The lead author of the study is Nick Glozier, MBBS, MRCPsych, PhD, associate professor of psychological medicine at the Brain and Mind Research Institute and the Centre for Integrated Research and Understanding of Sleep (CIRUS) at the University of Sydney in Australia.

The study found that young adults (17-24 years of age) who get fewer than eight hours of sleep per night are at greater risk of experiencing psychological distress – a combination of high levels of depression and anxiety. The study showed a 14% increase for each hour of sleep less than eight hours.

As the researchers point out, shorter sleep duration may be a cause of mental distress or a symptom of underlying mental distress or both (comorbid). However, according to Glozier, “The increased reporting of stress seen in many countries over the past decade or two in this young adult population may reflect lifestyle or other changes that lead to too few hours of sleep.”

The authors are careful to point out that their study does not call for any broad efforts in increase sleep duration among all young adults. Targeting those at greatest risk – those suffering from mental distress or experiencing extremely brief sleep cycles of 1-5 hours per night – is key.

The take away lesson from this study and others like it is the importance of getting a sufficient amount of sleep (for children and adults both young and old), and the importance of intervention when sleep durations become extremely brief.

• Prescribing substantial doses of medications such as Abilify or Seroquel.
• Using loading doses of Depakote to reduce acute mania more rapidly. A loading dose is a higher initial dose than normally prescribed. Loading doses are used to ramp up a medication to a therapeutic level more rapidly.

These more aggressive interventions for mania are often performed in hospital. When providing outpatient treatment, doctors usually ramp up these medications more slowly to reduce side effects. Lamictal, which is used to prevent mood cycles, requires many weeks to reach a therapeutic level because of the risk of a skin condition that is much lower if the doses are increased very slowly.

Antidepressants are another story. Routinely, patients are told that they won’t be likely to experience any benefits from their antidepressants for at least a few weeks. Sometimes it can take much longer, and doctors rarely, if ever, suggest what to do in the meantime. Patients are often expected to tough it out. And if the person complains, the doctor often advises them to “BE PATIENT.” Easier said than done in the midst of debilitating depression.

So, what can you do in the meantime to start feeling better right away? Consider the following strategies:

• Use your non-medication interventions aggressively during this time. Engage fully with your therapist to identify ways to reduce environmental mood triggers, increase the availability and effectiveness of your support network, and improve your coping skills.
• Sometimes the doctor can prescribe shorter acting medications to address associated symptoms, such as anxiety/panic or insomnia. Benzodiazepines, such as Xanax, can be used judiciously to more rapidly reduce acute anxiety symptoms, and then be tapered off as the antidepressants or anti-manic agents kick in. Similarly, medicines to help you sleep can be quite beneficial early on in the process while waiting for antidepressants or anti-manic agents to take effect.
• Communication with your prescriber is the key to developing the most effective strategy. Keep asking for help and utilize your therapist as well as your doc – ask whether they can speak to each other to more effectively coordinate your care and come up with ideas to help you manage during the medication trials.

Important: If risks of self harm or hurting someone else are present, then hospitalization or day treatment may be necessary while the medications are being adjusted. You and your doctor must continue to monitor the level of your safety and risk throughout these medication trials.

While she’s waiting for her circadian clock to reset, she usually ups her dose of melatonin and uses other sleep aids to “knock herself out.” She does a pretty good job of getting herself back on track, but it usually takes a week or two.

Does setting your clock ahead or back upset your mood balance? If so, what do you do, if anything, to deal with it?

Before we crack open the medicine cabinet, I’d like to say a few words about bipolar disorder and sleep. Sleep is a biggie. Too much could trigger or be symptomatic of depression. Too little could trigger or be symptomatic of a manic episode. At least one study shows that changes in sleep patterns can be an early predictor of a manic episode. Sleep plays a major role in mood disorders and recovery, so if you’re having trouble sleeping, you and your doctor need to do something about it.

That something could consist of many strategies, ranging from very simple (such as going to bed the same time every night) to more involved – medication, avoiding caffeine and other stimulants, maintaining a strict sleep schedule, and convincing other family members to stop banging around in the kitchen till two in the morning. In stubborn cases, you may benefit from a sleep study to identify factors that may be contributing to the sleep disturbances.

Assuming your doctor and you decide that sleep medication is necessary, your doctor may prescribe one or both of the following:

• A mood stabilizer, atypical antipsychotic, anxiolytic (anti-anxiety agent), or other medication that’s not primarily used for sleep but will hopefully help your sleep if it treats underlying mood or anxiety symptoms. Occasionally these medications are used just for the sedating side effects for sleep, but this is not so common.
• A bona-fide sleeping pill (sedative), which brings us to the main point of this post.

A little-known fact is that the active ingredient in many over-the-counter sleeping pills is diphenhydramine – the generic form of Benadryl!

Prescription Sedatives

Several effective sleeping pills are available, which vary in terms of safety, side effects, and other considerations. The following list provides a quick rundown of some of the more common prescription sleep medications currently in use:

• Ambien (zolpidem): Ambien is available in two forms – Ambien (and its generic), which help you fall asleep, and Ambien CR (no generic), approved to help you fall asleep fast and stay asleep. Ambien may not be safe for those who have a history of depression, liver or kidney disease, or respiratory conditions. Ambien may lose its effectiveness if taken longer than two weeks, while Ambien CR can be taken for a longer period of time. Ambien can trigger unusual side effects such as sleep walking, sleep eating, and even sleep driving. Ambien should not be mixed with alcohol – the combination increases the risk of these types of side effects. For more about Ambien CR, visit http://www.ambiencr.com/.
• Lunesta (eszopiclone): Lunesta is approved to help you get to sleep and stay asleep, so you wake up feeling rested. It has a low-risk for developing a dependency, so you can use it short- or long-term, and rebound insomnia (increasing severity of insomnia after stopping the medication) is rare. Lunesta may not be safe for those who have a history of depression, mental illness, or suicidal thoughts; a history of substance abuse or addiction; liver disease; or are pregnant, planning to become pregnant, or breast feeding. Lunesta should not be combined with alcohol. For additional information, visit http://www.lunesta.com/.
• Sonata (zaleplon): Sonata is approved to help you get to sleep. Its particular niche is that it is short acting, so is less likely to produce a hangover effect in the morning. It is so short acting that you can take it a second time if you awaken in the middle of night. Sonata can be habit forming and may not be safe for those who have a history of depression, mental illness, or suicidal thoughts; a history of substance abuse or addiction; severe liver impairment; or are pregnant, planning to become pregnant, or breast feeding. Sonata should not be combined with alcohol.
• Rozerem (ramelteon): Rozerem works differently from other sleep medications and is designed to work in conjunction with your body’s internal clock. It’s non-habit-forming, won’t make you feel groggy the next day, and is safe to use with many prescribed medications. (It’s not a controlled substance like most other prescription sleep medications.) Although Rozerem is generally considered safer and gentler than other prescription sleep medications, it may not be safe for those who have a history of kidney or respiratory problems, sleep apnea, or depression, or are pregnant or breast feeding. It may interact with alcohol, and high-fat meals may slow absorption of the drug. For more about Rozerem, visit http://www.rozerem.com.

Some older sleep aids include Restoril (temazepam), Halcion (triazolam), and ProSom or Eurodin (estazolam). These are not used frequently anymore – and have a history of being addicting and causing a number of side effects. Halcion has been withdrawn form the market in several countries. If your doctor recommends one of these medications, question the reasoning for using an older drug.

Atypical Sleep Aids

Some medications that are not bona fide sedatives are often used for this purpose. Following are a few of the more common and effective medications in this group:

• Trazodone: This is an old fashioned antidepressant, rarely used for depression anymore, but, because it is so sedating, has become popular as a non-habit-forming sleep aid. Its use is limited to women for the most part though, because of a risk in priapism for men – an erection that will not go away. This seems like it might be fun but it is actually a medical emergency.
• Remeron: Another antidepressant used for sleep because it is so sedating, Remeron is pretty effective, but causes weight gain.
• Clonidine: This medication was primarily used for high blood pressure, but is quite sedating, is often used in children with ADHD, and is a good sleep aid that’s not habit forming. It can sometimes cause a drop in blood pressure or rebound high blood pressure. In high doses, it can cause liver problems.

What about melatonin?

Melatonin is a natural hormone, released by the brain when it gets dark. It is available over the counter. It is an effective sleep aid and is well studied even in children. The safety profile is quite good. Doses range from 1-5 mg per night, and it comes in pills and spray forms.

Common Possible Side Effects

All medications have side effects. Prior to taking any prescription or over-the-counter sleep aid, consult your doctor let her know all the medications you are currently taking, including over-the-counter medications and “all natural” or herbal remedies. In addition, be aware that any sleep aid can cause drowsiness, so avoid driving or operating machinery while taking these medications, especially when you first start taking them and are unsure of the effect they may have on you. Additional side effects may include the following:

• Dizziness
• Allergic reaction, possibly severe
• Facial swelling
• Headache
• Prolonged drowsiness (especially the sleep aids designed to help you stay asleep)
• Sleep behaviors, such as sleep-driving and sleep-eating or a combination of the two, like if you sleep drive to McDonald’s

Sleep Aids in My Practice

I recommend or provide sleep aids frequently, because sleep problems are so commonly associated with mood disorders and other psychiatric conditions. I encourage people to practice good “sleep hygiene” as a primary intervention:

• Regular bed time and wake up times
• No stimulants after 12 noon
• No vigorous exercise in the evening
• Turn off screens and phones and work one hour before bedtime
• Try to keep the bed for only sleeping and sex – no work or other activities
• No TV in the bedroom… it’s bad for sleep

If we do need to use a sleep aid, I will often start with melatonin before proceeding to prescription interventions. We try hard to use medications for brief periods of time. Getting enough sleep is important in recovery from mood disorders, so treating aggressively is important.

If you have bipolar and accompanying sleep-related issues, please share your experiences and insights and any helpful suggestions. This goes for you doctors and therapists out there, too!

Sitting: Peter Smole and Roman Peklaj and Maja Valic; Standing: Joe Kraynak, Darja Budja, Cecie Kraynak, Emi Kladnik, Ana Sorc, and Katja Jus

Cecie and I were invited to visit Ljubljana (lyoo-blee-ah-nah), Slovenia for the release of the Slovene edition of Bipolar Disorder for Dummies. We accepted and have been in Slovenia since this past Thursday, 10/8/2009. We flew into Venice on Thursday to meet our gracious hosts, Darja Budja (“j” is pronounced “y”) and her husband Simon Perko. Darja translated the book into Slovene and is a devoted bipolar advocate. She has created her own bipolar blog (bipolarna.si) and is one of the organizers of an active bipolar support group in Ljubljana.

Darja informed me that Bipolar Disorder For Dummies is one of the only books on bipolar to be translated into Slovene – the other two being children’s books – hence all the hoopla surrounding the release of our book.

Thursday evening, Cecie and I met with Darja’s support group to present the book, share our experiences with bipolar, and discuss various bipolar-related topics. A high percentage of the Slovene population speaks English, so we had no huge communication barrier. Many of the group’s members are accomplished professionals and all were very articulate with an excellent sense of humor. During the meeting and afterwards, we shared plenty of laughs.

A couple highlights from our meeting included the following:

• Dr. Mojca (moy-tsah) was in attendance. I had heard much about her (all good). Several of her patients were in attendance and all sung her praises. She stressed the need for sleep and informed us that she provided her patients with medication and instructions on how to use it effectively to enable them to more effectively manage their own sleep issues. We found this surprising. Our experience is that doctors in the U.S. seem reluctant to prescribe sleep medication out of fear of the patient developing a dependency. Dr. Moyza said she preferred using Klonopin (clonazepam), an anxiolytic, to help with sleep, because she found it to carry less of a risk of dependency. Specifically, she said that at high doses, it causes the tongue to swell, which is generally enough to convince patients to back off on the dose.
• When relating our experiences with bipolar, I described the illness as a monster that could create all sorts of chaos and meanness in a family and that it’s the monster that causes all the trouble, not any of the individuals involved. Everyone seemed to relate well to that. One member joked that his monster was now a little kitty, but he was always aware it was still there and could turn into a lion at any time.
• The members also seemed to welcome the message that although chaining up the monster is important, we needed to be careful about locking our dreams away. I pointed out that I found most people with bipolar to be highly intelligent and talented, and with bipolar, we need to be careful about letting it become our lives rather than simply a part of our lives.
• We discussed the stigma of bipolar disorder (and mental illness in general). I pointed out that we still have a problem with this in the U.S. but I thought it was improving due to efforts in the community to educate the public. One member pointed out that he has noticed more movies and television shows coming out of the U.S. about mental illness or with characters having a mental illness, and he saw this as a positive sign. The consensus, however, was that in Slovenia, the stigma was still rampant.
• Dr. Mojca pointed out that because Slovenia is a smaller country, it is easier for them to get things done, especially in terms of passing legislation to help with mental illness. Organizing efforts in Slovenia may be a little easier than in the U.S. and may have more of an impact.

On Saturday, we traveled to Koper, on the coast of Slovenia (Adriatic Sea) to present Bipolar Disorder For Dummies at a conference on the state of psychiatry. The conference began with a roundtable discussion (in which I did not participate) followed by the book presentation, which was relatively brief. Attendees seemed to be a bit worn out by the end of the roundtable discussion, so having a brief book presentation was probably a good thing.

Today, we will hang out. Tomorrow (Monday) we are doing another book presentation in Ljubljana. Later in the week, we may have an opportunity to appear on local or national television to discuss bipolar. We sincerely hope that the book will help our new friends in Slovenia and contribute in some small way to reduce the stigma surrounding this illness.

I would like to thank Darja Budja for organizing this trip and pulling everything together to make it possible, her husband Simon for patiently attending to all our needs, and his parents for giving us a place to stay. Thanks also to the DAM Society, Zalozba Pasadena, and AstraZeneca for their efforts in publishing the book and their financial support of this trip. Thanks also to my mother-in-law, Jo Howard and my parents, John and Adeline Kraynak, for their contributions; PsychCentral’s John Grohol for pledging his support; and all the wonderful people of Slovenia we have met who have been so hospitable and generous.

Medications in this group work differently from SSRI’s (including Prozac and Paxil), SSNRI’s (including Effexor and Cymbalta), and Wellbutrin. While tricyclics have fallen out of favor since the introduction of the newer generation of antidepressants, they remain effective and may be useful alternatives in some cases.

Tricyclic Antidepressants

Tricyclics (so called due to a three-ring chemical structure) inhibit the re-absorption (reuptake) of serotonin, norepinephrine, and (to a lesser extent) dopamine, increasing their availability to brain cells. Tricyclics include the following medications:

• Amitriptyline
• Amoxapine
• Desipramine (Norpramin)
• Doxepin (Sinequan)
• Imipramine (Tofranil, Tofranil-PM)
• Nortriptyline (Pamelor)
• Protriptyline (Vivactil)
• Trimipramine (Surmontil)

Tricyclic antidepressants are effective agents for treating depression and many types of anxiety disorders. However, in individuals with bipolar disorder, tricyclics present a risk of manic switching – quite possibly a higher risk than with more recent agents such as SSRI’s. The tricyclics also have some “niche” uses, including treating insomnia, migraine headaches and some chronic pain syndromes, bedwetting, and ADHD.

Potential Side Effects

Tricyclics also affect a number of other brain chemicals, such as histamine, possibly causing many of the side effects attributed to this class of antidepressants, including (in some cases)…

• Manic switching
• Agitation and suicidal ideation
• Drowsiness
• Dry mouth
• Blurred vision
• Constipation
• Urinary retention
• Dizziness
• Impaired sexual functioning
• Increased heart rate
• Disorientation or confusion
• Headache
• Low blood pressure
• Sensitivity to sunlight
• Increased appetite
• Weight gain
• Nausea
• Weakness

Because of this somewhat overwhelming side-effect profile, doctors typically try tricyclics only when other antidepressants, such as Prozac and Cymbalta, are ineffective or not well tolerated.

Important: Tricyclics are generally contraindicated for people with untreated narrow-angle glaucoma, enlarged prostate, or certain types of heart disease (due to a higher risk of heart attack), or heart-rhythm abnormalities. Tricyclics can also affect blood sugar levels, so if you have diabetes, your doctor may instruct you to check your blood sugar levels more often. If you have a history of seizures or thyroid problems, use tricyclics cautiously, if at all.

Tricyclics in My Practice

When I was training in psychiatry, tricyclics were still the most widely used antidepressants, as the SSRI family of medicines was just starting to appear in the US. They were effective and often well tolerated but could have many side effects. People often felt a little druggy and sedated on them, at least for a while. In my current practice, I rarely use tricyclics unless other options have been ineffective or not tolerated. I have a few people on them who benefit from the medication making them feel sleepy. A few of my patients take low doses specifically for sleep.

In the 70′s and 80′s tricyclics were popular alternatives to stimulants for treating ADHD in children. But after a number of reports of sudden death in children on tricyclics, these medications rapidly fell out of favor and are almost never used in children anymore.

A few people I work with are on low dose tricyclics to treat migraine headaches – the neurologists will sometimes use these medicines for headache and other pain-management situations.

Remember: Any antidepressant can take 2-3 weeks or even longer to become fully effective, and it may take several weeks to work up to a therapeutic dose, so your depression may not lift for several weeks. Patience is key. Give the medication a few weeks to become effective and give your body a few weeks to adjust to it. Any negative side effects you experience are likely to fade over time.
Schedule an appointment to follow up with your doctor 3-4 weeks after you start taking the medication, but don’t hesitate to call earlier if you’re concerned about the medication’s effectiveness or any side effects you may be experiencing.

If you’ve taken any tricyclics for bipolar depression or other conditions or are a doctor who has prescribed any of the antidepressants in this class, please share your experiences, insights, and observations.

Just about everyone living with bipolar disorder knows the importance of establishing a regular sleep routine to help maintain mood stability. But this study suggests that establishing such a routine may be more challenging for those with bipolar disorder than for those without the condition.

If you have bipolar disorder, would you consider yourself a night owl or an early bird? Do you feel as though your biological clock is in sync or out of sync with the rest of the world around you? If you feel it is out of sync, what do you do, if anything, to cope or perhaps even take advantage of the situation?

In Bipolar Disorder for Dummies, we offer several recommendations for getting to sleep and getting enough sleep, but not too much. We recommend setting (and sticking to) a sleep routine, winding down with pre-bedtime rituals, laying off the caffeine, getting your family (or roommates) to cooperate, teaming up with your doctor, and so on.

My wife and I have a great bedroom that’s terrible for sleeping. If it had any more windows or skylights, it would officially qualify as a greenhouse. Even worse, it has no door. The only thing setting it off from the rest of the house is a flight of stairs. My wife usually runs a fan to create some white noise so she can sleep; otherwise, if someone happens to be watching late-night TV in the living room, she can forget about sleeping. (On the other hand, I can sleep through just about anything.)

If sleep is an issue in helping you maintain mood stability, please share your experiences, insights, and suggestions. What challenges do you face in getting to sleep, staying asleep, or waking up in the morning? How have you addressed these challenges? What suggestions, if any, do you have to offer other visitors to the Bipolar Beat? (Working a split shift can really make you toss and turn. If you work a split shift, has it posed a problem? What have you tried to do to deal with it?)

What really got to me this time around is just how messed up the system is for dealing with bipolar (and probably other mental illnesses). We knew what was going on. My wife knew what helped her sleep in the past – temazepam, and still she’s teetering on the edge of full blown mania because the system is so irresponsive. The doctor refuses to prescribe temazepam because he’s afraid she’ll develop a dependency. The insurance company denies coverage for Ambien CR, because it’s too expensive. The doctor prescribes Lunesta, instead, which helps my wife sleep 4-5 hours but has her waking up WIRED. And all the time, the bipolar is raging out of control.

My wife calls it frustrating. I call it stupid and irresponsible. It would be like firefighters showing up at your house to put out a small kitchen fire and then arguing about how to proceed as the house burns down.