Helene A. Emsellem, MD, is the Director of The Center of Sleep & Wake Disorders in Chevy Chase, Maryland, and a Clinical Professor of Neurology at George Washington University. She enjoys all aspects of sleep medicine, including direct patient care, research into new agents and devices for the management of sleep disorders, teaching, and public advocacy about the importance of sleep.
Dr. Emsellem wrote the book Snooze… or Lose! Ten No-War Ways to Improve Your Teen’s Sleep Habits to help teens and parents understand the unique aspects of adolescent sleep.
Sleep Foundation (SF): Thank you for participating, Dr. Emsellem.
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?
Helene Emsellem (HE): We were surprised, initially, by the number of patients who reported that they were getting more sleep — they love not having to commute to the office, and they were using the additional time they gained from being quarantined for sleep.
On a positive note, we were surprised by the patients who were coping better. I think we also saw that the more anxious people were at baseline prior to the pandemic, the more difficulty they have had during it.
In addition to more sleep and better quality sleep, people seemed to exercise more, certainly early on. I think that’s gone down the drain with the cold weather the last 2 months, but people were breaking up their day, going out, and exercising. So, other than the psyche piece of it, there were some aspects that really seemed healthier.
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?
HE: We truly are not rural, although, we have patients in rural Virginia, West Virginia, and a little bit of the Eastern shore of Maryland. I think we saw less of those people at first. We had the first 3 months where people were just hunkered down, worried about survival, and we had a huge drop off in referrals. So, we had time to think out how we were going to deal with it because there was not much going on. But, even as it’s ramped back up and went probably a little beyond the baseline from before that, I do think that the rural population is a little less aggressive about dealing with it. They may be dealing with more financial issues than the inner city folks and coping with survival life things more so.
I would add to that, there’s an age divide, too. We still have a subset of the 80 year olds and older who are very aggravated about not being able to come in. We have a very simple, portable apnea screening device we’ve been using that’s been working really well. Our techs will Zoom them — and they’re on their computers all day long — but they just want to come into the office.
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?
HE: There’s a subset of our patients who aren’t too anxious and have really taken advantage of that. My international travelers are missing their travel a little bit, but they are getting a ton more sleep on a much more regular schedule. Some have been able to reduce medications, even though I know the overall trend: I read something from Express Scripts that they had a 14.5% increase in hypnotic medication, to treat insomnia, this past summer.
Plus the lack of commuter time, the lack of international travel, the lack of travel just for the people who shuffled between New York and Washington or Washington and Philadelphia, people have recouped that time. As we said before, initially, I think they were using that for helpful things. I think some of that’s gone to the dogs, as we’ve all gotten a little notch down in our enthusiasm, this thing keeps dragging on… and it’s cold.
Another point, too, to add to that is some occupations — my bookkeeper, for instance — have been run ragged throughout this pandemic. Being forced to work at home makes some things take more time. So, she had to help everybody with the PPP loans and then their PPP loan forgiveness, then the taxes were done, and then they changed the tax rules. Every time I call her, it’s like, “I’ll jam it in… I’ll figure out when to call you.” Some people have a ton of work during this pandemic, and some aspects of having to do it at home, where you don’t have access to everything that you need, does make it more complicated.
SF: There are a lot of people in high-stress situations, from frontline workers to students navigating a new academic world. What are the repercussions of this that you are seeing in your community?
HE: We keep using the term “stress”, but we are also seeing depression, too. The social isolation was lovely for a few weeks, and then it gets old really quickly. I think my adolescents with social anxiety are the only ones who are totally thrilled with getting educated remotely; a couple of college students I’ve had home are headed back here in January and perked up at the thought of getting back to school. But, I see and I know for the working people with kids at home and trying to juggle — how do you get any uninterrupted time? Just the interruptions from deliveries coming to the door and the dogs barking disturbs you. My staff can’t tell when I’m talking to somebody, they don’t like to look at the schedule to see if I’m going to be on the phone or not.
I think that there is an element of depression that we’ve seen more of as well. On the plus side, the psychiatrists have been a little more accessible than usual. It is always hard to find a psychiatrist in Washington. They have a little more time in their schedules because they’re not commuting, and they’re having sessions via telemedicine. We can open up the spectrum of where people have to go. They don’t have to get 15 minutes from the office to get to a psychiatrist. They can log into see somebody in Virginia, even if they live in Northern Maryland. There is a little more flexibility, but there’s depression out there, too.
SF: Let’s talk about parents with school age kids. Without social interaction they are now dependent upon their parents to provide that interaction. Are you concerned that this is producing adolescent depression?
HE: Very much. I have two 3-year-old grandchildren. Their social isolation, terrible desire to be with other kids—look at them, be next to them, touch them, and be on the playground with them—is very hard and wears their parents out. The parents get irritable and are trying to work at the same time. So, juggling who’s going to get children’s 5:00 AM to noon shift and who’s going to get the afternoon or evening shift, altogether, is pretty frantic.
A lot of people who had help at home have one parent who stopped working as a solution. Then a working parent suddenly becomes a full-time, in-home parenting figure, and they are not coping with the change terribly well. Certainly, I wouldn’t cope with that very well! So, it gets pretty hairy. A husband and wife with kids — younger elementary school kids — counted the number of times their kids came and interrupted them during their “shifts” when they were both parenting and working. It was spectacular. It was almost once a minute.
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?
HE: I don’t know that you can talk about this at all without talking about the political climate, too. I mean, we live it and breathe it here, in Washington, so maybe we see the worst of it. People have just been like, “Okay, I could cope with the pandemic, but I can’t cope with the division and the divisiveness in the country right now.”
SF: Are you seeing more hypersomnia?
HE: We have seen some hypersomnia patients who have defined themselves as having hypersomnia now that they’ve had enough time to sleep. Some of the college students got back and said, “I was tired all the time. I thought it was because I was up late, and I was partying late. And then, I behaved all summer and was on a 9.5-hour routine, and I’m still dog-tired all the time.”
I think the problem of people being anxious, not being able to fall asleep, and getting in bed too early is a big deal — too much time in bed begets more awake time at night. And, that the intuitive thing to do when you can’t fall asleep, well, is to just keep getting in bed earlier and earlier, and it ends up being a mess. So, I think some focus there is helpful for people in terms of coaching them.
We have taken to using a lot of the things that we do with delayed phases patients, in terms of controlling blue-light exposure in the evenings, and we’ve been applying it to the insomnia population as well.
We recommend the basic insomnia stuff of having people carve out 15 to 20 minutes of personal downtime before even trying to go to sleep. Also, we’ve been putting people in Uvex orange-lens glasses 2 hours before their desired bedtime. We have some general info on the website about how to set the orange filter on an iPhone, Droid, and Mac or Windows computers.
My iPhone complaint is you can set the schedule, but people just turn it on. They figure it’s good to filter blue light, so they’re filtering blue light 24/7. Some instructions on how to use that feature. I mean, I find those things to be really helpful in the background.
SF: What do you tell your patients about sunlight exposure? Strong morning light, diminished, nighttime light, depends on the patient?
HE: I have steered clear of light boxes in the last few years. We used them quite aggressively 10 years ago. However, I’m very sensitive to the idea that if you don’t know where someone’s circadian phase is, and you expose them to light at the wrong time, you will throw them further out of whack. So, I don’t augment or diminish light. I don’t want them in a dark cave in the morning. I leave them with ambient light in the morning.
I focus most of my light control on getting blue light out of everything in their lives in the evenings, specifically within the 2-hour timeframe before bed. I’m a huge fan of, for the delayed phases, parking them in bed on a schedule. So, I like the idea of cocooning yourself into sound, walling-off the environment and your internal thoughts, too.
For the delayed-phase people, when they have to be on a schedule, we don’t try to move them very much, very quickly. But, we do try to give them not cognitively demanding strategies as distractors and keep them away from the light at all costs.
I think Uvex orange lens glasses are relatively inexpensive and just something that probably should be in Health 101 in the 5th grade and everybody should have, as they simulate dusk — a key biological cue for transitioning to sleep. By wearing orange lenses in the final 2 hours before bed, we can eliminate the alerting influence of environmental blue light on the brain, which could ease the transition into sleep at the appropriate time. Then you get the night owls, who can’t sleep, and they listen to the insomnia instructions [from the cognitive behavioral therapists, who I have a lot of respect for], but not everybody should get out of bed if they can’t sleep. Some of them just have to stay there in the dark and distract themselves so that they will be in the right place when they get drowsy.
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?
HE: We tell people to try those. Some people’s minds are too active, and they cannot stay focused on a relaxation strategy, especially if they are worried. So, I generally recommend a hierarchy of listening to music, a podcast, or, when that doesn’t work, TED Talks. Increasing the complexity, as needed, to override internal thoughts. I suggest you find a TED Talk on something you would like to listen to a little bit but you don’t really care about, so if you fall asleep in the middle of it, it won’t be the end of the world.
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?
HE: It’s not a huge number. I don’t think I’ve seen a substantial notch-up in the number of new narcolepsy hypersomnia patients during the pandemic period. In a way, the last couple of years, there has been marketing for some new drugs, which I think has some impact for sure, but I track new narcolepsy patients who have good data. We’ve had a couple during the pandemic that we’ve treated empirically with the plan of, hopefully, sometime later in the summer, obtaining a nap study. We did some nap studies at the end of last summer, just with one patient in the lab per day, to try to make some diagnoses before school restarted. But overall, net, I don’t know that I’ve seen more.
I think that people at home have more opportunities to complain to spouses. We may have seen a little bit of a notch-up in the snoring complaints, in addition to the insomnia complaints. Maybe a few more apnea workups. I think that we’ve got a pretty good system with the available technology for auto-pap devices, monitoring remotely, and portable studies at home that we can mail out to people and they can throw in the trash in the morning, without having to bring back and forth. I think we’re doing well with those diagnoses, but I’ve seen more circadian misalignment insomnias and some nightmares, but not so much more hypersomnia. A few of those stood out just because they had the opportunity to sleep and realize that something was wrong, but not really a big bucket of them.
The only other comment from the discussion that this led into, in terms of self-help, is encouraging patients to take a 20-minute break and go walk outside alone to empty their head out. So, these Headspace and Calm apps that people are doing at night, accessing some of that really in the middle of a day can help, especially when there are two working parents in a house and kids around — everybody needs a rotating break time to just get out and empty their heads. I was talking to a speech pathologist who’s running the COVID long-hauler clinic at a hospital about what she’s seeing with the cognitive complaints and the insomnias in those patients. They’re tying a lot of that back to anxiety and that people are trying to multitask in a brain that isn’t quite ready to multitask again.
SF: COVID has impacted all of us in so many different ways. If you had to give one sleep recommendation, what would it be?
HE: A sequel to this whole discussion is: what are we really going to see when we start to see the masses of the people who’ve had COVID? For example, my daughter’s entire family was charmingly infected by the nanny, who didn’t tell anyone she was sick for 3 days. They all got COVID and were really sick from it — which I have to say, close-up, is one hell of a frightening experience to watch. Plus, a whole sick house with no one’s help is also a mess. We were dropping food at the doorstep, and all kinds of stuff.
The cognitive complaint — a lot of people are multitasking all day long and that multitasking skill set is precious. You don’t even realize how much you’re doing it, and head emptying and clearing during the day to break it up is needed so that you can take on another task. Having people take tasks, one at a time, as best they can is a decent suggestion, but I’ve been encouraging people to get outside and take a 20-minute walk with their mask on, even when it’s freezing. You can do that almost anywhere on this earth, just change venues.
We’ve also talked about the idea of your “day pajamas” and “night pajamas”, and trying to maintain a little bit of schedule. Get up, get dressed, and keep the defining aspects of your day in place to keep it alive.
All-in-all, it’s a slow process. The cognitive impairment is the thing that is most striking. From watching my daughter, who is a speech pathologist: her husband got sick as a dog with a very high fever for 3 days, but he cleared cognitively afterwards, immediately. But she… You couldn’t talk to her on the phone. She couldn’t string a sentence together. It’s frightening for her. She’s smart and knew that it wasn’t right. It was terrible to watch and slow to recover. So, it does get better. The term “brain fog” is an understatement for the cognitive impairment that’s seen in processing speed, the ability to multitask. I’m sure we’re going to see psychologists give us much more data about that.
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?
HE: I always say that I’m the worst at following my own advice, but I have tried to follow my own advice about trying to maintain a schedule. On the topic of binge-watching and just saying, “It’s midnight now. It’s not going to be the end of the world if I get to sleep until 7:30, but I’m going to have to not watch another episode,” and putting the lid on that. I’m the least anxious person on the planet.
I’m Type A+++, but I don’t get anxious talking to people. I don’t get anxious in crowds or any place else. However, when I got that COVID shot in my arm, there was this sensation of relief that maybe I’m going to be okay, maybe I’m going to be protected. I think that being a little more conscious and nurturing yourself a little bit by taking that warm shower, listening to some music, taking a walk by yourself, and emptying your head are very important. We’ve been in this so long, you don’t even consciously feel the level of stress that you’re carrying in you. So, I’ve been a little bit more conscious of that.
SF: How have you filtered all the national and political news that is occurring in such close proximity to your work and home?
HE: It’s too much and I desperately want to hear it, even though I know we should stop listening to it. So, it’s really conflicted.