Troubleshooting the mystery of post-COVID insomnia with a sleep tracker

If you've experienced relentless, torturous insomnia in the wake of a COVID infection, I'm here to tell you that it's not all in your mind. An emerging body of research suggests that insomnia, along with other sleep disturbances, can be an unexpected part of COVID infection and recovery.

I know this misery firsthand. When struck by a very "mild" case of COVID in June, I slept deeply, in almost a stupor — until I didn't. Then, I experienced the strangest, most painful months-long stretch of insomnia of my life. Nearly every night, I would awake sometime around 2 a.m., my body humming and brain buzzing for hours at a time. This lasted for several weeks, until it tapered off to more manageable wakings of about 45 minutes that could be calmed by guided meditations.

I'm not alone in my post-COVID insomnia. Nearly half of the 13,628 people surveyed about persistent symptoms following an infection said they experienced insomnia, findings recently published in the Journal of Sleep Research. A separate survey of 682 patients at the Cleveland Clinic's COVID recovery treatment center found that almost half experienced moderate or severe sleep disturbances, including insomnia. But the anecdotal cries of despair on social media, where people express shock over the intensity of their mid-infection insomnia, suggest it's not just the long haulers who can't sleep.

Like anyone made desperate by sleep deprivation, I tried a lot of things, but none of them were the first-line treatment for insomnia: CBT-I, or a type of psychotherapy known as cognitive behavioral therapy designed specifically for chronic insomnia. I made the common mistake of overlooking CBT-I because my doctor recommended prescription-strength medication but never mentioned the treatment when I reached out to them for help.

That experience sent me down a rabbit hole searching for non-pharmaceutical ways to tame the sleeplessness. One thing I decided to try was an Oura ring, a wearable sleep tracker that's been evaluated against polysomnography, the comprehensive, gold standard test used in sleep labs. I thought if I better understood my sleep trends, it might help me identify bad or unhelpful habits standing in the way of a good night's rest.

Indeed, there were a few revelations, though I can't say with certainty that any Oura-related sleep hygiene changes vanquished my insomnia. Those adjustments included no alcohol past 7 p.m., as little exposure to blue-light emitting devices as possible after 9 p.m., and more pre-bedtime yoga. I also had acupuncture treatments. At some point, my body calmed. When I awoke in the middle of the night, I fell back asleep within 15 to 30 minutes.

As I learned interviewing sleep medicine experts, including those who study and treat post-COVID insomnia, we simply don't know enough about why sleep disturbances emerge following an infection, or why they stop. Some people's symptoms resolve after three to six months, even without evidence-based treatment. Others find little to no relief. The phenomenon could be the result of changes in areas of the brain that regulate the body's circadian rhythm. The widespread inflammation that COVID can leave in its wake may similarly affect the sleep-wake cycle. Anxiety related to becoming ill could also lead to persistent nighttime wakings, without a direct biologic link to the infection itself.

Nevertheless, that doesn't mean you should give up on trying to sleep well if you've been afflicted. Ask a health care provider about CBT-I, consult a sleep medicine expert or long COVID clinic, and consider tried-and-true sleep hygiene practices. A sleep tracker, or a smartwatch with sleep-tracking capabilities, can help identify what works best for you, but it isn't essential — nor is it universally accessible with prices ranging from $70 to $549. (The Oura ring I tested retails for $549, but its base model sells for $299. A monthly membership that provides access to comprehensive data costs $5.99.)

If you slog through insomnia because getting it under control feels impossible, just remember what Dr. Rebecca C. Hendrickson, a University of Washington psychiatrist and neuroscientist studying persistent symptoms after COVID, told me about why it's vital to get consistent, high-quality rest: "It's worth the effort to stabilize sleep even when it seems like there's so many different things going on," she said. "It's really hard for anything else to go well when sleep is severely disrupted."

Understanding COVID and insomnia

Hendrickson, a research investigator at the VA Puget Sound Medical Center in Seattle, recently published a preprint of her study on COVID and insomnia in healthcare workers. While the study is under review at a major journal, its early publication suggests the urgency of the problem. Hendrickson and her co-authors found that both occupational stress and history of a COVID infection were significantly associated with insomnia in the 594 healthcare workers they studied. Forty-five percent of those participants reported at least moderate insomnia symptoms, and 9 percent experienced severe symptoms at some point in the study.

This alone doesn't necessarily mean that COVID caused or contributed to the insomnia, so the researchers used statistical analyses to isolate the effects of an infection on insomnia versus the effects of workplace stressors on the study participants' insomnia symptoms. The researchers hoped to determine whether becoming sick with COVID played a significant role in insomnia and discovered that an infection was, in fact, specifically and strongly associated with the disorder.

The finding suggests that risk of insomnia increases following COVID, and doesn't seem to be associated with stress and anxiety alone. Instead, it could be the result of underlying changes in the body caused by COVID, which may continue after the infection itself is over.

Hendrickson told me the study isn't perfect. The researchers didn't know exactly when participants' COVID infections happened, just that insomnia occurred after certain timepoints. Typically a randomized clinical trial would be the best way to determine whether COVID causes insomnia, but randomly infecting people with the virus is unethical, so researchers must rely on observational studies for clues.

The researchers did ask participants to complete the Insomnia Severity Index, a seven-question survey that yields a score. Before talking to Hendrickson, I filled it out independently, answering as if I was experiencing my peak insomnia symptoms. I scored a 23, which falls into the severe clinical insomnia range of 22 to 28. Then I answered based on my current symptoms and scored a three, which put me in the range of no clinically significant insomnia.

How I got there remains somewhat of a mystery, but Hendrickson said that for many people, post-COVID symptoms including insomnia resolve on their own within three to six months. This is based not on the study results but her own clinical observations, along with those of her peers.

She is, however, concerned that some people will have "very persistent symptoms" until researchers find an effective treatment. Hendrickson noted that my description of post-COVID insomnia as clearly distinct from past episodes of sleeplessness matched what she's heard from other patients. At the peak of my insomnia, I fell asleep just fine, but once roused from slumber, I experienced a vibrating or buzzing sensation, as if a jolt of energy was coursing through my body.

Hendrickson says the complexity of sleep makes it difficult to know what exactly is happening in post-COVID cases. As an essential bodily function, sleep is regulated by a number of biologic processes to ensure that it occurs.

"When things go wrong, often there's multiple systems involved," she says.

COVID insomnia may not be just about mental health

While insomnia is often thought of as a condition born of stress, anxiety, poor sleep hygiene, or a combination of those factors, Hendrickson believes we should take seriously the possibility that COVID has wreaked havoc with one or more of the systems regulating sleep.

Hendrickson and her colleagues at the University of Washington are exploring the possibility that COVID may affect noradrenaline signaling in the brain. Past research has shown that patients with PTSD often wake up with insomnia, in the midst of what they describe as an "adrenaline storm." They're not groggy or disoriented but alert, with a pounding heart. In these cases, the thinking is that excessive signaling through one of the primary noradrenaline receptors is disrupting the sleep-wake cycle. Patients commonly receive a prescription for Prazosin, a medication that treats high blood pressure by relaxing blood vessels to ease blood flow throughout the body.

Hendrickson stresses that there's no evidence yet that Prazosin could be an effective treatment against COVID insomnia. In fact, she believes that because COVID's effect on the body and brain is so complex, creating various pathways for disruption and dysregulation, what works for one person's insomnia may not work for another's. This is why she believes that clinical trials, very specifically designed to identify different features of post-COVID insomnia, will be critical to delivering effective treatments.

Hendrickson is hopeful that CBT-I will be quite helpful for many people with post-COVID insomnia, but she notes that it's most effective at treating aspects of the disorder that arise when people try different strategies to cope. Getting in bed earlier, for example, sounds reasonable, but can worsen insomnia as someone struggles even more to fall asleep. While CBT-I can be useful for tackling such problems, it may not be fully effective for insomnia that originates from a biologic change in sleep regulation.

She's also clear that pinning post-COVID insomnia solely on a patient's mental health isn't the right answer. While supportive practices like relaxation and meditation, in combination with improved sleep hygiene, have their roles, Hendrickson emphasizes the importance of "taking this seriously as something that can't be attributed just to stress and anxiety." Doctors also shouldn't fall into the trap of "assuming that teaching people skills to manage stress and anxiety, while important, is going to be enough to address it."

Troubleshooting my COVID insomnia

When I saw my doctor for an annual checkup six weeks after my COVID infection — my first visit since the pandemic began — I was so concerned about other lingering symptoms, including moderate nerve pain in my hands and feet, that I managed to not mention the insomnia at all. Two weeks later, I messaged them for advice. The reply came back: Was I interested in prescription-strength sleep aids? I was not, because the drugs can be habit-forming and may cause parasomnia, or unusual physical experiences during sleep like sleep terrors and sleepwalking. There was no mention of CBT-I, which I later learned is not well-known by primary care physicians.

Based on a friend's recommendation for temporary relief, I took Unisom, an over-the-counter antihistamine that can make you tired. Sleeping through the night felt heavenly at first. But by two weeks, which is the drug's maximum length of use, my sleep quality started to decline. Side effects include dizziness, headache, blurred vision, and dry mouth, the last of which became unbearable for me after several days' use.

Enter the Oura Ring. I received a Horizon Gen3 model in rose gold to test. The ultralight ring contains sensors that detect movement, heart rate, temperature, and blood oxygen. Among other things, Oura promises to reveal how much time you spent in various stages of sleep, when you awoke, and how fast (or slow) your heart beat overnight. By then, in late September, I was no longer awake for hours. Instead, I hoped the ring's data might provide clues about shorter but still stubborn episodes of wakefulness.

Fine-tuning my sleep

I got those insights but found, almost as importantly, that having the ring helped me become more protective of my pre-bedtime ritual and sleep than I'd ever been before.

On one Saturday night, I had an alcoholic drink at 8:30 p.m. I stayed asleep all night long but woke up feeling wrecked. Sure enough, the Oura ring app estimated I'd gotten half the amount of REM sleep I'd experienced over previous nights. That stage of rest plays a role in memory formation, emotional processing, and learning. I was only an occasional nighttime drinker, but the data was enough to permanently convince me that tossing one back after 7 p.m. wasn't really worth it, especially if it meant threatening my already delicate sleep.

The same became true of logging onto my computer or picking up my phone after 9 p.m. A few nights of skipping blue light-emitting devices, which can screw with the body's circadian rhythm, seemed to show up in my Oura data. Within a week of making that change, the amount of time I spent awake at night dropped from 45 minutes or so to between a reasonable 15 and 30 minutes.

I'd also had three acupuncture treatments before, during, and after that period. While that form of alternative medicine is not yet a primary treatment for insomnia, research suggests it can be effective against the disorder. On my acupuncturist's recommendation, I began taking L-Theanine, an amino acid found in certain tea leaves that's thought to influence neurotransmitters that promote relaxing brain activity, thereby leading to improved sleep. Separately, I decided to revive my 10-minute bedtime yoga practice, which left me feeling calmer and sleepier.

I can't say with certainty that any of these strategies finally quelled my insomnia after three-plus months, or if it was mainly that my body had finally recovered from COVID. I just know that Oura's data and insights helped pinpoint factors within my control. Knowing that information empowered me advocate for myself. No more getting online to chip away at the to-do list at 9 p.m. No more scrolling Twitter as a form of bedtime procrastination. If I wanted a drink, it'd be a happy hour beverage or two that I could finish by around 7 p.m.

What to know about sleep trackers

It's worth plainly stating that sleep trackers are not the answer for insomnia. First, they're not an evidence-based treatment. Second, they are typically a luxury item. But it speaks to the fractured, profit-driven nature of our healthcare system, and our growing reliance on consumer technology to solve what that overburdened, underfunded system cannot, that my generally excellent physician could offer me nothing more than prescription sleep aids, and as a result, I turned to a wearable for help.

I should also note that some experts are skeptical of how sleep trackers perform, the claims that companies make about them, and how useful they can be to wearers. In a 2018 study published in the Journal of Sleep Research, researchers fed two separate groups of participants false positive and negative feedback from a sleep tracking device. Those who received negative feedback demonstrated poorer daytime cognition, as well as increased sleepiness and fatigue, relative to the participants who got positive feedback.

That study's lead author, Dr. Dimitri Gavriloff, senior clinical psychologist at the University of Oxford’s Sleep and Circadian Neuroscience Institute, told me in an email that if someone suspected their tracker was making things worse, it would be sensible to stop using it. (He also recommends CBT-I for treating insomnia, and seeking clinical help when appropriate.)

"For some people, using these devices is about getting a better understanding of their sleep, with the risk that they pay less attention to their own appraisal of their sleep, taking the sleep tracker's word for it, rather than that of their own experience," he said. "If you're able to sleep well and are functioning well during the day, what more can a sleep tracker provide?"

One quirk I noticed was that Oura sometimes mistook overnight meditation sessions, conducted when I'd awoken and wanted to fall back asleep, for shut-eye. Caroline Kryder, Oura's science communications lead and product marketing manager, told me that while I may not have been sleeping, my low heart rate and lack of movement effectively suggested to the ring's sensors that I was resting well.

Oura also measured my overnight heart rate and heart rate variability, a sensitive metric that can reflect the body's response to stress. Both can suggest that you might be struggling, perhaps guarding against illness or dealing with mental or physical strain. While I compare those measurements against how I feel each morning, particularly if the app flags an increased heart rate or low heart-rate variability, I take with a grain of salt its sleep and readiness scores. Gavriloff said such algorithmic scores, which other fitness trackers use, can be quite arbitrary.

Kryder told me that the scores are "grounded in science." She noted that certain wearers, like an athlete or someone giving a big presentation, choose to skip opening the app when they wake if they're worried the results will have a negative impact on their performance for the day.

"We're not fine"

Dr. Michael Grandner, Ph.D., director of the Sleep and Health Research Program at the University of Arizona, is skeptical of sleep scores, noting that the best function of a high-quality tracker is its ability to demonstrate when you were awake and asleep, based on sensors that detect overnight movement. Grandner also points out that just as a bathroom scale isn't a weight-loss program, a sleep tracker isn't treatment for any sleep disorder. (He is a scientific advisor for Fitbit, which has a sleep tracker function.)

In Grandner's opinion, too few physicians know the guidelines for treating insomnia and sleep disorders. He says this is perhaps because patients and doctors alike don't know how to understand sleep complaints, so physicians feel like their only options are a handout on sleep hygiene or prescription-strength medications. While sleep aids can be appropriate for insomnia, they are not the first line treatment when CBT-I is available, and many of the medications used aren't effective. Instead, they just have sedating side effects. He's worried that doctors are increasingly turning to anti-psychotics to treat insomnia because the drugs "zonk" people out.

Instead, Grandner recommends CBT-I, which he's found to be effective in treating patients with post-COVID insomnia. When appropriate, he also incorporates evidence-based supplements like melatonin to help re-establish circadian rhythm. (Grandner is scientific advisor to nutritional companies.) While he says that behavioral factors play a major role in chronic post-COVID insomnia, he believes its onset following an infection is complex, and likely has multiple biologic pathways.

"COVID just seems so messy and variable that it's hard to nail down," he says.

This concerns Grandner for several reasons. One of them is the concerted effort to wave off lingering effects of COVID, like insomnia, because they can't be easily explained. I'm grateful that the grueling emotional and physical toll of my insomnia was temporary, but I will never forget it. I could only manage my insomnia with regular meditation and workplace compassion and flexibility.

The meditation helped me stay emotionally grounded even when I started the day feeling desperately tired. My editor's understanding, including when I needed to take breaks to rest, meant that I could work without the added anxiety of worrying that I would lose my job thanks to insomnia-induced exhaustion. Insomnia is a significant risk factor for suicide, but I never contemplated taking my own life. Others who experience post-COVID insomnia may find themselves in a battle for their livelihood — and their life.

"We're trying to act as if nothing's there, as if everything's fine, we're moving on, we're doing what we need to do," says Grandner. "But at the same time, we're not fine. There's a lot of people who still are having problems."

If you're feeling suicidal or experiencing a mental health crisis, please talk to somebody. You can reach the 988 Suicide and Crisis Lifeline at 988; the Trans Lifeline at 877-565-8860; or the Trevor Project at 866-488-7386. Text "START" to Crisis Text Line at 741-741. Contact the NAMI HelpLine at 1-800-950-NAMI, Monday through Friday from 10:00 a.m. – 10:00 p.m. ET, or email [email protected]. If you don't like the phone, consider using the 988 Suicide and Crisis Lifeline Chat at crisischat.org. Here is a list of international resources.