UCalgary podcasts feature interviews with experts from our community on the COVID-19 situation.
Episode 23: The Importance of Sleep
May 22, 2020
Sheltering in place is wreaking havoc on many people's sleep patterns, which can cause associated problems like substance use and depression. We talk to registered psychologist Dr. Lianne Tomfohr-Madsen, about the importance of getting proper sleep, especially in stressful times, and what people can do if sleep is an issue for them.
Dr. LTM Tomfohr-Madsen (LTM): There is so much convincing research now that long or adequate and consolidated sleep. Sleep that is feels refreshing where you don't wake up a lot is associated with better mental health. Every single age. Sort of infancy up to a 100 years old, people need to be sleeping at night and our brains really need that period of downtime to work through basically emotion regulation.
DY: That was registered psychologist, Dr. Lianne Tomfohr-Madsen, and this is UCalgary COVIDcast. I'm Deborah Yedlin. Thanks for joining us. One side effect of sheltering in place during the coronavirus pandemic is that for many of us, our sleep patterns are out of whack. Whether it's sleeping too much or too little, a lot of individuals seem to be having a hard time getting proper rest. They might be eating too much, not getting enough exercise. The fact we're on Zoom calls all day long could also be affecting our sleep. Today on COVIDcast, we're talking with Dr. Lianne Tomfohr-Madsen, a registered psychologist, an associate professor in the Department of Psychology, and an adjunct associate professor in the Department of Pediatrics here at the University of Calgary. Lianne's with us today to talk about the importance of getting proper sleep, especially in stressful times, and also what people can do if sleep is an issue for them.
DY: Lianne, thanks for joining us.
LTM: Oh, I'm happy to be here. Thanks for having me.
DY: We're here, we're talking about the importance of getting sleep and how challenged people are right now with their sleep patterns interrupted for various reasons, whether it's stress related, environmentally related, how are you sleeping?
LTM: I'm sleeping pretty well. I like many people, am at home with a three year old and so I'm noticing that I'm getting up really early in the morning. Mostly because that's the time that I have that feels like free time, but I am generally falling asleep okay. I've had a couple of nights that are a little bit worry related. Just having difficulty staying asleep in the night.
DY: Yeah. I think a lot of people are having that kind of challenge. They fall asleep and at 3 o'clock in the morning, they're waiting for the newspaper to show up on their doorstep.
LTM: Totally, 3 o'clock is the worst. How are you sleeping, Deborah?
DY: Not great. Yeah. My sleep comes and goes. It varies if I have, if I manage to get some really good exercise periods in I'm good, otherwise it can be a challenge and I'm trying to watch the caffeine, trying to do all those things that are the right things to do. We've heard a lot about for the longest time people would say, "Sleep's a waste of time. We don't need to sleep." But that mentality, that idea has changed a lot in the last little while, in the last few years. Why is sleep so important?
LTM: Many reasons, but I think the best thing that people can kind of do to get a sense of why sleep is important is reflect on how they feel during periods of intense sleep deprivation. And so, you often hear people talk about one night of sleep, they can kind of power through, but two, three, four, you start to feel physically run down and emotionally and mentally run down. And that's because what happens when we go to sleep is our body does a pretty serious reboot. Physically sleep is when all of our growth and kind of restoration happens, which we mostly think about for little kids. It's really, really important for little kids, but as adults too, we need that kind of recharge. Something happens in our brain when we sleep, where we consolidate new memories. And so if you learn something and then you get a really good night sleep, you're way more likely to remember it the next day then if you get a junky night's sleep, which is probably why a lot of us right now feel like we're just sort of slogging through the day. Just not our peak performance at work. Yeah.
DY: Do you think that the amount of screen time we're all experiencing right now, whether it's Zoom, Teams, Google, is that disrupting our ability to shut down? Even though we may practice proper sleep hygiene and not look at our computers an hour before we go to sleep, but is the cumulative effect of what we're dealing with throughout the day, having an impact on our sleep, ability to sleep?
LTM: I don't know that there's been research on this, but I would say almost definitely, yes. The fact that we're on our computers all day and we're just getting pinged constantly and we're not exercising as much. We're not getting up and walking around as much. And I think that has a kind of cumulative effect. By the end of the day, you haven't really moved a lot. And then you're also, at least for me working from home, so just kind of having difficulty shutting off from work. I can close my computer, but I kind of know it's there. And a lot of parents are doing this double duty shift right now where they're not just parents, a lot of people are working all day at just weird times. And that sort of creeps into our bedroom at night.
DY: Yeah. It's not, there's no, the boundaries aren't as well defined as they need to be. And that's causing our brains not to shut down. One of the things we alluded to earlier is people wake up in the middle of the night. They ruminate, they can't sleep. How do you break out of that? What do you do if you wake up at 3:00 o'clock in the morning? Do you have any suggestions for how to calm your mind to help yourself go back to sleep?
LTM: Yeah, definitely. We were just talking about this. I'm running a big sleep intervention trial right now. And I was just meeting with the therapists who are seeing people with insomnia. And we were talking about what people should do when they wake up at 3, 4 in the morning. And the best thing you should do is ask yourself, "Is there any chance I'm going to fall asleep again?" And if the answer is, no, you should get out of bed because we don't want to make associations between our bed and not sleeping. We want to be, we're sort of like animals this way. Our bed should be Pavlovian. When we get into it, we should be sleepy. And so we don't want to do things in our bed that aren't sleeping. If people wake up at 3, 4 in the morning, which is totally understandable right now, and they're really feeling like I'm probably not going to fall asleep, the best thing they can do is get out of bed. Move to the couch, make a cup of tea and then do something that's calming or something that can be helpful for reducing stress. One of the things I say to most of my clients is worries that are 3:00 and 4:00 AM worries are not often the same worries you have at 8:00 AM. It's good to just write them down, just to get them out of your head. And sometimes writing them down is just enough so that they stop running around, over and over again. And then, once they're out of your head and you feel a bit calmer, if you can go back to sleep, try that. And if you can't, don't force it. There's no reason to be in bed if you're not sleeping.
DY: What about trying breathing exercises or something like that? I know that there's been a lot of literature lately in the last, just talking about how you can breathe to help yourself calm down, to help yourself fall asleep. Are you also a proponent of that approach before you get out of bed?
LTM: I think if you are doing it for a couple of minutes, it's fine. But generally if people wake up and they're so anxious that they're doing a bunch of breathing exercises, my recommendation is usually get out of bed and do it. Just again, it's sort of like you open the fridge and you salivate. We want to make this strong association between you get into bed and you fall asleep. You don't want to do a lot of other things to mess with that. What I am a big proponent of is these breathing or relaxation exercises as part of people's pre-sleep routines. Yeah. Winding down with maybe a little bit of stretching, some relaxation or some breathing and doing that every day, instead of just when you need it really strengthens that muscle.
DY: Right. And I guess right now we have an unprecedented opportunity to, to log into yoga, nidra classes anywhere, at any time that could fit our particular sleep cycles. Maybe that's something people need to think about in terms of incorporating into their evening routines just as a way to wind down.
LTM: Yeah, I think that's really the best place to put it.
DY: How do you think the sheltering in place has affected our sleep patterns? Have you seen some literature that talks about how the fact that we are so confined and limited in terms of our ability to move, how it has affected our sleeping?
LTM: Yeah. We've done a little bit of research on this so far with a group that I'm working with. And basically what we're seeing is people are saying that their sleep feels much more impaired than it did before the pandemic. And that makes total sense because our sleep is exquisitely sensitive to stress and disruptions in routine. Yeah. The both of those things are happening now at probably the highest levels than I've ever seen in my life.
DY: Are you saying that we're not getting that REM sleep, that we generally rely on to repair our brain cells and to give us the energy to get through the next day? Is that sort of what you're talking about?
LTM: I think people are often reporting a lot more fragmented sleep, so they're waking up a lot more. And a lot of people are saying they're having difficulty falling asleep at night. And then people engage in these compensatory measures that can often prolong the problem. Instead of getting up at their regular time, maybe you normally get up at 6:00 so that you can be at work for 8:30, well, we don't have to go to work anymore, or we don't have to do the drive or the commute so people will sleep in much later than they normally did because they had a hard time sleeping last night. Will take sort of a strange nap in the middle of the day that they wouldn't have normally taken, which then can make it harder to fall asleep at night. These disrupted routines just, they are really hard for keeping our sleep schedules on track.
DY: There's some literature actually that shows napping is a good thing. And companies are saying, "Yes, it's fine for you to sort of close your door and nap for 20 minutes." You're saying that's not a good thing? Or not right now because we're not sort of running at the same level of intensity?
LTM: I'm not an anti-nap person, but I'm an anti-nap person if you have insomnia.
DY: Okay. Fair.
LTM: And so generally what you need to fall asleep at night is a lot of sleep pressure. And sleep pressure means you've been awake for a long enough time to get sleepy, not like fatigue like we maybe all feel all the time, but to actually get sleepy. And so if you take a nap, you really want to take it before about, I'll say 2 PM and be up because you got to have time to build up some sleep pressure. If you take a nap from 3 to 4 or 3: to 5, you're probably not going to be sleepy when you get into bed at night.
DY: Right. That's I've never heard that before sleep pressure.
LTM: Yeah. We got to build that up.
DY: For me, it's decreasing the caffeine intake. But I think that's something we all have to think about is how much caffeine, how much sugar, what else we do that sort of can artificially keep us going when we probably need to be winding down. What are your thoughts on how we manage that? Because we're stressed, we tend to be creatures of habit. We look for things that are comforting and of course, sugar and chocolate are two items that people often will look for some sort of relief from how they're feeling.
LTM: Yeah. Well, I think it's a two way street. About the caffeine, I want to be totally honest. I've been having four cups of coffee a day for two months. I'm on a detox routine right now because I know it's way too much, but it's been, I work in my kitchen. And so this is, it's comforting to me. I like to have a cup of coffee. It's a nice break. And so I think a lot of us are doing that kind of thing. And one of the things we know getting to your point about food is if you are sleep deprived, you really crave fatty, sugary things. Your body wants those things, it feels better for having them. I think we get sleep deprived, then we eat a lot of stuff that we wouldn't maybe normally eat, that maybe influences our sleep the next night. And so it's just kind of this vicious cycle that we get into.
DY: One of the symptoms for depression though, is insomnia and not sleeping. At what point do we start to say, "Okay, I have insomnia, but actually it's not insomnia. It's sliding towards that marker where I could be depressed." What should people be looking for in that regard? Do you have any markers that people should be aware of?
LTM: Yeah, we often we say sleep disturbance is the harbinger for low mood. It's often the first thing to go before people start kind of sliding into depression. And I think that the two main things to look out for, well, one is just feeling sad. People are feeling sad all day, most of the day for more than is normal. And I mean more than is a normal because I think we really have to differentiate feeling sad right now from the grief we're all feeling. We're all feeling sad a lot of the time, but the difference is, many of us are feeling like this profound grief and it passes and then we can get on with our day. We can have a moment where we sort of sit and feel the loss of our friends or activities, or I miss my office at work and then it goes away. People with depression have that sort of, that feeling of sadness or that low mood most of the time. Or the other thing is not wanting to do things that normally are delightful to you. People who would normally want to really get on a Zoom call with their grandchild just don't really feel it. And that's a warning sign.
DY: But I think I'm just, I guess my question is, if you're starting to sleep less than five hours a night and that's consistent, is that sort of the kind of thing you should be watching and thinking, okay, this could be going in a direction which is not, which will require some more help. And just to be aware, is there a number of hours of sleep you should be sort of thinking about at which point you should start to get concerned that you could be heading towards a depressed state?
LTM: I don't think there's any number of hours that we need to be thinking about, but we need to be looking at how refreshed people feel when they wake up. If you wake up two or three weeks in a row and you feel like I have not had a good sleep, I just don't feel refreshed. That to me is more of a warning sign than anything else.
DY: I was reading some statistics a while back and it was notable that alcohol sales in Alberta are way ahead of the national average since the pandemic started and we started to shelter in place. We're hearing reports that substance abuse is increasing. And can we talk a little bit about how the use of substances, whether it's alcohol or other measures, other substances, how that affects our sleep? Because sometimes people think, well, I can fall asleep, but there's an impact to that.
LTM: Yeah. Alcohol, is a sedative. People drink alcohol to calm down and if you are not a longterm drinker and you have a couple drinks, yes, it's totally going to calm you down and it's probably going to help you fall asleep. But the problem with alcohol is because it's a depressant, we call it a depressant in our body. Once it wears off, our body goes into this stimulant phase. It goes into a rebound kind of excited phase. And so that's why people start to talk about, "Yeah, I had a couple of drinks before bed and then I was up at 2 or 3 in the morning and I was totally wired." Physiologically, your brain is just rebounding from being depressed. And so one of the things that I'm a bit concerned about is we're hearing people are drinking to fall asleep, but then they can't stop drinking because one of the side effects of withdrawing from alcohol is insomnia. It's the longest lasting side effect. Cannabis as well. If you're having a couple of drinks or if you're getting high to go to sleep, maybe for a day or two that's going to work, but eventually it's just going to lead to longer term problems.
DY: That was my next question, the alcohol is one piece, but of course cannabis use is increasing because it's now legal. What are the things that we should be thinking about if we're using cannabis, if we're taking CBD oil, what is, just can you sort of walk us through some of the things we should be thinking about?
LTM: Yeah. I've got a personal issue with the fact that this isn't being marketed enough, but one of the main, most robust symptoms of cannabis withdrawal is disrupted sleep. And people will start talking about having insomnia. They have these sort of strange dreams, and of course, many people are using cannabis to fall asleep, but they don't realize that once you do that for three, four months, stopping doing it has of course side effects. And one of the reasons that people say they have to keep using it is because their sleep is so disrupted when they start trying to stop. And so I think we just need to be really careful around helping people understand when is the time to use cannabis or CBD oil, what it's good for and when it could be harmful and sleep is just a known sort of casualty of excessive cannabis use.
DY: One of the things we also see, we're watching TV and the marketing of over the counter medications to help people sleep. Any thoughts on that? Either maybe on a temporary basis, or is that again, one of your, we have to be really careful about what we do because this is also going to cause, there's a rebound effect for that as well.
LTM: Yeah. I think sleep medications were invented for a reason and sometimes you need them for short term help. After a parent dies or you lose your job, maybe you need some medication for a couple of days, but I think most people don't realize that they become off-label after 10 days.
DY: What does that mean?
LTM: It means they're no longer being prescribed the way that they should be or the way that they've been tested. After 10 days, there's none of these medications that people should be taking. They have a black box warning on them now from the FDA, they're definitely their longterm use is associated with some pretty serious problems and they disrupt your sleep architecture. You don't get as much deep sleep. My feeling about them is yes, short term, if you're in a period of acute stress and you need to get some sleep, it makes total sense. Longterm, they're not a good solution.
DY: Let's just shift gears a second, because the other thing was, you talked about routines and how you're getting up early. Well, for those of us who have kids at home, and let's say they've been used to a routine going to school, all of a sudden that's been completely upended. How should we help our children to, from let's say K to 12 or in university, how do we help them stick to a routine? Because they don't have to be at school for 8 o'clock. What should parents do? How can we help our young children, our teenagers stay in a routine that's helpful and helps them sleep?
LTM: Yeah. First of all, so much compassion for these parents and these kids that are at home, this is an impossible situation to manage. I think probably we first need to reevaluate what is an appropriate wake up time, because if you needed to get up at 6 before and you don't need to now, it's probably not realistic that you're going to keep getting up at 6.
DY: Right. Like if you had swim practice. That's off the table now, so why would you get up that early?
LTM: Exactly. Let it go. Figure out what your new wake time is that's realistic. That might be 8. Maybe Zoom school starts at 8:30, but just sort of making that decision with your family and then working backwards because bedtime is going to need to get shifted too. Kids, that whole age range five through 18 need a lot of sleep, nine, 10, 11 hours a night, depending on the age group. But if we anchor that from, let's say a 7 AM, wake up time, that might mean kids are going to bed a little bit later. We also don't want kids laying in bed not sleeping same as adults. That's just going to create a ton of worry. Helping people get that new routine and that new kind of sleep wake window and being really honest with what that's going to look like, I think is a good place to start.
DY: I guess one of the things we've also been reading about is how school needs to start later for teenagers because they need some sleep. I'm wondering if you think that what we're dealing with right now could result in the shifting of classroom time for students, for teenagers, because really their sleep patterns, they tend to stay up a little later and they need to sleep a little later.
LTM: Yeah, wouldn't that be a wonderful side effect of this pandemic?
DY: But do you think it's a possibility? We're learning online. Maybe this is the way we balance it a little bit better because we know that teenagers need more sleep, but we know that they tend to get up a little later.
LTM: Yeah. And we know they do better at school when they've had a little more sleep. I think particularly as I hear people talking about staggering kids going back to class, it would make sense for some of these school times to be later so that some kids could get this extra hour, hour and a half at night.
DY: Let's talk a little bit about just sleep and mental health and how important it is from that perspective. I think we touched on a little bit earlier, but I think the connection between the two and how important it is to have that rest and to support your mental health and of course the mental health in your family. Can we just talk about that connection a little bit more and just tell us what that looks like?
LTM: Yeah. There is so much convincing research now that long or adequate and consolidated sleep. Sleep that is feels refreshing where you don't wake up a lot is associated with better mental health. Every single age. Sort of infancy up to a 100 years old, people need to be sleeping at night and our brains really need that period of downtime to work through basically emotion regulation. And so I always tell people, if you're getting five or six hours of sleep at night, yes, your body will take what it needs physically to for growth and repair. But a lot of the emotion regulation stuff that happens during sleep happens in the later half of the night. And so we really need to be giving ourselves, and I think particularly our kids, time to get that long and long sleep. I can speak to my daughter who's three. If she misses a nap or has a really bad night of sleep, the tantrums in our house are epic. You would think that we're in a physical fight sometimes over turning off Paw Patrol, but it's really just because she's too tired to regulate. And she's such a good paradigm for what the rest of us go through except hopefully we aren't, I don't know, throwing our fake kitchen across the living room. But maybe we are, if we're really tired.
DY: We're a little more self aware. I'm curious if there is a difference between the patterns of sleep in females and males? And what you're noticing there in terms of sleep patterns and how women cope versus how men cope when they don't have enough sleep.
LTM: Yeah. One of the things we know is women are much more likely to develop insomnia than men are. And probably because just biologically they're more attuned to stress. And also if you think about it, home is often a more dangerous place for women than it is for men. If you think about domestic violence or who's going to perpetrate violence, that is going to happen more likely to women at home, and it is impossible to sleep, it's so hard to sleep in a really deep way if you're scared. We think that some of the reasons that we see these pretty big gender differences in how people sleep.
DY: Then of course, if you're dealing with other situations, whether it's, you're worrying about extended members of your family and you have no control over that because they're not close by, women tend to as nurturers, we tend to worry more about more people and it's hard to shut that down.
LTM: Yeah, I think so. And I think I don't want to gender stereotype. I know there are many men who are so compassionate and caring and worried, but I think there tends to be more of a focus, at least from what I've experienced in the literature, men are more concerned about safety a lot of the time and women are more attuned to maybe what's going on in terms of noises from their kids. And there's no judgment around that. That's just maybe socialization. And I think that just sort of happens that way.
DY: Moms have bat sonar.
DY: They can hear everything. If you had to come up with three things to think about in terms of making sure we are getting the sleep we need, what would they be? And what recommendations would you have that we think about as we look to establish this sleep pressure that you were talking about?
LTM: Yeah. Okay. These are easy. I want people to be able to remember them. The first one is, try and get up around the same time every day, even on the weekend.
DY: Oh, that's not fair.
LTM: I know. I know, but we are, our sleep is just driven by hormones and they're on a circadian rhythm and they don't do well with disruption. Within an hour on the weekends of when you would normally get up would be my recommendation. Anchor your sleep. And then the other thing is if you're not sleepy and by I mean sleepy, you could close your eyes and fall asleep. If you're not sleepy, get out of bed. There's no reason to be in your bed if you're not sleepy.
DY: Or don't go to bed.
LTM: Or don't go to bed.
DY: Yeah. Okay. Yeah.
LTM: Absolutely. Don't go to bed. If you feel that you're not sleepy, maybe you're tired, rest on the couch. We don't want our bed to be associated with anything but sleeping. And my third tip is cleanse your bedroom of its devices. Get your TV out of there, get your computer out of there. Buy an old school alarm clock so that you don't need to use your phone to wake you up because our phones, even it's not just the light on our phones that keeps us up. It's because they're so stimulating. If you can, clean your room of those things.
Deb: So Lianne, you said to get out of bed if we can't sleep. What should we do if we do get out of bed? Should we turn on the TV? Should we read? What kinds of things are you giving us license to do in order to sort of distance ourselves from that inability to sleep?
LTM: So do something that is calm and that can be time-limited. So if you do get tired, you don't want to be in the middle of baking a cake. You want to be able to actually go back to sleep. I think reading is a really good option if people have good books to read. If they want to watch something calm on TV or listen to a calm podcast. Don't turn on something you can't turn off, that's too exciting. One of the things that we've been talking a lot about is don't look at the news in the middle of the night. It's not the time to jump onto Facebook or to turn on your favorite news site. Because it's often just very distressing and you kind of want to save that for a time when you're not trying to get sleepy, you're not trying to get extra rest.
Deb: Can you talk about the news in the context of your day as well? Should you limit your exposure like once in the morning, once in the afternoon, just once, either morning or afternoon? Is that playing into, people's inability to settle down because they're watching the news too often? Do you shut down your notifications in your browsers? What do you think we should do?
LTM: Yeah, I think the news is very anxiety-provoking right now, at least for me, and it's moving really fast. So there's this kind of temptation to check every hour and see if something has happened. I think in terms of just general mental health and stress reduction, the best thing people can do is check, maybe decide to check once a day in the morning and maybe once in the afternoon. But then look into their own sort of emotions and see, after you go and scroll through the news, how do you feel? And so if that is, I feel worse... I can tell you for myself, I feel kind of tired. Sometimes I feel kind of sad. That's not something I want to put myself through 20 times a day.
Deb: Yeah. No, I think that's good advice because people were so used to watching what's going on and now it's just the adrenaline that starts running when you start to read what's going on, coupled with the uncertainty isn't helpful.
LTM: Yeah. And I think there's a real lack of differentiation of risk because we're seeing what's happening in every single province, every single country right now. And I think that what gets on the news is what's bad that's happening. And so if you can just limit your consumption of that and try and really focus on what's happening in your local place, what are the measures in place, what do you need to know to get through the next day? And then you give yourself permission to not know any more than that.
DY: You didn't mention exercise. Is that something that, if you can, that's something that will help build that sleep pressure?
LTM: One hundred per cent. People who exercise regularly report way better sleep than people who don't exercise even an hour walk will generally help.
DY: Yeah. And one other thing I read recently was it was important to be hydrated. That if you weren't properly hydrated and hadn't had enough to drink during the day, it would also interrupt your sleep.
LTM: I have not heard that. It is very interesting.
DY: It is very interesting. I just read about it and I thought, well, that's interesting. If you haven't drank enough through the day, it can sort of interrupt your sleep or just impair your quality of sleep. Just something to add to your study that you are currently involved with.
LTM: I work mostly with pregnant women so I'm telling them to stop drinking after 8 PM because they have to go pee all the time. But if you're not pregnant.
DY: Yeah. Maybe you need to increase your consumption of water and other beverages that are not dehydrating. Lianne, thank you so much for joining us today. Where can our listeners get more information?
LTM: Oh, that's a great question. The National Sleep Foundation has beautiful articles about sleep for every age. And I think that they're a great resource to be able to tune into.
DY: Thanks so much for being with us today. Hopefully the next time we chat, everybody will be sleeping better.
LTM: Yes. That would be wonderful.
DY: Thanks, Lianne.
LTM: Thanks Deborah.
DY: The city of Calgary also offers resources to help cope with the pandemic, including a 211 number you can call, text, or chat if you or someone you know needs support. There's also a 24-hour family violence hotline available. Visit calgary.ca to find out more. Before we go, I'd like to remind our campus community that our mental health supports continue to be available. For students, support can be accessed through Student Wellness Services. For after hour support, or if you are in crisis, call Woods Homes Community Support at (403) 299-9699, or the Distress Center at (403) 266-4357. For staff, faculty, and post-doctoral scholars, supports are available through Staff Wellness. Additionally, Homewood Health is available and provides 24/7 mental health and crisis support. For domestic violence, support visit ucalgary.ca/sexualviolence-support. For drug and alcohol harm reduction supports, visit the Wellness Services website at ucalgary.ca/wellness-services. This has been UCalgary COVID-cast. To subscribe or to listen to past episodes or to get more online resources for coping with the coronavirus pandemic, visit ucalgary.ca... This has been UCalgary COVID-cast. To subscribe or to listen to past episodes or to get more online resources for coping with the coronavirus pandemic, visit ucalgary.ca/COVIDsupport. Thanks to Dr. Lianne Tomfohr-Madsen for taking the time to chat with us today. I'm Deborah Yedlin. Thanks for listening.