Sleep

Why sleep is important to your quality of life

Sleeping and being awake are two sides of the same coin. Better sleep can improve your physical health and cognitive function (i.e., thinking, remembering and planning), as well as help balance your moods and feelings (emotion regulation)1. When you find it hard to fall asleep or have broken sleep, this can be distressing2, and long term poor sleep can worsen your physical health3,4. For people with bipolar disorder, the link between sleep and better health is especially important because poor sleep can also be involved in increased bipolar symptoms and relapse5.

Sleep is a time when the body rests and mends itself and the brain processes memories of the day so they can be remembered later6. However, while sleep is very important for mental and physical health, this doesn’t mean that you should worry too much about a single bad night’s sleep. Like exercise, long-term sleep habits matter more than individual events. Developing and keeping good sleep habits can have long-term benefits. Below, you will be introduced to some important strategies for improving sleep habits. But first, it’s useful to understand a bit about how sleep works.

There is no single correct amount of sleep for everyone. The average adult needs and wants about 8 hours of sleep a night; however, there is a range in the amount of sleep a particular person needs. The time at which we prefer to go to bed also differs across people—morning types (called “larks”) sleep and wake earlier, while evening types (or “owls”) sleep and wake later. People usually become more “owlish” in adolescence (causing problems with getting up for school) and more “larkish” in middle age. People with bipolar disorder tend to be owls.

Key Messages About Sleep

What to know about sleep:

  • Sleep problems negatively impact mood and motivation
  • Concentration, attention, memory and planning impaired by poor sleep
  • Changes in sleep can precede relapse in bipolar disorder

What determines how well we sleep?

There are three main factors that determine when, and how well, we sleep. Ask most people, and they’ll guess that we sleep because we’re tired. As hunger increases the longer a person hasn’t eaten, the drive for sleep increases with hours awake. This is one of the three factors that influence when we sleep, and it is important to remember that all three can be targeted to improve sleep.

The second factor is the brain’s internal clock – if you’ve ever worked shift work or had jet lag, you know that it’s hard to go to bed when the body doesn’t think it’s time to sleep. No matter how tired, a person just doesn’t sleep well if their internal clock thinks it’s time to be awake.

One way to improve sleep is by training your internal clock to provide a strong signal to sleep and wake up around the same times each day (called regularizing or synchronizing your internal clock). Strengthening your internal clock is important for people with bipolar disorder, because having an unstable internal clock is linked to symptoms of both mania and depression. You can strengthen your internal clock by training it into a regular daily routine (a bit like training a pet to expect food at a certain place and time).

The third factor influencing sleep is arousal at bedtime. This means that if you are calm, quiet and relaxed at bedtime, you will sleep better than if you go to bed feeling very excited or stressed. The feeling of being tired but unable to sleep is distressing. Trying your best to relax at bedtime and teach your body to associate your bedroom with sleep can be very helpful.

A short-haired Caucasian woman wearing glasses is sleeping under a blue checked blanket. In the foreground, a white chihuahua looks into the camera. Sleep is very important for bipolar disorder - and pets can help, too!

The link between sleep and bipolar disorder

Sleep problems are a core symptom of bipolar disorder. During depressive episodes, many people experience problems with insomnia (falling and staying asleep at night) and hypersomnia (waking up or getting out of bed in the morning). In manic and hypomanic episodes, people can feel a decreased need for sleep and sleep can be short and interrupted. Insomnia also commonly occurs in manic and hypomanic episodes. Even when people with bipolar disorder are not experiencing a mood episode, they commonly report problems with their sleep. One study found that up to 70% of people with bipolar disorder report sleep problems between mood episodes, and up to 55% of people have sleep problems as wide-ranging and severe as the problems reported by people being treated for sleep disorders7. So, it may help you to remember that problems with sleep originate with the illness, and aren’t a personal trait or flaw.

Importantly, changes in sleep are not only symptoms of bipolar disorder – there is a lot of research evidence to suggest changes in sleep may contribute to bipolar disorder relapses5. People with bipolar disorder typically experience early warning signs of their manic and depressive episodes, and people have better outcomes if they can identify these early warning signs and make the changes needed to manage them. Changes in sleep are the most commonly reported early warning sign for developing episodes of mania, and the sixth most commonly reported early warning sign for depression8. Monitoring for sleep changes can help people make the changes needed to prevent relapse. Being mindful of sleep is a very important part of staying well with bipolar disorder.

Take Action

Strategies for getting a good sleep:

  • Support your biological clock: wake and go to bed at regular times, create routine, keep active in the daytime
  • Strengthen sleep drive: avoid napping, caffeine, nicotine, stimulants
  • Decrease arousal at bedtime: manage anxiety, develop a pre-sleep routine, associate bed with sleep

How you can take action

People who live well with bipolar disorder report using self-management strategies to improve their sleep that are consistent with the behavioural strategies recommended by Cognitive Behavioural Therapy for Insomnia (CBT-I). CBT-I is a therapy that aims to help people develop good sleep habits that can help to facilitate good sleep and to minimize insomnia and hypersomnia. It is the first-line treatment for insomnia, and is even preferred over medication in many cases9,10. Importantly, some small clinical trials have shown that CBT-I can be used safely and effectively to reduce insomnia for people with bipolar disorder11,12. Interestingly, this early research seems to show that strengthening your internal clock by regularizing your wake time across 7 days of the week may be the most powerful strategy for improving sleep. However, one study did show that a strategy called sleep opportunity restriction resulted in mild mood elevation for some people. If you are interested, your healthcare provider will be able to assist you further in finding out if it’s right for you and work with you to implement it safely.

A South Asian woman and her husband, who is black, are waking up from sleep and talking. A small fluffy light brown dog is in the left side of the picture.

Based on expert recommendations and the findings of these clinical trials, CBT-I is now provisionally recommended for the management of sleep problems in bipolar disorder13. The behavioural strategies suggested by CBT-I target the three controllable factors mentioned earlier that determine when and how well we sleep: being tired, the internal clock, and arousal levels at bedtime. For detailed advice about how to apply the skills described in the next section you should read The Bipolar Workbook: Tools for Controlling Your Mood Swings written by M. R. Basco and published in 2006.

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Strategies to increase your sleep drive

The more tired you are, the easier it is to fall asleep at night. To make sure you’re sleepy at bedtime, it’s important to try your best to both avoid daytime napping and to minimize stimulant use. Caffeine in coffee, tea, energy drinks and sodas, nicotine, or energizing drugs will decrease your sleep drive if used after midday. After a poor night’s sleep, it’s tempting to use naps and stimulants (like coffee) to get through the day. This is a perfectly understandable strategy, but it can become a vicious cycle if continued for more than a day or two. It’s also important to know that while alcohol can help people fall asleep, it disturbs sleep during the night. Also, there are more effective ways to relax in the evening than by having a few drinks, as we’ll discuss later.

Successful psychological treatments for depression encourage plenty of daytime activity (some of these types of treatments are called behavioural activation and activity scheduling), which has positive effects on sleep as well as mood and motivation14. Increased daytime activity is a good sleep strategy for people with bipolar disorder, but one important warning must be added – because of the risk of mania, be mindful of over-stimulation. Monitoring activity and mood levels is important in bipolar disorder generally, and needs to be used when dealing with sleep problems15.

Some people with significant sleep problems may be prescribed a short course of hypnotic medications to help increase their sleep drive. If you are taking hypnotic medications for sleep problems, it is particularly important to keep reviewing their use with a clinician, as studies suggest that long-term use of these medications may have harmful effects16 or be inappropriate for people with other substance use concerns17.

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Strategies to train your internal clock

You can train your internal clock to better align with appropriate sleep and wake times by keeping a regular routine. One of the most powerful strategies for improving your sleep is to have a regular wake-up time every day – this includes weekends! The brain’s internal clock needs to be set every day, and it gets the information on how to set itself from our activity and exposure to light. With a reliable wake-up time throughout the week, your internal clock can create a steady 24-hour pulse and can work better when it tries to set you to sleep again about 16 hours after waking up18.

For many people, a wake up time of around 7:30 AM is a good goal; however, lifestyle and other factors might make a wake time of 8:30 AM or even 9:00 AM more appropriate for some people with bipolar disorder. It’s important to get out of bed as soon as you wake up, even if you feel that you haven’t had enough sleep. Many people find that gentle exercise (especially outdoors) upon waking up improves mood; it’s also very good for your internal clock.

The internal clock also benefits from regular timing of other daily activities. The most important ones to keep in mind are socializing, eating and exercising. It may be surprising to hear that sleep at night depends strongly on the regularity of a person’s daytime activities. Some lifestyles help you keep regular daily activities (e.g., a 9-to-5 job), others challenge regularity (e.g., night shifts, on-call jobs). As well, some life events can be predicted to disturb regularity (e.g., a new baby or a holiday): you can plan for these events and be aware that they will impact your daily routines so that you will be better able to make changes and even possibly keep some of your routines intact19.

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Strategies to decrease your wakefulness at bedtime

There are three main things you can do to decrease arousal and increase relaxation at bedtime: develop a pre-sleep routine, don’t let stress or excitement follow you to bed and associate your bed and bedroom with sleep.

First, develop a relaxing pre-sleep routine. In the 2 or 3 hours before bed, avoid stimulation. Emotional stimulation arises from intense discussions with partners and housemates, stimulating television, music or Internet surfing. Stimulation from light can really disturb sleep at night, and is an easy thing to stay away from before bed. To do this, keep room lighting to a minimum and avoid the light from screens – especially close-up screens like laptops, smartphones and tablets.  Physical stimulation comes from exercise close to bedtime.

If you have a cat, you may have noticed that cats prepare for sleep by calmly circling around and clawing the couch – we humans also benefit from rituals around bedtime. Develop a routine around sleep so that your body learns that bedtime is coming. Some people have a habit of an evening drink (milk or chamomile tea may aid sleep), others have routines around their pets or closing up the house for the night.

Second, manage stress and excitement that can interfere with sleep. It’s just not usually possible to solve big problems after dark. When we’re tired and under-resourced, molehills inevitably turn into mountains. To improve sleep, it’s important to address concerns and anxieties before the sun sets. Practicing meditation or progressive muscle relaxation before bedtime can help you to relieve residual stress from the day. If any concerns do arise around bedtime, a strategy to effectively get them off your chest is to write them down to take care of the next day.

For people with bipolar disorder, excitement and stimulation are very important to manage in the evening. It can be tempting to pursue new ideas and projects into the night, but it’s useful to remind yourself that these things can wait: if it’s really a good idea, it will still be a good idea in the morning.

If you have worries about sleep itself, these should be actively addressed with your healthcare professional. Some people have distressing associations with sleep and bed – careful discussion with your healthcare professional can help you to form more beneficial and realistic thoughts about sleep.

Third, try to associate your bed with rest and relaxation, rather than productivity. Spending hours in bed tossing and turning, binge-watching the latest true-crime documentary on Netflix or writing the great novel of the 21st Century can associate the thought of the bedroom with hyperarousal. It is an extremely useful sleep habit to only use your bed for sleep, but it is also okay to use it for sex and brief reading, if these are calming activities for you.

Finally, to make the bedroom a good place to sleep, it should be cool and quiet (try foam earplugs and a fan), dark (try a sleeping mask, good blinds or curtains), and disconnected from the social world (try removing the TV from your bedroom or not taking phone calls in bed).

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Talk to your healthcare provider

There are lots of self-management strategies that can help improve sleep if you live with bipolar disorder. Learning these new behaviours takes some effort – the assistance of a healthcare professional will be helpful in bedding down these new habits. It is also beneficial to discuss your sleep problems with a healthcare provider to rule out possible physiological factors that contribute to poor sleep. Up to 25% of people with bipolar disorder also have obstructive sleep apnea (obstruction of the airway during sleep)20, which is diagnosed by overnight assessment in a sleep laboratory and treated with a continuous positive airway pressure machine. About 10% of people with sleep problems and bipolar disorder have delayed sleep phase syndrome, which often requires specialist support from a sleep clinic. Finally, some medications for bipolar disorder can disrupt your sleep via side effects such as restless leg syndrome21, or by making you feel sleepy at inappropriate times. If this happens to you, it’s worth talking to your physician about whether a change to the timing, dose, or type of your medication may be right for you.

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References

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  2. De la Fuente-Tomás, L., Sierra, P., Sanchez-Autet, M., García-Blanco, A., Safont, G., Arranz, B., & García-Portilla, M. P. (2018). Sleep disturbances, functioning, and quality of life in euthymic patients with bipolar disorder. Psychiatry Research, 269, 501-507. doi:https://doi.org/10.1016/j.psychres.2018.08.104 
  3. Vancampfort, D., Stubbs, B., Mitchell, A. J., De Hert, M., Wampers, M., Ward, P. B., . . . Correll, C. U. (2015). Risk of metabolic syndrome and its components in people with schizophrenia and related psychotic disorders, bipolar disorder and major depressive disorder: a systematic review and meta-analysis. World Psychiatry, 14(3), 339-347. doi:10.1002/wps.20252 
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  8. Jackson, A., Cavanagh, J., & Scott, J. (2003). A systematic review of manic and depressive prodromes. Journal of Affective Disorders, 74(3), 209-217. doi:https://doi.org/10.1016/S0165-0327(02)00266-5
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  11. Kaplan, K. A., & Harvey, A. G. (2013). Behavioral treatment of insomnia in bipolar disorder. Am J Psychiatry, 170(7), 716-720. doi:10.1176/appi.ajp.2013.12050708 
  12. Harvey, A. G., Soehner, A. M., Kaplan, K. A., Hein, K., Lee, J., Kanady, J., . . . Buysse, D. J. (2015). Treating insomnia improves mood state, sleep, and functioning in bipolar disorder: a pilot randomized controlled trial. J Consult Clin Psychol, 83(3), 564-577. doi:10.1037/a0038655 
  13. Garland, S. N., Vargas, I., Grandner, M. A., & Perlis, M. L. (2018). Treating insomnia in patients with comorbid psychiatric disorders: A focused review. Canadian Psychology/Psychologie canadienne, 59(2), 176-186. doi:10.1037/cap0000141
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  16. Wingard, L., Taipale, H., Reutfors, J., Westerlund, A., Boden, R., Tiihonen, J., . . . Andersen, M. (2018). Initiation and long-term use of benzodiazepines and Z-drugs in bipolar disorder. Bipolar Disord, 20(7), 634-646. doi:10.1111/bdi.12626
  17. Gold, A. K., Otto, M. W., Deckersbach, T., Sylvia, L. G., Nierenberg, A. A., & Kinrys, G. (2018). Substance use comorbidity in bipolar disorder: A qualitative review of treatment strategies and outcomes. Am J Addict, 27(3), 188-201. doi:10.1111/ajad.12713
  18. Grandin, L.D., Alloy, L.B., & Abramson, L.Y. (2006). The social zeitgeber theory, circadian rhythms, and mood disorders: Review and evaluation. Clinical Psychology Review, 26(6): 679-694.
  19. Suto, M., Murray, G., Hale, S., Amari, E., & Michalak, E. E. (2010). What works for people with bipolar disorder? Tips from the experts. Journal of Affective Disorders, 124(1-2): 76-84.
  20. Stubbs, B., Vancampfort, D., Veronese, N., Solmi, M., Gaughran, F., Manu, P., . . . Fornaro, M. (2016). The prevalence and predictors of obstructive sleep apnea in major depressive disorder, bipolar disorder and schizophrenia: A systematic review and meta-analysis. Journal of Affective Disorders, 197, 259-267. doi:https://doi.org/10.1016/j.jad.2016.02.060 
  21. Steinan, M. K., Morken, G., Lagerberg, T. V., Melle, I., Andreassen, O. A., Vaaler, A. E., & Scott, J. (2016). Delayed sleep phase: An important circadian subtype of sleep disturbance in bipolar disorders. Journal of Affective Disorders, 191, 156-163. doi:https://doi.org/10.1016/j.jad.2015.11.025