Ashwin Lewis
Sleep disturbances are a common symptom of bipolar disorder, with insomnia persisting in 70% of patients even when their mood is stable. This lack of sleep can lead to an increased risk of mania and depression. While bipolar disorder is often treated with medication, certain drugs can affect sleep as a side effect, so it is important to consider other ways to improve sleep quality. This could include psychological interventions, light therapy, or sleep deprivation. Additionally, creating a sleep plan that respects the body's circadian rhythm can be an effective way to manage sleep disturbances and prevent mania.
| Characteristics | Values |
|---|---|
| Type of treatment | Pharmacological and non-pharmacological |
| Non-pharmacological treatments | Psychological interventions, light therapy, cognitive behavioral therapy, interpersonal and social rhythm therapy, family therapy, psychoeducation |
| Pharmacological treatments | Hypnotics, sedating antidepressants, antipsychotics, lithium, melatonin, selective serotonin reuptake inhibitors |
| Sleep tips | Consistent sleep schedule, 7-9 hours of sleep, limit naps, no screens or caffeine before bedtime, cool room temperature, bright light therapy in the morning, exercise |
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What You'll Learn
Medication and psychological interventions
Sleep disturbances are a common symptom of bipolar disorder, with insomnia persisting in 70% of patients even when their mood is stable. This puts them at risk of episodes of mania and depression. Other sleep problems associated with bipolar disorder include hypersomnia (oversleeping), a decreased need for sleep, and delayed sleep phase syndrome, a circadian rhythm sleep disorder resulting in insomnia and daytime sleepiness.
Several medications and psychological interventions can help with sleep disturbances in bipolar disorder. These include:
- Hypnotics: Some clinicians prescribe hypnotics, but these come with problems, including the potential for abuse. Examples include benzodiazepines and z-hypnotics (e.g., eszopiclone, zaleplon, zolpidem). However, these medications lack controlled trials in bipolar disorder patients, and observational studies have shown mixed results.
- Sedating antidepressants: These can be problematic, especially in bipolar I disorder, as they carry a high risk of triggering mania. Examples include trazodone and mirtazapine.
- Mood stabilizers with sedative effects: Certain antipsychotics can improve sleep quality while stabilising mood. These include quetiapine, lumateperone, olanzapine, risperidone, and ziprasidone. Lithium is rarely sedating but can positively affect the circadian system, reducing the "night owl" tendency associated with poorer health and a higher risk of depression.
- Melatonin: This hormone, taken 30 minutes to an hour before sleeping, can help regulate the body's 24-hour clock. Dr John Preston, co-author of 'Take Charge of Bipolar Disorder', suggests a 0.5 mg dose. However, it's important to avoid serotonin reuptake inhibitors (SSRIs) without mood swing prevention in bipolar disorder.
- Cognitive Behavioural Therapy for Insomnia (CBT-i): This therapy stabilises the circadian system, making it suitable for mood disorders. While traditional CBT-i has been avoided in bipolar disorder due to concerns about triggering mania through sleep deprivation, a modified version called CBT-iBD includes a safety valve, limiting bed restriction to no fewer than 6.5 hours. It also addresses circadian rhythm abnormalities and helps establish consistent sleep and wake-up routines.
- Light therapy: Bright light therapy in the morning can help reset the sleep-wake cycle.
- Psychological interventions: These approaches are advantageous as they tend to have fewer side effects, are often preferred by patients, are durable, and have no abuse potential. Examples include interpersonal and social rhythm therapy (IPSRT), family therapy, psychoeducation, and cognitive behaviour therapy (CBT).
In addition to these interventions, maintaining good sleep hygiene is crucial. This includes keeping a cool, dark, and quiet bedroom, establishing a consistent sleep schedule, and refraining from caffeine and screen time before bed. Relaxation techniques, such as visualisation and white noise, can also aid sleep.
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Sleep deprivation and light therapy
Sleep deprivation therapy and light therapy are two treatments that can be used to manage bipolar disorder. Bipolar disorder is characterised by a disruption in circadian rhythms, and these therapies aim to manipulate these rhythms to stabilise mood.
Sleep Deprivation Therapy
Sleep deprivation therapy, or 'wake therapy', involves depriving a person of sleep for 36 hours, or allowing only partial sleep of 3 to 5 hours, followed by extended wakefulness. This therapy has been shown to have an antidepressant effect, with improvements in mood reported. However, it may also trigger mania and should be used in combination with a mood stabiliser. Sleep deprivation therapy has been found to be particularly effective when accompanied by mood stabilisers or antidepressants.
Light Therapy
Light therapy, or chronotherapy, is a non-pharmacological treatment that aims to manipulate the body's circadian rhythms using light. Bright light therapy involves daily exposure to bright artificial light, typically above 2000 lux, and is administered through a light box or other device. This therapy is well-tolerated by patients and can be used alongside other treatments. The mechanism of action is not yet fully understood, but it is thought to involve chronobiological effects and effects on neurotransmitters such as serotonin.
Dark therapy is another form of light therapy, where decreasing light dampens manic symptoms. For this treatment, amber glasses that block blue light are worn in the evenings.
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Mood stabilizers and sedatives
Bipolar disorder is a mental illness characterised by mood swings from extreme highs (mania) to the depths of depression. Doctors often prescribe mood stabilizers to treat bipolar disorder. These are a group of medications that treat and prevent full episodes of mania or depression that last for several days or weeks at a time. They also help to keep mood swings from interfering with work, school, or social life. Mood stabilizers work by affecting certain receptors in the brain that regulate the release and maintenance of neurotransmitters.
There are three main types of mood stabilizers: lithium, anticonvulsants, and antipsychotics. Lithium is a naturally occurring element and 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 are also used to treat seizure disorders and include carbamazepine, lamotrigine, and valproic acid. Antipsychotics are also common in bipolar treatment plans and can be taken alone or with mood stabilizers to help with symptoms of mania.
It's important to note that the term "mood stabilizer" can be misleading. If you take one, your mood can still change during the day. Additionally, mood stabilizers are not addictive in the traditional sense, but many people who take them do so for long periods of time. When your brain gets used to a mood stabilizer, it will take some time to adjust when you stop—especially if you stop taking them suddenly. Therefore, it's important to talk to your healthcare provider before stopping any prescription medication.
In addition to mood stabilizers, other medications can be used to treat the various symptoms of bipolar disorder, including antipsychotics, antidepressants, and benzodiazepines. Doctors may also consider electroconvulsive therapy (ECT) for severe cases of mania.
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Circadian rhythm and sleep hygiene
Sleep disturbances are a common symptom of bipolar disorder, with insomnia persisting in 70% of patients even when their mood is stable. Sleep problems can put bipolar patients at risk of episodes of mania and depression. Therefore, it is important to maintain good sleep hygiene and respect the body's circadian rhythm.
The body's 24-hour clock, or circadian rhythm, is regulated by the afternoon release of the hormone melatonin and the morning surge of the neurotransmitter serotonin. Serotonin is related to mania, and an increase in serotonin is caused by exposure to bright light. Therefore, it is recommended to avoid bright light or overstimulating activity before bedtime. This includes exercise, television, and the use of phones, laptops, and other screens.
To improve sleep and stabilize the circadian rhythm, it is recommended to take a 0.5 mg dose of melatonin 30 minutes to an hour before sleeping. Other ways to stabilize the circadian rhythm include bright light therapy in the morning and cognitive behavioral therapy (CBT). CBT-i, or CBT for insomnia, has been modified to include a built-in safety valve for bipolar disorder (CBT-iBD). This therapy addresses common circadian rhythm abnormalities in bipolar disorder, such as sleep inertia and nocturnal hyperactivity. As part of CBT-iBD, patients develop a wake-up routine that includes bright light and energizing activity, as well as an evening wind-down routine that involves dimming the lights and avoiding screens.
In addition to respecting the circadian rhythm, maintaining good sleep hygiene is crucial for preventing mania and depression in bipolar disorder. This includes keeping a consistent sleep schedule, getting a full 7 to 9 hours of sleep, and taking naps thoughtfully and carefully when needed. It is also recommended to reserve the bed for sleep and sex only, avoid caffeine before bedtime, and keep the room temperature cool. Creating a cozy and quiet atmosphere, exercising earlier in the day, and practicing relaxation techniques can also improve sleep hygiene.
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Relaxation techniques and sleep environment
Sleep is critical for managing mood in bipolar disorder, and a lack of sleep can lead to an increase in mania and depression. Relaxation techniques and a suitable sleep environment can help those with bipolar disorder get the sleep they need.
Relaxation Techniques
Relaxation techniques can help calm the mind and body, reducing the manic energy that can interfere with sleep. Visualization and breathing exercises are two techniques that can aid in relaxation. Visualization involves creating a mental image of a calming scene or experience, which can help distract from racing thoughts and worries. Breathing exercises, such as deep breathing or counting breaths, can help slow down a racing mind and promote a sense of calm.
Another relaxation technique is cognitive behavioral therapy for insomnia (CBT-i), which can help stabilize the circadian rhythm and improve mood disorders associated with bipolar disorder. This therapy includes limiting time in bed and gradually increasing it to improve sleep quality. However, this approach should be used cautiously in bipolar patients as sleep deprivation can trigger mania. A modified version called CBT-iBD includes safety measures to prevent sleep deprivation-induced mania.
Sleep Environment
Creating a conducive sleep environment is essential for individuals with bipolar disorder. Maintaining a dark, quiet, and cool bedroom can enhance sleep quality. Utilizing tools such as fans, heaters, blinds, earplugs, or sleep masks can help achieve the desired temperature and minimize distractions.
It is also important to avoid stimulating activities and screens before bedtime. This includes exercise, TV, phones, and computers, as the blue light emitted by these devices can interfere with sleep. Instead, opt for relaxing activities such as reading or listening to soothing music. Additionally, caffeine should be avoided before bedtime, as it can disrupt sleep.
Establishing a consistent sleep schedule is crucial for individuals with bipolar disorder. This involves maintaining a regular bedtime and wake-up time, even on weekends. Napping can be beneficial, but it should be done thoughtfully and carefully to avoid disrupting the sleep schedule.
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Frequently asked questions
Bipolar disorder is a common, severe, and chronic disorder. It is often life-threatening, with approximately 1 in 5 individuals completing suicide. Bipolar disorder type I is defined by the presence of at least one manic or mixed episode. Bipolar II requires at least one hypomanic episode and at least one major depressive episode.
Sleep issues are very common in people with bipolar disorder. Some of the sleep issues they face include insomnia, hypersomnia, decreased need for sleep, and delayed sleep phase syndrome.
Sleep has a critical mood regulatory function. Shorter total sleep time is associated with increased mania and depression severity over time. Sleep deprivation can also trigger hypomania or mania.
There are several pharmacological and non-pharmacological treatments for bipolar disorder. Medication approaches include hypnotics, sedating antidepressants, antipsychotics, and mood stabilizers. Non-pharmacological treatments include psychological interventions, light therapies, sleep deprivation, and cognitive-behavioral therapy.
