September 20, 2021

Writers: K Ballesteros, Gie Lenna Dela Peña, Kamille Huelgas
Translation: Tobey Calayo
Editor: K Ballesteros
Researchers: Jerwin Regala, Kamille Huelgas, Nel Fortes
Creatives: Krystle Mae Labio, Jacklyn Moral, Klein Xavier Boiser
Moderators: Eula Mei Labordo, Marc John Paul Agbuya
Documenters: Kamille Huelgas, Ian Stephen Velez
Spaces: Richardson Mojica, Azie Libanan, Kamille Huelgas, Jomari  Gimongala and the rest of the #UsapTayo Volunteers

The bilateral relationship between sleep and overall health–including physical and mental health–is commonly accepted: lack of sleep can cause poor overall health, while experiencing stress can disrupt sleeping patternsAccording to Christina Pierpaoli Parker, postdoctoral fellow of clinical psychology and behavioral sleep medicine at the University of Alabama at Birmingham, “good sleep undergrids every aspect of mental and physical health” [1]. However: the specific and complex role that sleep plays in overall health especially in the face of external factors–job environment, socio-economic factors that limit access to appropriate tools, and continued stressful environments–renders this topic fertile ground for more research. 

According to the Sleep Foundation’s Dr. Anis Rehman and Danielle Pacheco [2], sleep problems are conditions that affect an individual’s quality of sleep, the time or duration spent asleep, and the individual’s capacity to function when they are awake. Sleep problems may include: difficulty getting enough sleep, sleeping at the wrong time of day, the inability to sleep properly, and, most commonly, a lack of sleep altogether. The last of these, sleep deprivation and sleep deficiency, have been linked to several negative health outcomes, including cardiovascular disease, type 2 diabetes, obesity and depression [3]. 

Experiencing mental health problems may exacerbate sleep problems, and poor quality of sleep may also contribute to either developing mental health problems, or have a compounding effect. For example: sleeping problems can become a source of worry, and lead to anticipatory anxiety, and sleep deprivation–or failing to sleep an adequate amount of time–may worsen depressive symptoms. The American Psychiatric Association (APA) [4] recognizes that sleep problems “often occur along with medical conditions or other mental health conditions, such as depression, anxiety, or cognitive disorders”, which emphasizes the complex relationship between sleep and mental wellness. Likewise, the Centers for Disease Control and Prevention [3] recommends that individuals with depression undergo assessment to describe quality and adequacy of their sleep, and that those with sleep disorders be monitored for depressive symptoms.  

A Descriptive Study on the Sleeping Habits and Correlation of Sleepiness with Academic Performance in  States University-run Medical School In the Philippines [5] found that the percentage of Filipino medical students experiencing excessive daytime sleepiness (53.3%) is greater than medical students based in Malaysia (35.5%), Pakistan (39.5%), and Saudi Arabia (37.8%). The study is valuable for its focus on a specific community, whose members–medical students and residents–report chronic partial loss of sleep as a common experience, while “those in more physically demanding specialities can suffer total loss of sleep [5]. Other studies focusing on more vulnerable communities, such as business process outsourcing (BPO) and call center workers [6], and women factory workers in the Philippines  [7] expand the study of sleep, its vital importance to quality of life, and the role it plays in overall health. 

Describing Sleep

According to sleep scientist Matt Walker [11], a professor of Neuroscience and Psychology at the University of California in Berkeley, the prefrontal cortex which sits directly above our eyes controls the deep emotional center which is the amygdala. The Amygdala is the centerpiece region that generates strong emotional reactions. 

An individual who has had a full night’s sleep produces appropriate and moderate degrees of reactivity from the amygdala, and is able to perform strong communication between this region and the prefrontal cortex to regulate emotions. 

Individuals who are sleep-deprived are the opposite: the amygdala is more reactive, and becomes an emotional accelerator with little regulatory capacity. Apart from waking up with a puzzled mind and feeling fuzzy due to lack of sleep, an unhealthy sleep routine has  much to do with our mental health. 

The Sleepiest Pinoys 

Among those who are made most vulnerable to mental health problems due to sleep problems or disrupted sleep are contractual workers or temporary workers, women, and those who engage in factory work. The study Assessing the Association Between the Night Shift Schedule and Mental Health Symptoms among Filipino Women Factory Workers: A Cross-Sectional Study (Lu & Lu, 2021) focuses on the association between working at night, or the nightshift, and the experience of women factory workers with mental health problems. According to this study: “among Filipino factory workers, night shift work is associated with mental health symptoms”[7]. The study describes some of the factors that contribute to increased vulnerability to more severe mental health problems due, in part, to sleep problems.

 Lu & Lu [7] described the risk of taking employment in the informal sector where unregulated jobs and poorer working conditions limit workers’ capacity to pursue better sleep habits: “women are more at risk for remaining unemployed than men, which forces them to enter any job available” [7]. Due to the precarity of women factory workers’ situation, they are 32% more likely to experience mental health symptoms more frequently [7].  Workers in economic sectors and the export zone — establishments which employ 75-90% females who are “preferred by employers for their alleged feminine characteristics such as being docile, ambidextrous, attuned to find work such as in electronics assembly, and less prone to unionizing” [7] — are among the most vulnerable communities where mental health and sleep problems are concerned. Looking at larger trends in industrialization, the establishment of special economic zones and the growth of industries that cater to global economies is par for the course in technology-based societies. Statistics quoted by the Lu & Lu [7] study reveals that in 2017, the labor force for the industry sector, 60.8% of workers are obliged to render more than 40 hours of work per week, including night shifts. Those who have few options to land qualified jobs, or workers who are under financial stress, are also more liable to accept poorer working conditions. Those who are currently temporary workers are 2.33 times more likely to have frequent mental health symptoms, decreased sleep hours, poor sleep quality, and other health issues [7].

Lee, a college student in the morning, and a BPO worker at night lend their experience and insight into the effects of night shift work. They recount their experience balancing the demands of the current curriculum under the pandemic, and pursuing a career at the same time. According to Lee: 

It is not a joke to rapidly change my body clock. I’ve observed myself becoming ill-tempered, often palpitating due to drinking too much coffee and having insomnia or hardly taking sleep. Some of my workmates tend to smoke during breaks because it helps them to refresh and regain energy. Various unhealthy coping mechanisms such as overeating, smoking, drinking, and bad mouthing others did indeed occur in my work environment.

Lee describes the toll of complying with the requirements of both study and work. According to Lee, the burden of adjusting and coping with the demands of their environment are taken on by individuals, themselves, in order to provide for their basic needs. 

BPO workers like Lee are obliged to shift their natural circadian rhythm to suit the demands of industry. Studies of BPO and call center employees in India (Raja & Bhasin, 2014) claim that “challenging the individual’s circadian rhythm…ultimately [results] in circadian rhythm sleep disorders”. These workers are unable to sleep adequately during daytime and hence develop cumulative sleep debt leading to significant sleep deprivation” [6]. The long-term effects of permanent night shift duties include burnout stress syndrome, chronic fatigue, insomnia, and altered biological rhythm [6]. 

Given the immense effect of external factors on an individual’s capacity to build the ideal environment for rest and sleep, the continuing stress and anxiety of living through the continuing COVID-19 pandemic also disrupts sleep cycles, causes sleep problems, and aggravates mental health issues. 

Coronasomnia and other sleep disorders 

Emotional disturbances are a direct effect of “studying in the contorted system of education” in the middle of a pandemic, according to Lee. Their experience coincides with the experiences of workers in other parts of the world. Individuals who do not manage to get enough sleep or good quality sleep are also less capable of coping with the lifestyle change that was the result of policies and restrictions during the pandemic. As a critical part of living within the current pandemic is coping with ever-present anxiety and stress — discomfort that people with insomnia often experience. Most people who live with insomnia are also more at risk of anxiety, which further exacerbates their capacity to sleep well. 

A study in China in February 2020 sought to describe correlations between insomnia, depression, anxiety, stress, and the threat of the COVID-19 pandemic [8]. The neologism ‘coronasomnia’ refers to COVID-19 related insomnia, or the inability to sleep caused by stress, anxiety, illness, medication, and lifestyle changes that arose due to living with the thread of COVID-19. Reports [1, 8] quote Dr. Marishka Brown, who stated that “the pandemic has exacerbated sleeping difficulties”. Lack of sleep or poor sleep also disrupts immune systems, causing a decrease in the production of antibodies and white blood cells, at a time when these natural defenses are most needed. 

Reports [1] identify the factors that contribute to coronasomnia. Sudden shifts in daily routines tend to unmoor and destabilize our experience of daily life; anxiety and worry over employment and finances are also more likely to occur during the COVID-19 pandemic, and, finally, the overwhelming threat of infection and transmitting COVID-19 also likely contributes to coronasomnia.  

Aside from lack of sleep, other sleep disorders may also affect mental wellbeing. Sleep Apnea, Restless legs syndrome (RLS), and Rapid Eye Movement (REM) sleep behavior disorder are among the most common sleep disorders recognized by the American Sleep Association [9]: 

1. Sleep Apnea refers to a repeated airway blockage which leads to oxygen deprivation, choking, and snoring. Sleep Apnea affects the amount of oxygen that reaches a patient’s brain, and may result in disrupted sleep. Sleep Apnea causes extreme fatigue, lack of energy, and headaches, among other complications. 
2. RLS is an uncontrollable urge to move legs while at rest. Part of the symptoms of RLS are tingling sensations in the calves, or in other parts of the body. These symptoms may occur any time an individual is at rest, but may worsen at night. 
3. Finally, REM Sleep Behavior Disorder is characterized by acting out dreams during sleep. Individuals may become violent and cause physical harm to others or themselves if the automatic muscle paralysis that should occur during sleep malfunctions. 

What you need for good sleep hygiene

The reality is that factors greater than those within the scope of individual influence contribute to the experience of sleep problems and mental health issues. Sleep hygiene refers to practices performed during the day or right before bedtime that create ideal conditions for healthy sleep [3, 10] 

1. Do finish eating at least two hours before bed. This includes limiting caffeine intake to the morning. Drinking caffeine later in the day promotes alertness and higher energy levels, which may impact the quality of sleep later on. 
2. Do remove or power off devices such as televisions, tablets, and phones in the immediate vicinity of the sleep space. Considering how urban areas in the Philippines are often narrow or cramped, it may not be possible to decrease noise, but it is possible to remove sources of blue light, which may delay the natural production of melatonin and decrease sleepiness
3. Do build a sleep routine, which can train your body to recognize the cues for rest and sleep, over time. A routine can include gentle stretches, and relegating relaxed activities to help yourself transition to rest. 
4. Don’t bring work to your sleep space. In case space is limited, relegate your sleep space for only sleep or sex. Other kinds of activities should take place away from this space. 
5. Don’t take long naps during the day. Long naps may interfere with your body clock and make it more difficult to sleep at night. 
6. Do respect others’ sleep schedules and promote behaviors that respect these practices. This may include being mindful of workers’ schedules, needs, and their mental wellbeing. 

Although provisions and tips like these may be difficult to enforce given the conditions in which the most vulnerable Filipinos find themselves, better individual understanding of the importance of rest and sleep may promote more humane practices in the long-run. 

Let’s talk about how we can promote better sleep hygiene, and prevent sleep problems on 20 September 2021 during our regular #UsapTayo tweetchat! 

Terms to Remember

1. Insomnia: difficulty falling asleep or staying asleep
2. Sleep Hygiene: practices that promote ideal conditions for healthy sleep 
3. Coronasomnia: sleep problems caused by lifestyle changes during the COVID-19 pandemic  

Questions:

1. Which Filipino communities are the most vulnerable to sleep problems, especially during the COVID-19 pandemic? 
2. What kind of sleep problems are you and members of your household most susceptible to? 
3. How can we promote better sleep hygiene within our immediate environment?

Works Cited

[1] Villano, M. (2020). “How the pandemic is contributing to your insomnia”, 27 October. CNN Philippines. Accessed from: https://www.cnnphilippines.com/lifestyle/2020/10/27/coronavirus-pandemic-insomnia-sleeping-problems.html (Accessed on: 18 September 2021). 

[2] Rehman, A., & Pacheco, D. (2020). “Sleep Disorders”, 01 December. Sleep Foundation. Accessed from: https://www.sleepfoundation.org/sleep-disorders (Accessed on: 18 September 2021). 

[3] Centers for Disease Control and Prevention. (2018). “Sleep and Sleep Disorders”, 08 August. Accessed from: https://www.cdc.gov/sleep/about_sleep/chronic_disease.html (Accessed on: 18 September 2021). 

[4] Torres, F. (2020). “What are Sleep Disorders?”, American Psychiatric Association. Accessed from: https://www.psychiatry.org/patients-families/sleep-disorders/what-are-sleep-disorders (Accessed on: 18 September 2021). 

[5] Jorge, M.P.C., Villalobos, R.E.M., & Nuñal, J.C.C. (2020). A Descriptive Study on the Sleeping Habits and Correlation of Sleepiness with Academic Performance in a State University-run Medical School in the Philippines. Acta Medica Philippina, Vol. 53 (2), 181-187. https://doi.org/10.47895/amp.v54i2.1513

[6] Raja, J. D., & Bhasin, S. K. (2014). Health issues amongst call center employees, an emerging occupational group in India. Indian journal of community medicine : official publication of Indian Association of Preventive & Social Medicine, 39(3), 175–177. https://doi.org/10.4103/0970-0218.137156

[7] Lu, Sophia Francesca D. and Lu, Jinky Leilanie D. (2021). Assessing the Association Between the Night Shift Schedule and Mental Health Symptoms among Filipino Women Factory Workers: A Cross-Sectional Study. Journal of International Women’s Studies, 22(1), 312-329. Available at: https://vc.bridgew.edu/jiws/vol22/iss1/18 

[8] Que, C. (2021). The angers of bad sleep this pandemic, (13 April). Manila Bulletin. Accessed from: https://mb.com.ph/2021/04/13/the-dangers-of-bad-sleep-this-pandemic/ (Accessed on: 18 September 2021). 

[9] Brooks, R. (2017). How to diagnose & treat the 5 most common sleep disorders, (24 July). American Association of Sleep Technologists. Accessed from: https://www.aastweb.org/blog/how-to-diagnose-treat-the-5-most-common-sleep-disorders (Accessed on: 18 September 2021). 

[10] National Sleep Foundation. (2021). Four Tips for a Better Night’s Sleep, (13 May). Accessed from: https://www.thensf.org/four-tips-to-improve-sleep-quality/ (Accessed on: 18 September 2021). 

[11] Walker, M. [Matt Walker]. (2019, June 03). Sleep is your superpower [Video]. Youtube. https://www.youtube.com/watch?v=5MuIMqhT8DM