Does long COVID lead to insomnia?

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Today, I'm talking about the connection between long COVID and sleep troubles with Dr. Antonio Culebras. He's a professor of neurology at Upstate specializing in sleep medicine. Dr. Culebras, I'm really glad to have you back on "The Informed Patient." Earlier in the pandemic, you and I did an interview focused on how to deal with anxiety and stress to get a better night's sleep, because so many people were saying how hard it was to sleep during the pandemic. But today we're going to focus on people who had COVID, but have not 100% recovered -- maybe they have long COVID -- and among the symptoms they complain of is insomnia. How often do you see patients who fit this description?

Antonio Culebras, MD: We find some, but not too many. I don't have too many patients coming to me saying I have insomnia because of COVID, or because of long COVID symptoms. I do have some patients who come in for a variety of reasons, and they tell me, "I had COVID six months ago. I developed a long COVID that lasted, three, four months. And during that time, I was not able to sleep as well as I used to." Yes, I do have those patients, but it is not epidemic.

Now let me go back to what I said maybe a year or two years ago was based on the information that we had, on surveys that were not very scientific. Problems with sleep are generally associated with depression and anxiety. And there are a number of mini studies, I would say, short studies indicating that there has been a lot of sleep dysfunction as a result of depression and anxiety occurring in people during the pandemic. In fact, I just read an article in JAMA, the Journal of the American Medical Association, indicating that a survey, the results of which were just released, of 1.4 million people in 2020. That's the last survey that we have showed that the prevalence of clinically significant anxiety and depression increased only modestly. So there, there is a little bit of a legend there, that there has been a lot of anxiety and depression as a result.

In fact, this article -- which is very well done, and and I have a lot of confidence in what they are saying -- this article says that there were many web surveys that were done hurriedly, without much scientific background. And those were the ones that showed a lot of anxiety, a lot of depression. And based on that, the legend has evolved. So has there been anxiety and depression? Yes. But it has been modest, at least during the first year. Now that anxiety and that depression had an impact in sleep, yes, but it was not as bad we thought it was. Now, the proviso is that we don't have results for 2021 and 2022. It might get worse. And that's what the article says. But during the pandemic, the first year of the pandemic, it was not as bad as people said it was. The prevalence of clinically significant anxiety and depression increased only modestly, and that affects, directly, sleep and the ability to initiate and maintain sleep.

Host Amber Smith: Well, let me ask you from a neurological point of view, what happens to patients with long COVID?

Antonio Culebras, MD: My short answer is that we don't know. However, there is a lot of hypothesis, if not speculation, on what happens. There is a strong suspicion that long COVID is the result of what we call encephalopathy, which is a subtle inflammation of the brain. We don't know whether that encephalopathy is the result of direct invasion of the virus or the result of all the products that are released in the system as a result of the viral attack. It is likely, in my opinion, that long COVID is subtle encephalopathy with inflammation of the brain resulting in many symptoms, including fatigue and including insomnia.

Host Amber Smith: I've heard people complaining of fatigue and brain fog. That could be attributed to swelling in the brain?

Antonio Culebras, MD: Yes. Those are symptoms that are very similar to what happens after a concussion. After a concussion, patients may complain for many months of brain fog, headache, insomnia, fatigue, and so on. In long COVID all those symptoms, including headache, occur. Being so similar, it is likely that long COVID is also the result of inflammation of the brain, but we don't have scientific confirmation of that.

Host Amber Smith: So how do these long COVID symptoms potentially interfere with sleep?

Antonio Culebras, MD: Well, it interferes as a result of that encephalopathy that I was mentioning. There is disturbance of the circadian rhythmicity. There is disturbance of the centers that control sleep, the centers that control vigilance, all that, all those centers are disturbed when there is inflammation. And, the clinical expression of that is inability to initiate sleep at the proper time, inability to maintain sleep, and even perhaps, somnolence the following day.

Host Amber Smith: So they may have trouble falling asleep, staying asleep, getting quality sleep?

Antonio Culebras, MD: Exactly. You know, high quality sleep is characterized by continuity, depth and duration. So if the continuity is not there, if sleep is fragmented or if sleep is delayed, then that continuity is of poor quality, and sleep becomes of poor quality. If the duration of sleep -- which in an adult should be anywhere between seven and nine hours, every 24 hours -- is not there, then the quality of sleep declines. And that applies also for depth of sleep. That's the third quality of sleep -- depth. If people don't go into a deep sleep as a result of, perhaps, fragmentation or as a result, perhaps, of sleep apnea that got worse during COVID, then the quality of sleep also declines.

Host Amber Smith: Have you seen any people that are developing sleep apnea because of long COVID?

Antonio Culebras, MD: No. What I have seen is people with sleep apnea, who had COVID, their sleep apnea got worse. Reason being that the COVID infection also causes inflammation of the bronchial system. And as a result of that inflammation, the sleep apnea problem gets worse.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith talking with Upstate sleep specialist, Dr. Antonio Culebras.

Do you think if people were able to get better quality sleep, that that would help their bodies recover from COVID or long COVID?

Antonio Culebras, MD: Well, yes, indeed, because sleep is one of the three pillars of good health, the other two being regular exercise and a balanced diet. So sufficient sleep is the third pillar of good health.

Host Amber Smith: What advice do you have for someone who's recovering from COVID and having trouble sleeping? Or even, it doesn't have to be COVID, it could be a flu or a cold. You know, it's harder to rest when your nose is stuffy and you're coughing. What advice do you have?

Antonio Culebras, MD: Well, the advice is get the remedies that the primary care physician will recommend for the sneezing and the coughing all that has to come under good control. And thereafter, try to be disciplined. In other words, go to bed at the same time. Get up at the same time. Try to be regular with your diet, balanced diet. And, over-the-counter remedies, at times, are very helpful.

Host Amber Smith: I wanted to ask you about over the counter remedies. I hear a lot about melatonin. Is that something you recommend?

Antonio Culebras, MD: Melatonin is a very powerful hormone that can be purchased in herbal stores without a prescription. Melatonin in our system when it's liberated by the brain, is intended to initiate sleep and maintain the first four hours of sleep. But when it's taken by mouth, the effects are very irregular. Some people react in a very positive way. Other people tell me it didn't do anything, nothing. It was just like taking sugar. But, the good thing about melatonin is that there are very few adverse effects. So if people are inclined to take melatonin, or if the doctor, the primary care physician says, "try melatonin," go ahead and do it. Three milligrams to 5 milligrams is the dose that we recommend.

Host Amber Smith: Let me ask you, at what point might a person be a good candidate for a sleep study to find out if there's something else going on that's causing them to have insomnia?

Antonio Culebras, MD: Generally, if the person has sleep apnea, and sleep apnea got worse as a result of COVID, and the symptoms of that getting worse could be that the C-PAP (continuous positive airway pressure therapy) is not working properly. That CPAP is seems to be giving less air than before, all that could be the result of that inflammation in the bronchial system that I was mentioning before. When those patients come to us with those complaints, my inclination is to repeat the, what we call titration of the CPAP. In other words, bring the patient to the sleep center and check pressures again. Sometimes we can do that with an auto CPAP that does not require in-center studies, but, patients with sleep apnea, particularly those who have been diagnosed with moderate or severe sleep apnea should be very careful if they develop COVID and come to the doctor's office or the sleep center as soon as they believe that things are not going right.

Host Amber Smith: So if someone is using one of those CPAP, the breathing machine for people with sleep apnea, and they are infected with COVID, they need to touch base with their sleep specialist?

Antonio Culebras, MD: Touch base if they feel that the machine is not working properly or is not getting them sufficient air or, if they're having episodes of gasping for air during the night, or if they are not sleeping properly because of interruptions caused by the CPAP machine.

Host Amber Smith: You talked about how so many sleep troubles can be traced to depression and anxiety. If you see a patient who comes to you with trouble sleeping, and you determine that, it's not something obvious and you suspect it's anxiety- or depression-related, if that gets treated, do you see them turn around and be able to get good sleep again?

Antonio Culebras, MD: The answer is yes, but let me qualify that we need to find out why the patient has anxiety and depression. And, we need to rule out what we call a primary sleep disorder. For instance, a primary sleep disorder is sleep apnea, or epilepsy or restless legs causing periodic leg movements, and so on. Once we have ruled out a primary sleep disorder, then we can go back and say, oh yes, anxiety and depression are causing your symptoms of sleeplessness. At that point, my inclination. Following the recommendations of the American Academy of Sleep Medicine, is to recommend CBT, cognitive behavioral therapy. It works very well. It works better than medications. Now, sometimes I need to add some sleeping medications to the effects of, cognitive behavioral therapy. By the way, let me mention that cognitive behavioral therapy can be obtained online. There are programs online that have been shown to be very efficacious, successful in reducing symptoms of insomnia.

Host Amber Smith: So cognitive behavioral therapy, that would be with a psychiatrist or psychologist?

Antonio Culebras, MD: It's the first line of therapy for insomnia. And that can be given by a psychologist, by a psychiatrist, and sometimes by even trained social workers, people who have been trained in cognitive behavioral therapy.

Host Amber Smith: And some of that is available virtually where you connect with someone online, correct?

Antonio Culebras, MD: Yes. There are online programs that are available, and recently studies have shown that those programs are as successful, if not more, than the old fashioned session, come every other week and so forth.

Host Amber Smith: Well, Dr. Culebras, I really appreciate you making time for this interview.

Antonio Culebras, MD: Well, my pleasure.

Host Amber Smith: My guest has been Dr. Antonio Culebras. He's a professor of neurology at Upstate who specializes in sleep medicine. "The Informed Patient" is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.