Many Americans cannot sleep — and the pandemic makes it worse

We’ve just ended a most difficult year, in which a raging pandemic claimed hundreds of thousands of lives, left many Americans disabled and in debt, with record job losses and mounting job insecurity, millions of kids out of school, and hunger like never seen before. Despite a presidential election with the highest turnout since 1968, its results and our current leadership vacuum have done little to change Americans’ feelings of fear and anger about the state of the U.S.  

In the New York Times, Meghan Markle recently was moved to ask her fellow Americans, “Are you ok?” Americans are struggling, but mental health remains a neglected priority. Many are coping with depression or anxiety, and this is also affecting their sleep. Prescriptions filled per week for antidepressant, anti-anxiety, and anti-insomnia medications have increased significantly since March. This likely extends to over-the-counter sleep medications, which account for a market of more than $400 million annually in the U.S. These medications are misperceived as being milder and safer because a prescription is not required, but they can have dangerous side effects.

Insomnia increases the risk for mental disorders, and even before the pandemic, insomnia symptoms occurred in a high percentage of the population; pre-COVID estimates range from 35 percent to 50 percent of U.S. adults. Remarkably, between April and May there was an increase of 58 percent in searches for “insomnia” on Google. A recent study found that the number of COVID-19 related deaths correlated with the number of days with an increase in internet searches for insomnia.  

All of this makes clear that insomnia symptoms should be part of routine mental health screenings, especially during the pandemic.

Insomnia symptoms may become chronic and more difficult to treat. The increase in prescriptions for sedative-hypnotics, or “anti-insomnia” drugs, used to induce or maintain sleep is concerning; they have been linked to potential harm and death. The increased usage also reverses the recent trend as this drug use had fallen sharply in the past five years. Despite the risk, patients rarely are referred to the first-line treatment for chronic insomnia recommended by the American College of Physicians: cognitive behavioral therapy for insomnia (CBT-I). Many are unaware such effective treatment even exists. 

Not uncommonly, primary care physicians do not feel comfortable diagnosing and treating sleep disorders, citing lack of sufficient sleep-health training in medical school. There also is lack of access to CBT-I, delivered mainly by trained and certified clinical psychologists who specialize in behavioral sleep medicine (BSM). There are very few CBT-I/ BSM providers, and they are disproportionately located in only a few areas of the U.S. Many states have no providers. Insurance coverage also varies, and self-pay is not affordable for most, especially now that patients may need to choose between affording food or mental health care. 

Adult insomnia negatively impacts quality of life, the ability to cope with stressors, and work productivity. It leads to lower life expectancy and costs the U.S. $100 billion per year. Insomnia disproportionately affects racial minorities. The resulting sleep health disparities and poor sleep health, which in turns leads to weaker immune systems, put these already vulnerable populations at risk for worse COVID-19 disease. 

With the Food and Drug Administration’s approval of digital based CBT-I, insomnia treatment can be expanded to the 90 percent of U.S. adults who have access to the internet and the 80 percent who have access to smartphones. The treatment has proven to be cost-effective, and can be a great tool during the COVID-19 pandemic. But treatment costs need to be lowered, and insurance coverage expanded. 

The time to act is now. Mental health needs have been unmet for millions of Americans for too long. CBT-I is effective, and telehealth can increase access to insomnia treatment and, with careful planning, help decrease COVID-19 related health-disparities.

Asking “Are you OK?” and listening empathetically is important, but we should not let our communities fight mental health and insomnia on their own. They deserve more. Clinicians, especially, must do their part by asking patients how they are sleeping and listening with empathy while recognizing and treating insomnia. Medications have a role, but also significant side effects and the potential for dependence and abuse. The best path is through CBT-I.

As the medical community raises awareness about the potential influenza and COVID-19 “twindemic,” the unseen “twindemic” may as well be COVID-19 and insomnia. It doesn’t have to be this way. We, as a society, need increased awareness and referrals for treatment so that Americans can sleep well and defend against COVID-19. 

Alejandra Lastra is an assistant professor of medicine in the Division of Pulmonary, Critical Care and Sleep Medicine and the program director for the Sleep Medicine Fellowship at Rush University Medical Center. She is a Public Voices Fellow with The OpEd Project.