Psychologist Jonathan Gallagher offers some expert advice to help you get a good night’s sleep during these difficult times.

Getting enough good sleep is vital for every aspect of our physical and mental health. Psychologist Jonathan Gallagher, who specialses in working with people with heart disease, explains why many of us may be having difficulty sleeping right now and offers some tips that might help

Q. Why is sleep so important for our mental wellbeing?

Approximately 15 per cent of the general population suffer from insomnia, and in people living with a heart condition this figure rises to 40 per cent. As we know, healthy sleep is critical for cardiovascular health, immunity, the management of hypertension, weight and diabetes. But sleep is also vital for our mental wellbeing.

Sleep plays a crucial role in strengthening new memories and helps flush away waste products that would otherwise be toxic to the brain. It also helps regulate our emotions, our ability to sustain attention and how well we manage stress. For example, we know that chronic insomnia doubles our risk of developing major depression.

The relationship between sleep and our psychological health can be complex. Sleep disturbance can lead to emotional changes such as depression or anxiety, but like a vicious cycle, these in turn can worsen insomnia, which ultimately impacts both physical and mental health.

Q. I am having difficulty sleeping since the onset of the coronavirus pandemic: is this common and why?

Sleep difficulties are different for everybody, but there are some common factors. Insomnia is more likely to occur in women, people over 60, people living with chronic illness and those with irregular schedules. While insomnia is most often triggered by stress or a psychological disorder (e.g. anxiety, depression), it frequently ‘decouples’ from the original cause and takes on a life of its own.

Many people have vulnerabilities that predispose them to sleep problems (e.g. genetics, personality traits) but they don’t go on to develop insomnia. However, these vulnerabilities can be activated when faced with a major stressful life event (e.g. cardiac event and/or a public health crisis like todays’ pandemic).

These stressors can ‘tip us over the threshold’ for insomnia, but when they eventually resolve the sleep disturbance passes. However, many of us, in an attempt to compensate for poor sleep, inadvertently do several things that maintain the sleep problem. These are typically the factors that give rise to chronic insomnia.

These maintaining factors might include increased coffee intake, going to bed early, watching TV in bed, napping at weekends, and worrying about sleep loss.

COVID-19 has also caused our normal routines go haywire, and so we can add further sleep-disrupting factors to this list: sleeping in, financial worries, job insecurity, health anxiety and social isolation. This provides fertile ground for insomnia.

Q. Can you give me some tips on ways to improve my sleep during the current time?

Good sleep is a 24-hour process and its foundations are laid down long before bedtime. It important therefore that we do all we can to adopt a ‘pro-sleep’ lifestyle.

15 tips to get better sleep  

Stick with a regular sleep schedule

Your sleep system craves regularity and a consistent routine trains your body to feel sleepy at the same time each night. Go to bed and get up at the same time each day seven days a week, even if you feel tired in the morning. The wake-up time is particularly important and should not be extended by more than an hour (even at the weekend).

Maintain stable daytime routines

Our daily schedules help set our circadian rhythms, the internal clock that helps us know when it’s time to wake and sleep. When we break from our normal routines (e.g. during a pandemic) our bodies can struggle to know when to be awake and when to be sleeping. Mealtimes help anchor our body’s sense of time. Try to eat meals (especially dinner) at the same times each day, but don’t eat large meals close to bedtime as this can cause indigestion. Also, maintain previous morning and evening routines – your shower, brushing your teeth, face washing, etc. — that cue your body to wake up or sleep.

Exercise for sleep

In addition to cardiac health, exercise is essential for sleep quality and is a powerful stress reducer. People with low fitness or a sedentary lifestyle are more likely to experience sleep problems, whereas regular aerobic exercise on most days (even 30-40 mins brisk walking) results in improved sleep quality. Avoid strenuous exercise close to bedtime as this raises core body temperature and ‘wakes up’ the nervous system which can delay sleep onset. Try not to exercise within 2-3 hours of bedtime, late afternoon before dinner is ideal.

Manage your light exposure

Melatonin is a hormone we produce that promotes sleepiness. Its production is suppressed by sunlight and stimulated by darkness, and therefore daylight is key to regulating our daily sleep patterns. Try to get outside for natural sunlight at least 30 minutes every day, preferably in the morning. If possible, arrange it so that you wake up to sunlight. Bear in mind it’s equally important to reduce your exposure to artificial (blue) light between dusk and bedtime as this suppresses melatonin when it’s required for sleep (see sleeping environment below).

Avoid napping

If you’re struggling to sleep and napping to compensate for that sleep loss, its highly likely that this is helping to maintain your sleep problem, particularly if you’re over 60. Late afternoon naps reduce your sleep ‘pressure’ and can make it harder to fall asleep at night. Avoid napping if you can, but if you must, limit them to 20 mins (use an alarm) and don’t nap after 3pm.

Limit caffeine

Coffee, energy drinks, colas, certain teas, chocolate and extra-strength headache tablets, all contain the stimulant caffeine. The effects of a strong cup of coffee in the early afternoon can take up to 9 hours to wear off fully, making it harder to fall asleep that night.

Avoid nicotine

Nicotine is also a stimulant, and often causes smokers to both sleep very lightly and wake too early due to overnight nicotine withdrawal.

Limit alcohol

While a ‘nightcap’ may seem relaxing initially, unfortunately it disrupts the structure of your sleep afterwards. When the effects of the alcohol wear off, you tend to wake up during the night due to dehydration and/or increased urination. Heavy alcohol use robs you of deep sleep and REM sleep, and may contribute to impaired breathing at night, all of which keep you in the lighter stages of sleep. Keep to a heart-healthy drinking pattern and try to avoid alcohol within 3 hours of bedtime.

Review medications

Commonly prescribed medications (e.g. for asthma), over-the-counter medications and herbal remedies can disrupt sleep patterns. Some heart medications have also been associated with insomnia as a side-effect, but these occur relatively rarely (1-3% of patients). Interestingly, while beta-blockers have also been linked with insomnia, patients taking this medication report fewer sleep problems than those taking a placebo (sugar pill). Do talk to your pharmacist to see whether you’re taking something that might be contributing to your sleep difficulties. If so, your doctor will be able to provide you with a substitute or advise you on altering the timing of your medications.

Relax before bedtime

Don’t cram your day so that you have no time left to unwind before bed. During the hour or so before you normally retire, systematically wind down your activity level and engage in quiet and relaxing activities such as reading or listening to soft music. This unhurried bedtime ‘ritual’ prepares your system for rest and can also include activities like checking lights, heat and locked doors – things that foster a sense of safety and security.

Take a hot bath

Your body naturally cools down as it prepares for sleep. A hot bath, as well as being relaxing, provides a rebound drop in body temperature (after getting out) that can help trigger sleep.

Be kind to your brain before bed

Flooding your mind with coronavirus updates (or other stressful news) within an hour of going to bed is not conducive to restful sleep. Consider keeping a journal in which you record the “unfinished business” of your day. Writing down your worries can help take them out of your head for now. Your mind can then rest safe in the knowledge that you will deal with it tomorrow (as best you can). Keep this fairly brief.

Optimise your sleeping environment

Your bedroom should not be a recreation centre, but rather, reserved only for sleep and intimacy. This ‘stimulus control’ results in your brain strengthening the association between your bed and sleeping, which is especially important. That means no TV, tablets or other screens, as these devices also emit stimulating blue light which suppress melatonin and throw your body clock. Keep the bedroom temperature at 18-20°C with noise kept to a minimum. Certain night-time sounds (e.g. street noise), even if we get used to them, can make our sleep lighter. In these instances, earplugs, white noise (even a fan) have been proven to help. Do not have a clock visible at night – it will only encourage you to calculate how much sleep you’re not getting. If you need it as an alarm keep its face turned away from you.

Mental Approach to Sleep

“It’s a bad thing to be awake when reason sleeps” (M. Perlis).

Humans seem to be primed for frightening thoughts at night, and a quiet dark room can result in uninterrupted worrying, particularly during stressful periods. Unfortunately, this is also the time when we are least able to think rationally about our concerns, and instead our thoughts can become intensified. Sleep experts recommend that we should think of ourselves as ‘12-year olds emotionally’ at these times. Remind yourself of this, and instead of catastrophising about COVID-19 at night, postpone these concerns until a time when you are better equipped to deal with them rationally. Muscle tension also feeds an anxious mind, so use deep relaxation techniques such as progressive muscle relaxation (PMR) to break this connection. Some of these have been adapted specifically for sleep difficulties

Don’t lie in bed awake

It’s important that your body doesn’t associate your bed with frustration and full alertness. If you are unable to fall asleep after 20 minutes, leave the bedroom and engage in a relaxing activity (e.g. read something light, sitting in a dimly lit room). Avoid eating a favourite snack at this time as it only serves to reward your body for staying awake. Return to bed only when you are sleepy.

Q. When should I consider professional help?

Sleep problems visit everybody occasionally, but these are different to a sleep disorder, which should be treated. The general advice would be to proceed with the simple measures first. Implement as many of the above 15 recommendations as you can, and you should see a significant improvement in your sleep.

If you suspect that emotional difficulties are the main cause your sleep problems, contact your doctor and/or consider a psychologist referral. Depression and anxiety commonly contribute to insomnia and can be treated effectively. Cardiac Rehabilitation Programmes have also been shown to improve patients’ sleep quality and many provide specialised Stress Management programmes which further target sleep.

If you continue to have trouble sleeping for more than 3 months (for more than 3 nights per week), and you feel this is significantly impacting your life, it’s likely you have an insomnia disorder and you should seek a referral to a clinician providing CBT for Insomnia (CBT-I). There are very few specialists in Ireland providing CBT-I but referral details can be obtained by contacting www.irishsleepsociety.org or www.sdsf.ie.

We are here for you

The Irish Heart Foundation’s nurse support line is available five days a week. Anyone living with heart disease and stroke who has concerns or questions about the coronavirus can contact the nurse support line on 01 668 5001 or support@irishheart.ie.

The Irish Heart Foundation’s new heart support group is on Facebook. Anyone who lives with heart failure or another heart condition or has a family member living with a heart condition can join here: www.facebook.com/groups/heartsupportnetwork/

The Irish Heart Foundation runs 21 stroke support groups and 5 heart failure groups around the country. All these groups have moved to telephone and online support. For more information, see https://irishheart.ie/get-support/.

The Irish Heart Foundation in conjunction with the HSE National Stroke Programme, has launched a new telephone support service for stroke patients who have recently been discharged from hospital. For more information, see here.