Practical recommendations on managing sleep problems during COVID-19 home confinement

The European Cognitive Behaviour Therapy for Insomnia (CBT-I) Academy has issued practical recommendations, adapted from elements of cognitive behavioural therapy (CBT), on dealing with sleep problems during home confinement due to the coronavirus disease 2019 (COVID-19) outbreak for those facing changed work schedules and requirements, those with health anxiety, and those handling childcare and homeschooling.

Given the current situation of global long-term home confinement faced by a large number of individuals, there have been unprecedented disruptions to lives and work, with changes in environment, light exposure, diet and environmental temperature, potentially leading to worsened psychological well-being and poorer sleep quality despite access to social media and other technologies ensuring continuation of communication, work and education. [J Sleep Res 2020;e13052]

Among the recommendations being put forward, the first is to ensure sleep hygiene by maintaining a regular sleep schedule. The circadian rhythm, governed by daylight, plays a key role in determining sleep pressure, which is the homeostatic drive to sleep and the key in ensuring quality sleep.

At the same time, individuals, especially night owls and adolescents, are encouraged to take the current opportunity to allow sleep pattern to follow their own natural sleep rhythm and circadian preference through ‘paradoxical intention’.  

Stress-related sleep problems are common, and those at high risk of stress-related sleep disruption are more prone to chronic insomnia. Applying a cognitive control technique through scheduling a brief  moment (eg, 15 minutes) during the day to reflect upon the stressful situation by writing or talking about it, and avoiding pondering on it thereafter is the second recommendation listed.

In addition, the bed should only be used for sleep and sexual activity, as of part of a stimulus control technique.

Through sleep restriction, in other words, restricting the time spent in bed for bedtime routines at nighttime and/or early morning relative to the average time spent asleep, sleep pressure and quality can be improved with sleep window expanded, especially among women in families with young children.

In times of increased workload and heightened levels of stress, individuals such as healthcare workers and businessmen are often more likely to feel the need for social communication and interaction with trusted colleagues and family members. Individuals are also suggested to look for tasks that are rewarding, which can serve as distractions from unwanted thoughts. Moreover, exposure to news or updates on the COVID-19 outbreak that are irrelevant to an individual’s work situation should be minimized to reduce stress level.

Recommendations on potential pharmacological treatment for insomnia have also been given, whilst general insomnia treatment guidelines should be followed by physicians. CBT-I is recommended by European guideline as the first choice of treatment, with short-term administration of benzodiazepine or hypnotic benzodiazepine receptor agonist reserved for second-line therapy if CBT-I is ineffective or unavailable. [J Sleep Res 2017;26:675-700]