Ashwin Lewis
Sleep is critical for people with bipolar disorder, as too much sleep can be symptomatic of depression, and too little sleep can trigger a manic episode. Treating sleep disorders is key, as it can also improve the symptoms of bipolar disorder. Sedative-hypnotics like Lunesta are often prescribed to treat insomnia in bipolar disorder, and sedating antidepressants or mood stabilizers may also be prescribed to treat both the mood and sleep disorder. However, sedating antidepressants are more problematic, especially in bipolar I disorder, where the risk of manic induction is high.
| Characteristics | Values |
|---|---|
| Sleep disorders caused by bipolar disorder | Delayed sleep phase syndrome, REM sleep abnormalities, irregular sleep-wake schedules, co-occurring drug addictions |
| Sleep deprivation effects | Triggering manic relapse, adverse impact on emotion regulation, increased mania and depression severity |
| Treatment approaches | Medication, lifestyle changes, behavioural therapies, light therapies, sleep deprivation |
| Medication types | Sedative-hypnotics (e.g. Lunesta), sedating antidepressants (e.g. trazodone, mirtazapine), mood stabilizers, antipsychotics |
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What You'll Learn
Sedating antidepressants: e.g. trazodone, mirtazapine
Sleep is an important part of managing bipolar disorder. Too much sleep can trigger or be symptomatic of depression, while too little can trigger or be symptomatic of a manic episode. Treating sleep disorders occurring with bipolar disorder is key, as treating the sleep disorder can also improve the symptoms of bipolar disorder. Sedating antidepressants, such as trazodone and mirtazapine, are often prescribed to treat insomnia in bipolar disorder.
Trazodone is a serotonin antagonist and reuptake inhibitor (SARI) that works through multiple mechanisms. At higher doses (150-600mg), it functions as an antidepressant by inhibiting serotonin transporters and antagonizing specific serotonin receptors. At lower doses (25-150mg), it primarily acts as a sleep aid through its effects on histamine and serotonin systems. When prescribing trazodone for bipolar disorder, healthcare providers must carefully evaluate multiple safety factors. The medication’s potential to trigger manic or hypomanic episodes represents a significant concern that requires thorough assessment and ongoing monitoring. Research suggests that trazodone’s safety profile in bipolar disorder depends significantly on how it’s used. When prescribed at lower doses primarily for sleep, trazodone appears relatively safe for bipolar patients, especially when combined with mood stabilizers. Higher doses used for antidepressant effects carry more risk and should be approached with caution in bipolar disorder.
Mirtazapine is a tetracyclic antidepressant that works in the central nervous system (CNS) to make certain chemicals in the brain stronger. It is available only with a doctor's prescription. Mirtazapine may cause some teenagers and young adults to be agitated, irritable, or display other abnormal behaviors. It may also cause some people to have suicidal thoughts and tendencies or to become more depressed. Some people may have trouble sleeping, get upset easily, have a big increase in energy, or start to act reckless. If you or your caregiver notice any of these unwanted effects, tell your doctor right away.
It is important to note that the use of sedating antidepressants for bipolar disorder requires careful consideration and consultation with a healthcare professional. The potential benefits and risks of these medications should be weighed before starting treatment.
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Hypnotics: e.g. Lunesta
Sleep is a critical factor in bipolar disorder. Too much sleep can be symptomatic of depression, while too little sleep can trigger or be symptomatic of a manic episode. Sleep disorders are commonly treated with lifestyle changes, behavioural therapies, and medication.
Sedative-hypnotics like Lunesta are often prescribed to treat insomnia in bipolar disorder. Hypnotics are a class of drugs that act on the central nervous system to induce sleep. They are typically prescribed for short-term use due to the risk of dependence and side effects. Lunesta, also known as eszopiclone, is a nonbenzodiazepine sedative-hypnotic agent that is used to treat insomnia. It works by increasing the levels of GABA, a neurotransmitter that inhibits nerve activity in the brain, resulting in a calming effect and promoting sleep. Lunesta is generally considered safe and well-tolerated, but it may cause side effects such as dizziness, drowsiness, and headache. It is important to note that Lunesta may interact with other medications and should be used with caution in patients with a history of substance abuse.
While Lunesta can be effective in treating insomnia, it may not be suitable for everyone with bipolar disorder. In some cases, it may even worsen symptoms or increase the risk of depression. Additionally, Lunesta may not address the underlying causes of insomnia in bipolar disorder, which can be complex and multifaceted. Therefore, it is crucial to consult a healthcare professional before taking Lunesta or any other hypnotic medication to ensure a comprehensive understanding of the risks and benefits.
It is important to note that the use of hypnotics for bipolar disorder is somewhat controversial. While some clinicians are liberal with their prescription, others prefer alternative approaches due to the potential side effects and lack of controlled trials specifically in patients with bipolar disorder. As such, it is recommended that hypnotics be used in conjunction with other therapies, such as behavioural interventions, to address the underlying causes of insomnia and improve overall sleep quality in patients with bipolar disorder.
In conclusion, Lunesta and other hypnotics can be a viable option for treating insomnia in bipolar disorder, but they should be used cautiously and in conjunction with other therapeutic approaches. Treating insomnia in bipolar disorder requires a careful balance between rapid sedation and the long-term goal of retraining the circadian rhythm for more lasting and substantial benefits.
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Mood stabilizers
Sleep is an important factor in managing bipolar disorder. Changes in sleep patterns can be an early predictor of a manic episode. Lack of sleep can take a toll on people with bipolar disorder, and disrupted sleep can aggravate a mood disorder. Treating sleep disorders that co-occur with bipolar disorder is key, as treating the sleep disorder can also improve the symptoms of bipolar disorder.
There are three main types of mood stabilizers: lithium, anticonvulsants, and antipsychotics. Lithium is a naturally occurring element that has been approved by the U.S. Food and Drug Administration (FDA) as a mood stabilizer since 1970. Brand names for lithium include Eskalith®, Lithobid®, and Lithonate®. Anticonvulsants, also known as antiseizure medications or antiepileptic medications, were originally developed to treat seizure disorders like epilepsy. Common anticonvulsants used to treat bipolar disorder include valproic acid (Depakote®), lamotrigine (Lamictal®), carbamazepine (Tegretol®), and oxcarbazepine (Trileptal). Antipsychotic medications are also common in bipolar treatment plans. They can be taken alone or with mood stabilizers to help with symptoms of mania.
It is important to note that it may take several weeks for mood stabilizers to reach their full effect. Therefore, other psychiatric medications such as antipsychotics are often used in the early stages of treatment to treat acute mania. Additionally, medication is generally considered the cornerstone of bipolar disorder treatment. However, combining medication with other types of therapy and support can help achieve better outcomes.
It is crucial to take bipolar medications as directed by a healthcare provider and make them a part of your routine. Stopping or changing medication without medical advice can be dangerous. Side effects of mood stabilizers vary depending on the type of medication, and regular monitoring of drug levels in the blood can help minimize these side effects.
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Antipsychotics
Sleep is a critical factor in managing bipolar disorder. Too much sleep could be a symptom of depression, while too little sleep could be a symptom of a manic episode. Antipsychotics are a class of drugs that have been used to treat bipolar disorder for about 70 years. They can be divided into three generations: first-generation antipsychotics (FGAs), second-generation antipsychotics (SGAs), and third-generation antipsychotics (TGAs). FGAs, such as phenothiazines and haloperidol, are used to treat acute mania and psychotic depression when combined with antidepressants. SGAs, such as clozapine, risperidone, olanzapine, and quetiapine, have antimanic properties and are effective for maintenance treatment of bipolar disorder. Clozapine is particularly useful for treating severe and drug-resistant forms of bipolar affective disorder. Quetiapine is also FDA-approved for treating manic and depressive episodes in bipolar disorder and may improve sleep quality and comorbid anxiety. However, it has adverse effects, such as sedation and hypotension, which can lead to discontinuation of the medication. Cariprazine and lurasidone are also FDA-approved for bipolar depression, with the latter being the only atypical antipsychotic proven to improve cognition in bipolar disorder. Aripiprazole and brexpiprazole are examples of TGAs. Antipsychotics can also be used off-label as sedatives to treat insomnia, anxiety, and agitation in people with bipolar disorder. They can help regulate brain circuits that control thinking, mood, and perception.
While antipsychotics can be effective in treating bipolar disorder, they may cause side effects. Some antipsychotic drugs can lead to significant weight gain, high cholesterol levels, and an increased risk of diabetes. Certain antipsychotics may also cause tardive dyskinesia, a movement disorder characterised by repetitive, involuntary movements. Older antipsychotics have a higher risk of causing tardive dyskinesia compared to newer atypical antipsychotics. People considering antipsychotics for bipolar disorder should be screened for their risk of heart disease, stroke, and diabetes.
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Behavioural therapies: e.g. Interpersonal and Social Rhythm Therapy
Interpersonal and social rhythm therapy (IPSRT) is a behavioural therapy designed to address rhythm dysregulation in bipolar disorder. It is not meant to replace medication but to be used alongside it to help regulate schedules and make medication compliance easier. IPSRT is based on the idea that changes in routine can trigger mood episodes in people with bipolar disorder, who are medically vulnerable to disruptions in their circadian rhythm.
The therapy aims to promote consistent daily routines to stabilize circadian timing and minimize disruptions to daily rhythms. This includes regulating sleep/wake cycles, meal times, and times of rest versus activity. IPSRT also focuses on improving the quality of interpersonal relationships and performance in key social roles. It involves addressing interpersonal issues such as grief, role transitions, and role disputes, which can be disruptive to social rhythms and trigger mood episodes.
The initial phase of IPSRT involves a review of the patient's mental health history to identify patterns between social routine disruptions, interpersonal problems, and affective episodes. Psychoeducation about bipolar disorder and the importance of stable routines to mood maintenance is provided. The Interpersonal Inventory is used to assess the quality of the patient's interpersonal relationships, and one of four interpersonal problem areas is chosen as a focus for therapy.
IPSRT has been found to be effective in preventing the onset of new affective episodes and improving occupational functioning. It has also been adapted for group therapy settings, where patients make interpersonal goals, reflect on their illness, and empathize with fellow group members. In a randomized controlled trial, participants who received IPSRT during the acute treatment phase went longer without a new affective episode and had higher regularity of social rhythms, resulting in a reduced likelihood of relapse.
Overall, IPSRT is a valuable behavioural therapy for individuals with bipolar disorder, helping them to manage their daily routines, improve interpersonal relationships, and prevent mood episodes. It is often used in conjunction with medication to provide additional support and improve medication adherence.
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Frequently asked questions
There are several medications that can be used to treat insomnia associated with bipolar disorder. Some of the medications include:
- Melatonin
- Hypnotics such as eszopiclone, zaleplon, and zolpidem
- Sedating antidepressants such as trazodone and mirtazapine
- Mood stabilizers with sedative effects such as quetiapine, lumateperone, olanzapine, risperidone, and ziprasidone
- Benzodiazepines
It is important to consult with a medical professional to determine the most appropriate treatment option for you, as medication may depend on the nature of your bipolar disorder and sleep problems.
While benzodiazepines can be effective in treating insomnia, there are some risks associated with their use in patients with bipolar disorder. One concern is the risk of abuse and dependence, especially in patients with a history of substance use disorders. Additionally, there is a lack of controlled trials specifically evaluating the use of benzodiazepines in bipolar disorder, and observational studies have produced mixed results.
Yes, there are several non-drug therapies that can be used to improve sleep in people with bipolar disorder. These include:
- CBT-insomnia (CBT-I)
- Bright light therapy
- Sleep deprivation
- Interpersonal relations therapy
- Social rhythm therapy
- Circadian therapies such as ramelteon and dark therapy
