Recovery

Managing Sleep

If you have a mood disorder you have sleep issues.

I was going to bed at around 11 or 12 in the evening and getting up at 8 or 9 the next morning. There was only one problem: These were west coast hours and I was living on the east coast. My inability to establish a regular sleeping pattern was directly related to my state of depression, which seemed to have me in a permanent headlock. Only half-jokingly I told my psychiatrist that perhaps a move to California would solve the problem.

(Update Feb 2008: Ready for the punchline? In late 2006, more than six years after writing this, I moved to California.)

Ever since college, I preferred working at night, even when required to keep daytime hours. Not uncoincidentally, that's when my bipolar features began to manifest in full measure, with devastating results. Still, I lived for the night, when the world had shut down with no distractions, and it was just me and my manic-fueled creative surges. But now I was faced with undoing thirty years of conditioning or having to submit to a force that had staked a claim to my brain. I had fought back hard, but make no mistake about it: I was still in the battle of my life, for my life.

Sleep and Depression and Bipolar Disorder

Sleep and mood are virtually joined at the hip. Everyone - literally everyone - I encountered in the support group I facilitated for three years in Princeton, NJ 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.

After the session, I followed up further on this. "If I were Oprah," I said, "I would say stop right there." (It's amazing what you can get away with when you say, If I were Oprah.) The upshot was Dr Goodwin confirmed the vital necessity of managing sleep, to the point of thinking of it as the primary illness if push came to shove.

According to Thomas Roth PhD, Chief of Sleep Medicine at Henry Ford Hospital, Detroit, sleep is one of the few things in medicine that is both a disorder and a symptom. Dr Ross was addressing a symposium, "Sleep Disorders and Psychiatric Illnesses: Scientific Foundations," at the American Psychiatric Association's annual meeting in Philadelphia in May 2002. The DSM-IV catalogue of sleep disorders includes primary insomnia, narcolepsy, and circadian rhythm sleep disorder, to name a few. Meanwhile "insomnia or hypersomnia" and "fatigue or loss of energy" are listed as symptoms for both major and mild depression, and "decreased need for sleep" is a symptom of mania and hypomania in bipolar disorder.

According to Dr Roth: "As many as 60 percent of psychiatric outpatients complain of disturbed sleep. Studies of depressives indicate that as many as 85 percent will at some point experience insomnia."

Research has linked persistent insomnia with the onset of another major depressive episode within one year, and sleep complaints are a reliable predictor of future relapses A 2004 University of Massachusetts, Boston study of 2,259 students aged 11 to 14 found that sleep decreased as the kids got older, and that sixth-graders with less sleep showed lower initial self-esteem and grades and higher initial levels of depression symptoms. Over time, students with less sleep reported heightened levels of depressive symptoms and decreased self-esteem, leading the authors of the study to conclude, "this study underscores the role of sleep in predicting adolescents’ psychological outcomes ..."

In bipolar disorder, the situation can be more extreme. According to one study, 25 percent of depressed bipolar patients flipped into mania when deprived of sleep for one night. A 2004 DBSA survey of 1,464 people has found sleep disturbance to be "one of the most common problems associated with mental illness." Respondents cited racing thoughts, emotional stress, and restlessness. Ninety-three percent thought lack of sleep impacted on their mood and caused sadness, anxiousness, and irritability.

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.

At the same APA symposium, James Walsh PhD, executive director of the Sleep Medicine and Research Center at St Luke's Hospital, St Louis, reported that the total direct and indirect costs of insomnia amount to some $100 billion annually. 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.

This is how your sleep shapes up during an acute depression episode:

Prolonged sleep latency, reduced total sleep time, reduced sleep efficiency (characterized by intrusions of wakefulness), reduced three and four (deep) sleep, reduced REM latency, and increased REM density. Also - increased body temperature, increased ACTH, cortisol, and cerebral metabolism (in non REM sleep), as well as decreased growth hormone TSH, prolactin, testosterone, and possibly melatonin.

I do not profess to understand exactly what all that means, but if my mechanic ever handed over a clipboard with something like that on it I would know it was time to get rid of my car.

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.

Part of her therapy (which complements meds) is getting patients to compile a life chart. This helps patients make the connection between many of their bipolar episodes and major life events that lead to marked changes in routine, such as the birth of a child. The therapist will work with the patient in finding the most unstable lifetime rhythms and setting goals (with reasonable expectations) for change, meanwhile searching for triggers likely to cause any disruptions. Rotating shift work, for example, is regarded as poison, but if the patient can’t change his or her schedule, then they work on getting eight hours of consolidated sleep.

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 stand-bys. 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. A member of my family goes to sleep to Boston Red Sox games on the radio. As she is not a baseball fan, the games are just so much white noise to her. Another member of my family, however, when he was alive, wouldn't leave the TV until the last pitch had been thrown, and then head to bed in a highly aroused state. (I can still hear it now: "The Red Sox blew it, again.")

Caffeine is to sleep as Attila the Hun was to a nice quiet day in the Roman Empire, though it may not be as simple as cutting out the stuff altogether. The Rip Van Winkles amongst us may legitimately need a pick-me-up, as well as those who find themselves waking up groggy from a meds hangover. Sparingly is the watchword. That morning caffeine is still in the system in the evening. Evening caffeine should be considered taboo (unless you work nights). Note that caffeine is often loaded in other foods and medicines, various Cola products being the most obvious example. Two tablets of Excedrin contain 130 mgs of caffeine, about the same as a cup of brewed coffee, while 12 ounces of Sunkist orange soda contain 41, five more than a 12-ounce Coke.

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

"We know that insomnia is probably a risk factor for depression," Dr Frank told this writer in a 2004 interview, "that people who have had insomnia earlier in life are at much greater risk for mood disorder than people who have never had insomnia. We know that children with insomnia are at very high risk for mood disorder. So there’s something about the sleep-wake cycle - it’s telling us something."

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

Dr Frank and her colleagues begin by talking about getting patients onto regular sleep-wake cycles, which doesn't necessarily mean conforming to the schedule of most of the rest of the world. Individuals with bipolar disorder are much more likely to be night owls than the rest of the population, and Dr Frank has learned from her patients to work at establishing a routine based on getting up later.

The demands of working life, however, impose formidable challenges. One patient on an afternoon-evening shift switched to a dream job that required him to be at work at six in the morning. Dr Frank worked with him to shift his sleep-wake cycle by a half-hour a day over a series of weeks to the point where he could finally manage his new schedule.

Shift work for people with mood disorders, Dr Frank 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.

Much of IPSRT focuses on anticipating things that will happen - both major and minor - say someone who has been single a long time and will be getting married or whether someone would be willing to fly from the east coast to the west coast on short notice to attend a funeral. IPSRT helps patients problem-solve these situations. In the former case, it may be better for two partners to sleep in separate bedrooms if they cannot get their routines into reasonable sync.

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.

Sleep Medications

Benzodiazepine receptor agonists are currently the drugs of choice for insomnia, which both inhibit arousal centers and promot sleep. Novel benzodiazepine receptor agonists include Sonata (zalepon) and Ambien (zolpidem). Their main advantage, according to Ruth Benca MD, PhD of the University of Wisconsin, at the same 2002 APA symposium, is "minimal disruption in sleep architecture," but they can cause dependence, especially after a few weeks on high doses.

Benzodiazepines are a type of benzodiazepine receptor agonist. Also referred to as hypnotics, benzodiazepines are the most common medication sleep aids, with anti-anxiety and muscle-relaxant properties. Their disadvantages include daytime sedation, cognitive impairment, respiratory compromise, post-seizure amnesia, disinhibition, and possible abuse or dependence. The most widely prescribed hypnotic is Halcion (triazolam). Others include Xanax (alprazolam), Valium (diazepam), and Klonopin (clonazepam).

Both benzodiazepine receptor agonists and benzodiazepines are generally prescribed on a short-term basis, as needed.

Many sleeping pills are metabolized through the 3A4 pathway, which is blocked by a number of antidepressants. Sonata may be relatively safe, and several reports indicate that Prozac and Ambien work well together, though more studies are needed.

Over-the-counter sleep aids contain antihistamines as their main ingredient, with potentially significant side effects, including sedation, psychomotor impairment, and blocking nerve impulses. Other sleep agents include melatonin and the herb valerian.

One's psychiatric meds may be enrolled in the cause. The following antidepressants have a sedative effect: The tricyclics, plus the novel antidepressants Serzone, and Remeron. Low dose trazodone (a novel antidepressant very rarely used as such) is often prescribed as a sleep med, with the advantage of being non-addictive and which can be taken on as as-needed basis. Low dose Seroquel, an atypical antipsychotic, stands in as an as-needed sleep med, and on higher doses may serve double duty for sleep plus treating mania or psychosis, taken daily.

Please ask your physician about the correct time for taking sleep meds. You may be one who is knocked out right away, but in general meds require an hour or more head start.

For those having trouble staying awake, there is what some are referring to as the next Viagra or Prozac, the next lifestyle drug, Provigil (modafinil), a novel wakefulness agent that is promoted as allowing normal sleep without the jittery highs associated with caffeine and other drugs. At present, the drug is only FDA approved for narcolepsy, but it is also being used off-label to treat hypersomnia associated with atypical depression. At the 2002 APA annual meeting, two studies presented as posters found Provigil rapidly reduced fatigue and improved wakefulness and concentration in depressed patients, and was well-tolerated.

The danger with this drug is many could abuse it to sustain a dangerous workaholic lifestyle. Please consider the drug only if you have trouble staying awake during the day.

Then there are the activating antidepressants, which include Wellbutrin, the SSRIs, Effexor, and the MAOIs.

The SSRIs are known to reduce REM sleep (rapid eye movement, when dreaming occurs), but because people who are depressed experience too much REM this may be a good thing.

Conclusion

For me, my Herculean struggle to bring my system to within a time zone or two of the one I was in was compounded by the spring changeover into Daylight Saving Time. I literally felt like poor Sisyphus, forced to push a rock uphill for eternity, only to have it roll down to the bottom just as he neared the summit. For awhile, I achieved a reasonable level of success by sticking to a strict lights-out policy no matter how wide awake I felt at the time.

Then I made the fatal mistake of loading the video game, Civilization III, into my computer. For those of you unfamiliar with Civilization, it takes a good week of dedicated playing to go from fending off Stone Age marauders to triumphantly rolling your armored vehicles into the capital city of your last remaining rival superpower. You guessed it, it was impossible for me to go to bed in the middle of a life-or-death struggle between my Persians and those sneaky Iroquois (who had built the Sistine Chapel and the Pyramids and had a fleet of aircraft carriers off my shore), with the nuclear-capable Babylonians ready to enter the fray on the side of the Iroquois and seal my doom, unless I could convince the French to come to my aid, which depended on them not holding a grudge against me just because I leveled their stupid little Great Wall of China six centuries ago.

Just 15 or 20 minutes, I would say at 11:00 PM. Then all sense of time would disappear and next thing it would be three in the morning. An hour later I would still be awake under the covers, plotting my revenge on those no good Babylonian bastards.

It took me many long months before I came out of denial and faced up to the fact that this was an addiction I couldn't control. I'm proud to say I've been Civilization-free for better than two years. My sleep is still far from perfect. There are nights when my racing thoughts threaten to keep me awake into the next millennium. There are mornings when my brain has gone missing and I realize it's going to be one of those days. There are afternoons when the power goes down like a plug being pulled from an appliance and the only option is to lie down.

I may not be a hundred percent in control, but I'm not entirely helpless. I'm grateful that I work from home, where I can still manage to cobble together 50 or so productive hours a week without the stress of being on my game for a full working day, five or six days a week. I do the best I can with what I've got. It's kind of a working arrangement, an uneasy truce between my ideals and my limitations. So far it's working, with no manic episodes since my diagnosis in early 1999. My occasional hypomanias are nothing to worry about while my chronic low grade depression, though a concern, is not incapacitating. In short, I have my life back, but I can never take this state of affairs for granted. I constantly need to remind myself that I'm one night's missed sleep or a morning or afternoon of oversleeping from possibly destroying everything I've worked to so hard to build.

If there's a Sword of Damocles suspended by a thread in my brain, sleep is it. I've learned the hard way to respect this fact. Please don't repeat my follies. Resolve right now to treat sleep as if your life depended on it. It does.

Updated Feb 10, 2008