Recovery

SLEEP: THE REAL PROBLEM - AND SOLUTION

 

SLEEP and mood are virtually joined at the hip. Everyone - literally everyone - I have encountered in support groups have had issues with managing sleep. Soon I was joking that difficulty with sleep was our main illness and the mood disorder was the downstream effect. As time went on, this came out less and less like a joke. Then, in Oct 2007, at an ask the doctor session hosted by the Capital Area DBSA in Washington DC, I heard Frederick Goodwin MD, co-author of the definitive "Manic-Depressive Illness" and former head of the NIMH, say the same thing, virtually word for word.

When I later double-checked with him, he confirmed it.

Sleep and Alertness

At a 2007 industry-sponsored symposium, "Still Sleepy After All These Years: Hypersomnia in Psychiatry," Stephen Stahl MD, PhD of the University of California, San Diego pointed out that the neurotransmitters of arousal are also the neurotransmitters of concentration. These include norepinephrine, dopamine, acetylcholine, and histamine.

Serotonin, he said is like an "anti-dopamine or anti-norepinephrine." Those talking SSRIs, he said, may feel flat.

Impairments in concentration can lead to poor judgment and impulsive decisions, apathy and lack of motivation, and often inappropriate fixation on one solution. Sleep-deprived individuals require more brain activation in order to process mental tasks. Brain scans reveal little activity in the dorsolateral prefrontal cortex until subjects are able to "kick it up a notch."

Mood disorders, hypersomnia, fatigue, and lack of concentration go hand in hand. Significantly, hypersomnia can also be found on what Dr Stahl refers to as the same arousal-concentration or hypersomnia-cognitive spectrum as depression, anxiety, sleep deprivation, numerous sleep disorders, ADD and even schizophrenia, often traveling along the same brain circuits, suggesting treatment with the same drug.

"There are very few pathways for the brain to get symptoms out of," Dr Stahl advised his audience, which raises the whole question of the relevance of a diagnosis in the first place. Dr Stahl confessed, with probably only slight hyperbole, to writing in a diagnosis "in order to get paid." Then, "I forget about it."

Dr Stahl was speaking in the context of off-label uses of Provigil (modafanil) and other meds. Provigil is FDA-indicated to improve wakefulness in patients with narcolepsy, obstructive sleep apnea, and shift work sleep disorder. (The drug’s manufacturer, Cephalon, sponsored the symposium, and Dr Stahl declared his financial interest as a paid consultant.)

The FDA, Dr Stahl advised, does not regulate the practice of medicine. Rather, it regulates "the sale of medicine."

"WE regulate the practice of medicine," Dr Stahl reminded his audience.

The Depression Connection

Almost anything that disrupts normal sleep contributes to hypersomnia, a number of speakers at the same symposium pointed out. These include medical problems, psychiatric problems, medications and substances, work schedules, sleep deprivation, and sleep disorders (such as obstructive sleep apnea, narcolepsy, restless legs syndrome, and delayed sleep phase).

Hypersomnia is different than fatigue. You will recover from fatigue from lying down, but not from hypersomnia. And the only treatment for sleep deprivation is sleep.

 

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Christopher Drake PhD of Wayne State University cited a 2002 National Sleep Foundation poll that found that more than one-third of Americans are so sleepy it interferes with their daily activities. Despite this, the same poll found that only 29 percent of physicians ask their patients about their sleep habits.

A 2005 study found that pediatric residents performed various cognitive tasks seven percent slower and committed 40 percent more errors after a heavy call rotation than a light call rotation.

Dr Drake explained that a sleep loss of four hours equates to five to six beers, or blood alcohol of 0.095, over the legal limit. The overworked residents in the 2005 study experienced impairment associated with a 0.04 to 0.05 alcohol level. Meanwhile, a 2003 study found that the mostly A students in a middle school population were more awake than C students.

According to an NIMH catchment study, 46.5 percent of patients with hypersomnia had a psychiatric disorder. Another study found that 29 percent of individuals with hypersomnia or excessive sleepiness had major depression. A 1999 study of patients with their depression in remission found the most common residual symptoms were sleep disturbances (44 percent) and fatigue (26 percent). Another study found that these residual symptoms were predictive of depressive relapse.

Fighting Off Sleep

At the same symposium, Leslie Lundt MD of Idaho State University hosted a coming out party for the neurotransmitter orexin, also known as hypocretin. Orexin/hypocretin was discovered in 1998 and originally thought to regulate appetite, but was soon found to be the main culprit in narcolepsy, and later to play a wider role in promoting sleep/wake.

Cortical arousal originates in the lower brain, with midbrain regions such as the hypothalamus acting as relay stations. Orexin-active neurons are located in the hypothalamus, from whence they interact with other neurotransmitter systems throughout the brain.

Other relevant neurotransmitters, besides the ones mentioned by Dr Stahl, include glutamate (wake), histamine (wake), GABA (sleep), and adenosine (sleep). Chardonnay, Dr Lundt said, is a GABA med.

Adenosine, by contrast, is why "people would be stupid enough to pay four dollars for a cup of coffee." Caffeine binds to adenosine receptors. The catch is that when the caffeine wears off the adenosine, which is still in the system, attaches to the naked receptors and the result is a crash. People who drink coffee regularly, Dr Lundt advised, develop a tolerance. If using caffeine as a drug, one should only use it on an as-needed basis.

Although NIDA has no position on the topic, Dr Lundt asserted, "I have seen patients addicted to caffeine."

Twenty-five to 50 milligrams of caffeine is all it takes for most people to feel more alert. An eight ounce cup of brewed coffee contains about 120 mg of caffeine, but who drinks just eight ounces, especially with refills? A Starbucks 16 oz grande weighs in at 330 mg. Tea contains about one quarter to one-half the caffeine as coffee.

Note that caffeine is often loaded in other foods and medicines, various cola products being the most obvious example. A 12 oz Coke contains 34 mg of caffeine. Excedrin, at 130 mgs in two pills, gives new meaning to instant coffee. As for energy drinks: Red Bull (8 oz) 80 mg, Monster (16 oz) 160 mg, Jolt Cola (24 oz) 280 mg.

One study found that 400 mg of caffeine three times a day (which equates to three Starbucks grandes, plus colas) over one week is all it takes for the stuff to have absolutely no sleep-disruption effect. Caffeine dependence is not uncommon. If you decide to go off the stuff, a slow wean (say over two weeks) is advisable.

As for meds treatments (and abuses): Amphetamines block the reuptake of dopamine, so much so that dopamine flows out of the neuron’s transporter rather than being sucked up. Methylphenidates such as Ritalin simply block dopamine uptake. Provigil has a "wimpy binding" to the dopamine transporter.

Non-meds treatments include strategic napping and managing light and dark.

Meds Side Effects

Bear strongly in mind that any psychiatric meds you are on - be they an antidepressant, an antipsychotic, an antianxiety med, or a mood stabilizer - will either disrupt sleep or induce sedation in some way. A treatment strategy that reduces depression, mania, anxiety, or psychotic symptoms at the expense of normal sleep and wakefulness is not sustainable over the long haul.

This bears emphasis: Good sleep and healthy wakefulness are vital to sound mental health. In no way (crisis situations excepted) is it acceptable to sacrifice sleep and alertness in the name of reducing psychiatric symptoms. Over the long haul, messed up sleep and compromised wakefulness is an invitation to depression, mania, anxiety, and psychosis.

Having said that, a smart meds strategy may promote good sleep and wakefulness. Some meds can even serve double-duty in both symptom-reduction and as sleep or wakefulness aids. As a general rule, the meds with sedating effects need to be taken in the evening, while those with energizing effects can be taken in the morning. Or a little at a time via slow-release pills or spacing out small doses.

These are matters you need to thoroughly discuss with your doctor or psychiatrist - at every visit. Do not - I repeat - do not leave the office without a thorough conversation on how you are sleeping and how alert you are throughout the day.

Messed Up Sleep - A Serious Problem

Modern times work against us. Back before electric lights, most people slept about ten hours. Now it's down to seven, with one third of us below six. Throw in shift work, jet travel, and the demands of having to be in two places at once, and one can see why many more of us - children included - fall victim to mood disorders.

On a personal scale, insomnia results in confusion, tension, fatigue, anger, cognitive impairment, and, of course, mood episodes. Those with sleep difficulties are more likely to be absent from work and have accidents or injuries than the general population. Among Navy recruits, poor sleepers occupied the lowest pay grades in disproportionate numbers, were far more likely not to re-enlist, and were far more likely to be hospitalized than good sleepers.

Sleep Hygiene

Maintaining a regular sleep schedule is considered paramount. It need not conform to the schedule of someone who needs to be at work at 8:00 or 9:00 AM, but it needs to be consistent. Excessive sleep is counterproductive, and napping should be resorted to only sparingly (as this can throw off one's sleep schedule).

At the 2001 Fourth International Conference on Bipolar Disorder, Ellen Frank PhD of the University of Pittsburgh reported on her use of interpersonal and social rhythm therapy. IPSRT evolved out of interpersonal therapy for depression developed in the 60s. Neither IPT nor IPSRT make any assumptions as to cause, but both assume that the amelioration of personal problems will result in the amelioration of the corresponding illness.

Unlike the general population, Dr Frank explained, those with bipolar disorder do not have a "Timex." None of this "takes a licking keeps in ticking" for us - we’re much more fragile, with genes, stress, behavior disturbances, disrupted circadian rhythms, and neurotransmitters from hell all combining to create one huge destructive feedback loop.

Dr Frank acknowledges that those with bipolar disorder seem to be phase-delayed, preferring to rise later. At first, she tried to get her patients to conform to the rest of the population. Now she doesn’t unless it’s essential to the job. Nevertheless, of all the goals that need setting, "getting out of bed seems to be the most important one."

Many people find it useful to have a one or two-hour winding down period prior to turning out the lights. This can involve various relaxing routines, including yoga, visualizations, breathing, and meditation. There are no shortage of tapes and CDs to assist. Those requiring further aural support can go to the bed to the sound of gurgling brooks and fountains and distant oceans (make sure your bladder is completely empty).

Reading (including audio books) and TV and radio are two standbys. Be mindful of books that are gripping page turners you can't put down, however, and stay away from programs that are bound to set off a strong emotional response.

Bear in mind that light at night is the enemy. A flick of the switch does more than turn on the lights. It throws out your body's biological rhythms, as well. If you must go to the bathroom in the middle of the night, learn how to negotiate your mission with the lights out, and with the toilet seat where you would expect to find it.

In the meantime, many of you may be faced with making some tough choices: If you are a shift worker you may have to find a job with regular hours. If your work involves travel, you may have to find employment that keeps you close to home. You may have to change from a fast career track to one not so demanding.

Students who burn the midnight oil are particularly susceptible. All-nighters are a necessary fact of academic life, but many of them can be avoided by staying on top of course loads.

Further Insights

According to Dr Frank, in an interview: "Everything we know about circadian rhythms suggests that sleep is the rhythm we can most easily manipulate."

Shift work for people with mood disorders, she says, is like "working with asbestos without a mask." Patients in this position, she advises, may want to disclose their diagnosis to Human Resources (but not necessarily their boss) and ask for special consideration.

Create an association between the bed and sleep, Dr Frank advises. Bed is "not where you read your book, not where you watch television. A lot of Americans have established the habit of doing maybe 15 things in their bed. What we want is the Pavlovian response to being in the bed and putting your head down that will initiate sleep." (Sex is allowed.)

Dr Frank also talks to her patents about caffeine intake, which disrupts sleep, as well as alcohol intake. Alcohol, she says, is good for initiating sleep, but it destroys deep sleep. Establishing regular mealtimes and exercise routines are also part of good sleep hygiene. Exercise early in the day rather than late in the day, she advises, as exercise stimulates rather than settles.

Fixing the Sleep Disorder

One in four individuals with bipolar have sleep apnea. Individuals with sleep apnea experience obstructed breathing during sleep, jolting them awake repeatedly. You hardly have to be a brain scientist to figure out the connection: fix the sleep apnea and you have a good chance of managing your bipolar. Sleep apnea can be corrected with surgery or with a special CPAP breathing mask. Or by learning the didgeridoo. (The breathing techiques employed by didgeridoo players tighten up the muscles in the air passageways, thus promoting unobstructed breathing during sleep. Plus, the didgeridoo is a cool instrument.)

In many cases, individuals must live with a sleep disorder, such as chronic fatigue syndrome (CFS) or insomnia. There are no easy answers, but as a general rule acknowledging the reality of your vulnerabilities and organizing your life accordingly - even if it involves scaling back certain expectations - is the best way to get the most out of the hand you have been dealt. In any case, managing one's sleep - whether as part of a mood disorder or as a separate condition that affects mood - has to be regarded as a top personal-health priority.

Published 2001, updated Jan 2, 2011, revised Dec 5, 2016

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