Dr. Brian Abaluck earned his B.S. in Molecular Biology from Yale University and his M.D. from the Perelman School of Medicine at the University of Pennsylvania. He completed a residency in neurology at the University of Michigan and a fellowship in sleep medicine at Harvard Medical School. His practice in Malvern, Pennsylvania, cares for patients with sleep disorders and connects these patients to trials of novel medicines and devices.
Sleep Foundation (SF): Thank you for participating, Dr. Abaluck.
Last year SleepFoundation.org released sleep guidelines at the beginning of the pandemic. As time has worn on, however, we’re in a different state. We’re now 11 months in, broaching on a year for the U.S. Many of the things we wrote about didn’t anticipate the length and consequences of social isolation, as well as the school closures, job loss, and this anxiety.
So, let’s start with this: now that we’re 11 months into this pandemic, what has surprised you as you look back?
Dr. Brian Abaluck (BA): I think that the pandemic has made me think more carefully about some of these social supports that we’ve taken for granted — especially for my patients who don’t live with family, or in particular, for some of my elderly patients who would see their children and grandchildren from time to time, and now find themselves isolated.
I’ve seen a lot of my patients struggling with the stress that goes along with isolation; and, for people who are still working, the stress that goes along with the disruption of one’s schedule. I feel like many of my patients have not been equipped to make up for the changes that the pandemic has foisted upon them.
“I feel like many of my patients have not been equipped to make up for the changes that the pandemic has foisted upon them”
SF: With respect to some of these general trends, are you aware of any difference between presenting issues you found from patients living in major urban centers versus more rural areas?
BA: I felt there was a divide among my patients to some extent. Our clinic straddles the affluent Western mainline area of Philadelphia, P.A., and an area that becomes more rural as you travel West. A lot of my patients who were from that more westerly area, were actually, even though they lived farther, I think from a cultural perspective, were more eager to come in and continue to see me in person, even though we had transitioned to telehealth. I had a lot more resistance from people farther away, in the rural areas, in perhaps the “redder” areas of Pennsylvania than I did from the inner “bluer” areas when we flipped.
On March 16th, we flipped entirely to telemedicine and a lot of people who were more affluent — more white collar — were thrilled by that. But, people who felt that the virus was being overstated were questioning, and even though we sent all reminders saying, “We are not seeing patients in person at this point,” we had a good number of people just show up at our doorstep and say, “Hey, I’m here for my appointment.” These were challenging confrontations actually, because we had to say to them, “We can’t see you in person. If you want to go back to your car, we can call you, but we’re not having people at the office right now.”
SF: Sleep opportunity has been one of the main educational awareness focuses of sleep in the last 15 years. We know that societal pressures — artificial societal, policy-caused pressures — have, unfortunately, resulted in volitional voluntary sleep deprivation. Have you seen anything that is promising about what we can take away from that? Have they become more in-touch with how valuable sleep is as a result of increased opportunity?
BA: I think that changing commute patterns has been another amplifier of inequality that we’ve seen that’s been so persistent with this pandemic. My white collar patients are doing great, and they can make their own schedules. There are trade-offs to that. On the one hand, when one can make one’s own schedule, when one has too much flexibility, sleep can suffer. It’s something that I think we’d seen routinely among artists, entertainers, and people that were in those fields before the pandemic.
Now, a lot of people have that degree of flexibility and don’t have regular out-of-bed times anymore, and so their sleeping/waking suffers — but it’s still a choice that people are making. It’s still a flexibility that they’ve gained.
When I talk to my patients who are on the other side of this divide, who are working in factories or were working in landscaping or they’re contractors, or they’re in pest control, many of them are still doing financially okay, but they still have to do what they did before. They still have to commute the way they commuted before. And, now, they just have the added stressors of the pandemic to deal with. So, their sleep I think has suffered a great deal just because there’s the added stress.
“I think that changing commute patterns has been another amplifier of inequality that we’ve seen that’s been so persistent with this pandemic”
SF: Forced school closures means that many school-related extracurricular and social activities are cancelled. What effect has that had on kids and families?
Brian Abaluck: Once people have more time, once people have more flexibility, they do need more education, more understanding of how to use that time, how to structure sleep when sleep is not being structured by extrinsic factors. I’d also want to highlight the increased use of substances and how substances are affecting sleep and what we’re seeing. More and more I’ve seen in my practice, patients are using medications in ways that I did not intend. During the pandemic, for instance, we’ve had more issues with people calling for early Ambien prescriptions.
We’ve had more issues than we ever had before with people getting controlled substances from multiple providers. I do think there’s this element of desperation that’s emerged in people who are anxious to start out with, who are now being pushed over the edge a bit.
I think the other challenges that we’re seeing, as you can imagine, is just so much alcohol consumption. We know people are drinking more alcohol during the pandemic. And, of all the substances that I see in my clinic, I would wager that alcohol is the biggest sleep disruptor.
When people are drinking more and more, and have more time at home…this is part of the paradox of having more time to sleep, but less and a lower quality of sleep.
SF: Let’s talk about parents with school age kids. Without social interaction, kids are now dependent upon their parents to provide that interaction. Are you concerned that this is producing adolescent depression?
BA: I had a couple of patients who were in their 40s or 50s who had parents in nursing homes and actually took their parents out of those nursing homes, and they are now living with those parents.
I’m also thinking of a couple of my patients with insomnia. In many of these cases, the parents were in nursing homes for a compelling reason. They had dementia, they have memory disorders. So, now, my patients are not only taking care of their kids who are not at school, but they’re taking care of their parents who previously were receiving a professional level of care and are now sort of turning to their children for that care.
A lot of these people are up at night, and they’ll come to their children. When I think of some of my insomnia patients who have made progress in some behavioral format, a lot of that is undone because they’re kind of being trained to wake up again, by their parents this time. So, I think there have just been so many disruptions from all different angles.
SF: There have been a lot of reports of nightmares and some other unusual sleep problems emerging from the anxiety and stress of the pandemic. Do you see that in your practice?
BA: I think all this is amplified by the fact that a lot of us now know people who have been very sick or died from COVID. It’s just so prevalent at this point.
In the rest of the country, it felt very distant until a couple months ago. And, I think my experience and the experience of a lot of our friends was that we didn’t know too many people who were really severely affected until the past couple of months.
Plus, I think that that sort of feeds into a feeling of fear, and fear leading to substance issues and sleep issues. COVID itself is not just an abstract issue at this point.
“Any time that you spend awake in bed trains your body to stay awake in bed. The time that you get up in the morning tells your body when to feel sleepy at night. Don’t allow daytime habits to sabotage your sleep”
SF: There is a strong body of evidence that suggests that fairly consistent sleep schedules and routines are a very powerful part of our circadian rhythms. Is there something we could take away from this pandemic to modify or strengthen those recommendations? Or anything that we’ve learned from this that might point us back to learning about circadian rhythms?
BA: When I talk to patients about insomnia, I think that these are the important principles that come up repeatedly. Any time that you spend awake in bed trains your body to stay awake in bed. The time that you get up in the morning tells your body when to feel sleepy at night. Don’t allow daytime habits to sabotage your sleep.
If people don’t have any sort of capacity to substitute kind of intrinsic scheduling for extrinsic scheduling, their sleep will fragment, and their quality of their sleep will decline.
SF: Are you seeing more hypersomnia?
BA: My hypersomnia patients are doing pretty well at this point. I think the biggest boon to my hypersomnia patients has been the lack of driving. They don’t have to get up early and drive. They don’t have to drive back from work.
We spend a lot of time thinking, also from a policy perspective, about what are the implications of sleepy patients on the road, and if people are on the road less, and if people are on the road at more favorable times, especially those who are fortunate enough to have a white-collar occupation during this pandemic. I think that sort of subset of my hypersomnia patients have done extraordinarily well.
SF: There’s an enormous market for meditation tapes and self-help guides, like Headspace and Calm. Tracking your sleep is also now widely available and relatively inexpensive or even free. They have come a long way in terms of technology, but some sleep people are opposed as they don’t want their patients to obsess over the data. What do you tell your patients?
BA: I have seen this phenomenon of patients who have become quite obsessed with Fitbit. I mean, several patients have come in with the chief complaint of “My Fitbit says I am not sleeping.” That’s not a sleep disorder, that’s just kind of a fixed delusion. I’ve seen that more and more during the pandemic, as more people are using these apps.
I think the apps cut both ways. Some of the apps that our CPAP patients use, we really like. This is a bit tangential, but apps that are providing meaningless data can interfere with sleep quality. If an app is actually providing data that is scientific and relevant to people’s experience, as the CPAP apps from ResMed and Respironics do at this point, I think we now have decent data that those apps improve compliance. And, if my patients are open to using those apps, I certainly want them to.
I think there’s been some kind of evolution in apps for insomnia, as well. I sat on an advisory board for Somryst. Somryst has a prescription digital therapeutic app that we’ve now, as part of an early access program, probably used in 70 or 80 patients.
In the absence of routine travel, it’s somewhat easier to access mental health professionals now perhaps than it has been in the past with telepsychology. But, it’s kind of an ongoing shortage. I like the idea that people have access to an app for something like cognitive behavioral therapy for insomnia.
SF: We know there is excessive sleepiness that is presenting in sleep labs as a result of the pandemic. Is it possible that narcolepsy is getting diagnosed quicker?
BA: People are now more likely to have adequate sleep opportunities. I’m seeing fewer people who are sleepy just because of inadequate sleep opportunities, and more who have biological reasons for sleepiness.
I do think that narcolepsy is something that’s broadly underdiagnosed. For so long people have not thought of it as a medical disorder. They’ve just internalized other people’s beliefs about them that perhaps they’re lazy, or there’s some sort of issue with their work ethic, when in fact there’s a disorder of wakefulness.
I would also reiterate the idea that telemedicine has been transformative for a lot of people. It’s certainly not for everybody. But, for many people — where it is a struggle to come to a provider, to take time off from work, who don’t have the flexibility to cancel half a day of work — telemedicine has given me access to my patients that I never had before.
There’s a population of people who we’d seen a couple of times, and we’d see them once every 6 or 7 months. It wasn’t quite enough to manage their somewhat complex sleep disorders — whether those sleep disorders were hypersomnia, or insomnia, or restless leg syndrome, or a little bit of all of the above.
Now, if we can find the space in the practice, we can see them a little bit more frequently. They can take that time, and we can make a medication adjustment. They can come back a month later, and we can make another medication adjustment. Instead of a process taking a year — because we’re busy, they’re busy, they can’t take time — we can see them frequently. We’ve seen in our practice that some people have been able to access care in a much more consistent way, and they have benefited from that.
“I do think that narcolepsy is something that’s broadly underdiagnosed. For so long people have not thought of it as a medical disorder. They’ve just internalized other people’s beliefs about them that perhaps they’re lazy, or there’s some sort of issue with their work ethic, when in fact there’s a disorder of wakefulness.”
SF: This relates to an earlier point you were making — that telehealth is a leveler of blue collar/white collar divides.
BA: Telehealth does level things to some extent. Certain people, certain groups have more comfort with technology, and so, the blue collar/white collar divide can cut in different ways. This is especially for my younger blue collar workers, who are more accustomed to Zoom, are a group that’s been able to access my services more consistently. I credit Medicare and CMS with taking the lead on this early on, really, in this country before private insurers were willing to do so. I think that transformed the medical experience for a lot of patients early in this pandemic.
SF: COVID has impacted all of us in so many different ways. If you had to give one sleep recommendation, what would it be?
BA: So much of handling this pandemic is about keeping a regular schedule and responding to isolation, depression, and anxiety in ways that are appropriate. I think it’s important for people to understand that sleep does not exist in isolation, and that anxiety, depression, alcohol, and substances all affect sleep. If we respond to anxiety and depression with substances, as so many of our patients are doing, we’re going to compound sleep problems.
“I think it’s important for people to understand that sleep does not exist in isolation, and that anxiety, depression, alcohol, and substances all affect sleep”
SF: So, after COVID, what comes out of this? Any crystal ball thoughts on what happens?
BA: I hope that, especially in my little corner of the world in healthcare, I hope that this COVID experience helps us figure out what can be done in-person, and what can be done via telemedicine. I hope it’s given us a window into our capacity to treat people in different ways. I hope that those changes are at least continued in some way and not just subverted because private insurers want to minimize the care that people receive.
I hope that we’re able to use telemedicine and remote treatment in ways that are reasonable. More broadly, as a society, we spent so much time traveling to work and from work and crossing time zones, suffering from jet lag. That’s been the standard of what 21st and 20th century Western civilization has looked like. But, maybe it doesn’t have to be like that. Maybe there are some things that we need to do in person, but a lot of stuff, maybe we don’t.
I hope at some point there’s a best of both worlds scenario where we’re not isolated anymore and people can see their families, and on the other side of this, can do the things they want to do in person. But, if people are fortunate enough to be in occupations where they don’t have to travel, maybe a lot of time can be saved and freed up for things that people enjoy more and sleeping properly.
SF: This has been such a rich conversation. One final question: How have you personally seen your sleep impacted? Do you find that it’s different from some of the presenting issues in your clinics? Just as an expert in the field who is experiencing all of this, how have you tried to guard against many of the disruptions that you’ve spoken about?
BA: So, I have a bit of a delayed circadian phase, and I happened to have a 2 year old who wakes up at 6:15 every morning. So, I’ve had to address my own delayed circadian phase tendencies. Fortunately, my wife does not have similar tendencies, so she has been quite helpful. I would say personally, I like lying down at night and just listening to a science fiction book on Audible because it’s totally different. I don’t crave the news anymore. I feel I’m a little compulsive during the day. I’ll look at the New York Times and others, but I realized I need to separate myself from all of that.
I just love listening to something that’s totally different, in a different world, and totally fantastic — and sound and not light. That’s been “cocooning” (as Helene has said), and I think I will borrow that expression and that’s been helpful. I think from a professional perspective, it’s been challenging but satisfying in that I think it’s shown us potentially a different way to treat patients. It’s created a set of challenges and opportunities that we just wouldn’t have thought of before and it lets us play around with: should we be using Zoom, or should we be using this or that?
Or what cloud-based chat should we be using? How should we organize our data if none of us are in the same place — it’s stuff that business people have been doing for a while. That’s not been my path. So, it’s been interesting to experiment with some of that, and learning to use some of these… being forced to use some of these new technologies for the benefit of my patients and my practice.