Can COVID-19 Trigger Insomnia?
More research points to sleep troubles as a possible long-hauler symptom of COVID-19. Here’s what experts know so far.
When Corey McPherson, 38, was first diagnosed with COVID-19, he slept like a log. “I was sweaty and tired, and my body ached, but I actually got what I would count as restful, meaningful sleep,” he recalls.
This was back in the spring of 2020, says McPherson. As April turned to May, his fever and other acute symptoms faded — but new, unrelenting ones emerged. McPherson, who lives in Detroit and works in information technology (IT), developed bewildering brain fog, intense fatigue, and other symptoms typical of “long COVID,” according to the Centers for Disease Control and Prevention (CDC).
His sleep also suffered. Between May and December of 2020, McPherson says, “I did not get a full night's sleep [where I] felt like I was rested.”
“I felt like I was living in a dream, or that I was actually in a coma and this was my coma life,” he adds. “Weird, I know.”
Not “weird” at all, as it turns out. In a study presented on June 6 during the Sleep 2022 conference, hosted by the Associated Professional Sleep Societies, researchers at the Cleveland Clinic found that more than 40 percent of people with “long COVID,” the formal name of which is “post-acute sequelae of COVID-19 (PASC),” had moderate to severe sleep disturbances. About 7 percent of the study participants reported severe sleep problems related to COVID-19, including insomnia.
“Moderate to severe sleep disturbances and fatigue are highly prevalent among patients with long-COVID-19,” says study co-author Cinthya Pena Orbea, MD, assistant professor of medicine at the Cleveland Clinic.
Some researchers believe the body’s autoimmune response to the virus may be causing these sleep problems, while others have linked it with post-traumatic stress disorder experienced by those infected, according to Dr. Pena Orbea.
Fatigue and Sleep Problems With Long COVID
For this study, she and her colleagues assessed the severity of long COVID-related sleep problems among 682 adult participants with standard questionnaires used to diagnose sleep disorders, including the Patient-Reported Outcomes Measurement (PROMIS) Sleep Disturbance and the PROMIS Fatigue tools. Everyone in the study was experiencing long COVID.
The data revealed study participants had average PROMIS Sleep scores of 58, placing them close to the threshold for “moderate sleep disturbance” (which is 60). Just over 41 percent of the participants reported scores above 60, while 7 percent had scores above 70, which indicates “severe” sleep problems.
More than two-thirds of the participants indicated they had “moderate fatigue,” while nearly 1 in 4 reported “severe” fatigue, the researchers say.
Participants who were overweight, as well as those with generalized anxiety disorder, were more likely to report sleep problems with long COVID than those without these health problems, according to the researchers. In addition, Black American participants had a threefold higher risk for sleep problems with long COVID compared with those of other races and ethnicities, they say.
“We found that Black race was linked with moderate to severe sleep disturbances,” Pena Orbea notes. “As such, it’s important to better understand race-specific determinants of sleep disturbance among Black Americans to provide early identification and interventions.”
Sleep is critical for overall well-being, and poor sleep health has been associated with several cardio-metabolic diseases, including diabetes and heart disease, she adds.
Other Evidence Suggests COVID-19 Can Lead to Sleep Problems, Too
Earlier studies also suggest that people with “long COVID” may be at higher risk of developing sleep problems. A study published in March 2021 in the Annals of Clinical and Translational Neurology found that roughly 1 in 3 COVID long-haulers had insomnia after COVID-19 (though about 16 percent of the group reported having trouble sleeping before getting COVID-19, too).
In another study, published in the February 1, 2021 issue of The Lancet Psychiatry, researchers looked at the health records of more than 60,000 patients who had COVID-19. They found “markedly elevated” rates of insomnia among COVID-19 survivors; nearly 2 percent of people had developed insomnia within 14 to 90 days after having the infection. Another noteworthy observation — the rates of insomnia among people who recovered from COVID-19 had surpassed the rates that accompany flu, respiratory tract infections, and other common infections and ailments.
The authors of a study published in October 2020 in Brain, Behavior, and Immunity screened more than 400 COVID-19 survivors for ongoing psychiatric issues. The researchers found that 40 percent of people in the study were dealing with insomnia after beating COVID-19, though the researchers weren’t able to establish whether COVID-19 directly caused insomnia.
“There are many studies that have linked poor sleep to inflammation — so, changes in inflammation due to COVID could be directly associated with sleep disturbance,” says Sara Nowakowski, PhD, an associate professor and clinical psychologist at Baylor College of Medicine in Houston, who was not part of the new Cleveland Clinic study. “In addition, the stress related to covid infection and pandemic may also contribute to sleep disturbance.”
“We have found up to 70 to 88 percent of people experience fatigue during and following COVID infection,” Dr. Nowakowski notes. (That figure comes from a study published earlier this year in the journal Brain Sciences; Nowakowski was the lead author.) “Some people may try to mitigate fatigue by spending extra time in bed, but this isn’t a helpful strategy because it usually doesn’t cure the fatigue.”
Also, ironically, spending too much time in bed — or for longer periods than the human body is actually capable of sleeping — can cause insomnia, she adds.
W. Chris Winter, MD, president of Charlottesville Neurology and Sleep Medicine in Virginia and author of The Sleep Solution, adds that even though data suggests there’s a connection between COVID-19 and insomnia, the data so far has not parsed out if and how one is causing the other. “It's hard to know what is related to COVID,” he says.
Does a COVID-Melatonin Interaction Explain the Virus’s Effects on Sleep?
Other research suggests melatonin — a hormone made by the body and released at night to signal to our bodies it’s time for sleep — may have a relationship with COVID-19 that explains why the infection can lead to sleep trouble.
An early study, published in March 2020 in Cell Discovery, linked melatonin to potential COVID-blocking benefits. Another study, published in November 2020 in PLoS Biology, suggested use of melatonin supplements reduced COVID-19 infection risk, and in some ongoing clinical trials, researchers aim to discover whether melatonin can help people who are recovering from COVID-19.
More recently, a small study with 67 participants published in June 2022 by the Journal of Taibah University Medical Sciences found that high-dose melatonin at 21 milligrams (mg) per day decreased levels of C-reactive protein (a marker of inflammation) in those who were intubated in a hospital intensive care unit with severe COVID-19, though the treatment did not affect patient outcomes.
Other theories of why COVID-19 leads to sleep problems include that the virus affects the body’s circadian clock and that infection may lead to brain inflammation. According to a review published in February 2021 by the journal Chronobiology International, research suggests that the virus may disrupt some of the genes in the brain involved in controlling the body’s circadian clock, which essentially governs sleep and wake patterns throughout the day.
In addition, a review published in September 2021 by the journal Clinical and Experimental Neuroimmunology notes that studies have linked the body’s autoimmune response to COVID-19 with encephalitis, or inflammation in the brain, in some people who experience persistent symptoms. This inflammation in the brain may affect the processes that control sleep, according to the review.
What Should You Do if You’re Having Trouble Sleeping After COVID-19?
The CDC now lists “sleep problems” and fatigue as symptoms of long COVID. For long COVID-related sleep disruptions, experts recommend taking the following steps:
- Get outside in the morning. This can help regulate your internal clock, says Daniel Barone, MD, associate medical director for the Weill Cornell Center for Sleep Medicine in New York City, and author of Let’s Talk About Sleep. If you don’t feel comfortable going outside, or you’re feeling too ill to do so, sit by a window in the sunlight, Dr. Barone advises. That should be enough to tell your body it’s morning and get it back on schedule, he adds.
- Reduce screen time at night. In particular, do this right before bed. The light in screen devices can impact your circadian clock, so try listening to a podcast, or meditating, or reading or listening to a book on tape during that last hour before bed, Barone suggests. “Something in the realm of relaxation,” he says.
- Avoid naps during the daytime. Naps can also throw off your “sleep-wake clock,” making it tougher to fall asleep at night if you’ve slept earlier in the day, according to Barone.
- Try melatonin. The sleep-regulating hormone melatonin may also be helpful as a short-term addition to your sleep routine. “Melatonin is very safe if taken in normal doses,” says Michael Grandner, PhD, director of the Sleep and Health Research Program at the University of Arizona College of Medicine in Tucson. A normal dose falls between 0.5mg and 5 mg. “Some people report headaches or stomach problems at higher doses, but those side-effects are uncommon,” Dr. Grandner adds. A 0.5-mg dose, taken three to five hours before bed, can help regulate your sleep cycle. Or alternatively, you can take a 5-mg dose right before bed, he adds.
- Limit time in bed (unless you’re sleeping). “We can’t force sleep, so if you’re unable to sleep after about 20 minutes of trying, either when getting into bed or waking in the middle of the night, get out of bed and do something relaxing,” Nowakowski says. Try stress-reducing activities, like reading, deep breathing, meditation, or other relaxation techniques until you feel sleepy and head back to bed. If you’re spending a lot of extra time in bed because of COVID-19 or long COVID fatigue, try reducing time in bed little by little. For example, if you’re spending 12 hours in bed each day, try limiting it to 10 to 11 hours by making bedtime later or wake time earlier, she says.