The quest for sleep
by: Milly Dawson
Reprinted with permission from bp Magazine, Spring 2006
Sound sleep in our busy society can be an elusive dream with profound implications for the way we live.
"We are living in the middle of history's greatest experiment in sleep deprivation and we are all part of that experiment," says Robert Stickgold, PhD, a sleep research specialist and associate professor of psychiatry at Harvard Medical School. Dr. Stickgold makes this dramatic assertion in a recent Harvard Magazine article that also cites some startling statistics.
Americans today sleep far less than people did 100 or even 50 years ago. Moreover, a 2005 poll by the National Sleep Foundation revealed that adult Americans sleep an average of 6.8 hours on weeknights. That's more than an hour less than they need according to most sleep experts. Indeed, says Dr. Stickgold, "it's not inconceivable … that we will discover that there are major social, economic, and health consequences to that experiment. Sleep deprivation doesn't have any good side effects."
The National Sleep Foundation poll also revealed that 75 percent of American adults experience symptoms of a sleep problem at least several times a week. Moreover, chronic insomnia may affect 10 percent of the population. Gallup research has indicated that as many as 40 percent of adults have trouble sleeping two or three nights each week, with depression and anxiety the chief causes.
As difficult as getting a good night's sleep is for most people, those who have bipolar disorder know all too well the significant health costs of poor sleep. "Most people who don't have bipolar disorder have a consistent sleep problem over a long period of time. In people who have bipolar disorder, sleep problems often occur cyclically," explains Michael J. Thorpy, MD, director of the Sleep-Wake Disorder Center at Montefiore Medical Center in Bronx, New York. "They may fluctuate week to week or month to month. So in the manic or hypomanic phases, they get very little sleep but at times of depression, they may sleep or just stay in bed for excessive amounts of time."
And, too, medications used to treat bipolar disorder sometimes disrupt sleep. Many widely prescribed mood stabilizers can induce fatigue and sedation as side effects. Several popular antidepressants, on the other hand, cause agitation and insomnia as common side effects. These side effects can be lessened in several ways. Sometimes reduced doses can eliminate or greatly reduce them. Also, when a drug induces sleeplessness, a person may do better taking it in the morning. A consumer may need a patient psychiatrist who is willing to tweak the medications repeatedly to help that individual achieve good sleep.
Although consumers face many and varied sleep problems, sleep is an area of human experience where good choices and habits can greatly improve matters. "Behavioral changes to support good sleep are absolutely essential," Dr. Thorpy emphasizes. "The more a consumer can maintain a regular sleep-wake pattern," the better he or she will feel, he asserts.
Sleep makes a difference in everything that you do
"The process of sleep, if given adequate time and the proper environment, provides tremendous power," says James B. Maas, PhD, professor of psychology at Cornell University and author of Power Sleep: The Revolutionary Program That Prepares Your Mind for Peak Performance (HarperCollins, 1999). "It restores, rejuvenates, and energizes the body and the brain. The one-third of your life that you spend sleeping has profound effects on the other two-thirds. Your sleep affects your alertness, energy, mood, body weight, perception, memory, thinking, reaction time, productivity, performance, communications skills, creativity, safety, and good health."
Dr. Maas acknowledges the "chickenegg" problem inherent in bipolar and other mood disorders: "Depression can cause extensive insomnia, and insomnia can cause depression - which comes first depends on the individual and the circumstance."
Of course, mania also can and often does cause insomnia. With 75 percent of the population sleep-deprived during the week, Dr. Maas points out that adding "a major stress, whether it's a family problem, a job issue, or something like a biochemical brain disorder … you're going to have even more of a struggle. But if somehow you can improve your sleep, even though you are suffering from a disorder like bipolar disorder, you will feel much better. The better your sleep habits, the more alert and energized you'll be."
"I used to joke that I didn't go to bed at night and get up in the morning, I passed out and came to," says Bill Thomas, 65. Bill volunteers often with the Depression and Bipolar Support Alliance (DBSA) chapter in his hometown of Oklahoma City, Oklahoma. "I had trouble sleeping for years and years. I ran seven companies at one time, in the fields of advertising and PR," Bill says. "I was completely over the top. I actually started a newspaper about the nightlife because I was always up anyway. I called it The Entertainer.
"Working on the paper, I'd party, close the clubs and then go out for breakfast with the musicians," Bill continues. "I just didn't need sleep like normal people—I'd sleep three or four hours a night and take catnaps. I was having long depressive periods but I didn't recognize depression as depression. I didn't actually realize that I was depressed until I was diagnosed with bipolar disorder at age 50 and started to study the illness. Later, my friends said they had seen the depression.
"I self-medicated a lot with recreational drugs and with booze. When I was depressed, I'd think instead that I'd just partied too hard and that I was hung over. So then I'd go for the 'hair of the dog,'" recalls Bill, who no longer drinks or uses recreational drugs. His doctor has addressed a number of his many sleep issues and has prescribed a mild tranquilizer. Bill has the tranquilizer, he explains, "to use as I need it. If my mind starts racing, it helps me to slow down enough to fall asleep. I also have sleep apnea. So I sleep now with a machine that helps me breathe." Currently, he says, "I try to get a good night's sleep every night and I do most of the time."
Sleep apnea, a serious breathing disorder, occurs during sleep and involves a partial or total obstruction of the upper airway and is not uncommon in overweight people. Consumers who have bipolar, who often gain major amounts of weight as a side effect of their medication, are at special risk for sleep apnea. That was the case with Bill, who gained 40 pounds in six months.
"I've tried several times to lose the weight but I have such trouble getting motivated to exercise," Bill says, "and while I'm not losing, I also seem not to be gaining anymore. Dick Cavett, the talk show host, said it best. 'Depression is, you're sitting in a chair and 10 feet away is a pill that will make you feel better, and you can't get up and get it.' I think this is the way we are about exercise."
Dr. Maas points out that "even without specific medications that may induce weight gain, lack of sleep leads to this problem. So people with bipolar disorder face a double whammy there."
Herb Hutson, 54, lives in San Diego, California, with his wife, Marilyn. "I was manic most of my life and I was a real hard worker," he says. For more than 30 years, Herb ran a furniture company, until he became ill at age 48 and stopped working.
Several months ago, Marilyn noticed Herb's deep loud snoring and frequent gasping for air. She suggested that he see a doctor to find out if he had sleep apnea. "I've been in a depression for about six months now and I've been staying in bed about twelve hours a day," says Herb, who attributes his depression to sleep difficulties caused by the apnea. "You still feel tired even though you've been in bed for a full night. It's not restful though, because you're not getting the oxygen you need."
At other times, Herb has slept very little, as often happens with mania. "There were times I'd stay up till 2:00 or 2:30 a.m. and wake up at 6:00 [a.m.] with lots of energy. I'd feel like I could stay up all night typing and write a whole book." During a period when he was sleeping far too little, his psychiatrist adjusted his medications. At one point, Herb explains, he was taking a medication for anxiety and depression "that really speeded up my system. So my doctor changed that to a different drug and also made it an afternoon dose instead of a nighttime dose. That way, the surge of energy was gone by bedtime."
The various problems that Bill and Herb have faced with sleep issues typify the lives of many consumers who have bipolar. "We don't know the underlying reasons, but sleep dysfunction is a core feature of bipolar disorder in both its manic and depressive phases," explains Susan L. McElroy, MD, professor of psychiatry at the University of Cincinnati College of Medicine. "We always assess for sleep issues in evaluating and treating the disorder. It's a key therapeutic target to return the person's sleep to normal.
"There's a common belief that only a few types of insomnia characterize bipolar disorder," Dr. McElroy continues. "That's not true. You can have any type of sleep disruption. People have trouble falling asleep or staying asleep. They may have early morning awakening or wake in the middle of the night. I often see patients with bipolar disorder who stay up late and then can't get out of bed in the morning. Basically, they are hypomanic at night and depressed in the morning. But they don't notice the mood fluctuations; they notice the sleep issues. Those are easier to recognize."
If sleep is a problem, the illness is not yet controlled
If a consumer has problems with sleep, "the psychopathological process is still active," emphasizes Dr. McElroy. That person needs proper mood stabilizer treatment. Standard sleep medications might help temporarily, but they will not treat the underlying problem, the bipolar disorder. What will help are mood stabilizers. If a person is taking one mood stabilizer and they have had a 75 percent reduction in their sleep difficulties, then they may need a second mood stabilizer.
"People with bipolar disorder often misattribute signs and symptoms of the illness to their medications," she adds. "Unfortunately, some of the side effects of the medications are identical to the signs and symptoms of the illness," Dr. McElroy acknowledges. "This is why it's so important for people with this illness to seek education and greater understanding about their treatment." They may also need the help of a sleep specialist, emphasizes Dr. Maas
"Sleep-correcting drugs are sometimes part of the regimen for a bipolar patient," Dr. McElroy reports, "but they are only adjuncts, not substitutes, for mood stabilizers. The goal is to get the person's sleep pattern to be as normal as possible with minimal use of sleep medication. That's why we also strongly stress good sleep hygiene."
Golden rules of sleep
Most people know that they need to eat well and exercise to be healthy and fit, but ignorance about sleep is widespread.
Dr. Thorpy, of the Sleep-Wake Disorder Center at Montefiore Medical Center, encourages consumers who have bipolar to exercise enough for optimal sleep. "It's vital to keep active even during a depressive phase," he says." But be careful not to exercise strenuously too close to the sleep episode" because doing so can be too stimulating. "Get exposure to bright light during the day," he adds. "Don't just exercise inside a dark environment. Get outside."
Sleep experts agree that developing healthful sleep habits (described in this spread) will help anyone maximize the advantages of a sufficient amount of sound sleep. For anyone facing a major stress (whether it's the loss of a loved one or a job, or a chronic disorder such as a mental illness), "sleep hygiene becomes even more important," says Dr. Maas. "You have to control the factors that you can control. Sleep is something people with bipolar disorder can and should regularize" as much as possible.
Milly Dawson, MS, writes about health, parenting, and business topics for major magazines and newspapers including The New York Times, Newsweek, GoodHousekeeping, and Cosmopolitan.
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