-making quality,” Killgore said.

Grandner agreed, adding that “stimulants, including caffeine, all improve fatigue, reaction time, and alertness, but they don’t rescue decision-making. People just make bad decisions faster,” he said.

The experts noted there are a number of strategies to improve performance and/or wakefulness while at work, at least in the short term (Table 2).

References

1. Zeng LN, Yang Y, Wang C, et al. Prevalence of poor sleep quality in nursing staff: a meta-analysis of observational studies. Behav Sleep Med. 2020;18(6):746-759.

2. Zhang C, Yang L, Liu S, et al. Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. Front Psychiatry. 2020;11:306.

3. Ferini-Strambi L, Salsone M. COVID-19 and neurological disorders: are neurodegenerative or neuroimmunological diseases more vulnerable?
J Neurol. 2021;268(2)409-419.

4. Alkozei A, Killgore WDS, Smith R, et al. Chronic sleep restriction increases negative implicit attitudes toward Arab Muslims. Sci Rep. 2017;7(1):4285.

5. Killgore WDS, Taylor EC, Cloonan SA, Dailey NS. Psychological resilience during the COVID-19 lockdown. Psychiatry Res. 2020;291:113216.

6. Morgenthaler T, Kramer M, Alessi C, et al; American Academy of Sleep Medicine. Practice parameters for the psychological and behavioral treatment of insomnia: an update. an American Academy of Sleep Medicine report. Sleep. 2006;29(11):1415-1419.

7. Buysse DJ. Insomnia. JAMA. 2013;309(7):706-716.