Last week Dan wrote to Ask The Savvy Insomniac with questions about cognitive-behavioral therapy for insomnia (CBT-I). Dan has bipolar disorder, and because of this diagnosis, his sleep doctor had reservations about him undergoing CBT-I.
So Dan tried a modified version for 2 weeks. His sleep did not improve. The doctor decided that “the only way CBT would be effective is if medication [sleeping pills] were the mainstay of my treatment,” Dan wrote. “So my question is, have you heard anything of the sort?” Dan also wondered about continuing with CBT-I on his own.
Bipolar Disorder and Sleep
Bipolar disorder is a diagnosis given to people who routinely experience extreme emotional states. Manic episodes are characterized by overexcitement and hyperactivity; depressive episodes, by sadness and hopelessness. The mood swings are disruptive to work and family life. The main goal of treatment is mood stabilization, which can be achieved with medication.
People with bipolar disorder often experience insomnia. Even when they’re successfully treated for the mood swings, the sleep problem doesn’t necessarily go away. In fact, say researchers in a September 2013 article in Sleep Medicine Clinics, “During the inter-episode period, clinically significant sleep disturbance persists in up to 70% of BD [bipolar disorder] patients.”
Insomnia associated with bipolar disorder is often treated with non-benzodiazepine sleeping pills and gabapentin (Neurontin). The efficacy of medications targeting the circadian system—melatonin and ramelteon (Rozerem)—is under study now.
But CBT-I, a drug-free treatment for insomnia, may also be effective for people with bipolar disorder—in a modified form.
CBT-I for Bipolar Disorder: Why Not?
Sleep restriction therapy, a key component of CBT-I, involves short-term sleep deprivation. This sleep deprivation helps build up pressure to sleep at night and reset the body clock.
Yet in some people with bipolar disorder, sleep deprivation triggers manic symptoms the following day. So sleep restriction should not be used for everyone with bipolar disorder.
Another component of CBT-I is stimulus control therapy. Guidelines specify that
- you wait to go to bed until you feel sleepy
- if after 15 to 20 minutes you can’t sleep, you leave the bedroom and do something quiet until you feel sleepy.
These instructions may be counterproductive for people with bipolar disorder, who often have trouble pulling away from arousing activities. Waiting to go to bed until they feel sleepy and getting out of bed in the middle of the night may arouse rather than calm them down.
Despite these caveats, UC Berkeley researchers Katherine A. Kaplan and Allison G. Harvey administered a modified version of CBT-I to 15 bipolar patients. The 8-week treatment was successful, with the majority of patients experiencing sleep improvement by the second week.
CBT-I Modified for Bipolar Disorder
While some insomnia sufferers can follow instructions and treat themselves, if you’re bipolar and want to try CBT-I, it’s better to work with a therapist who can tailor the treatment to your individual needs. Here’s what will likely be involved, say Kaplan and Harvey:
- You’ll keep a sleep diary throughout treatment.
- You should look out for symptoms of depression or mania. If you feel a mood swing coming on, your therapy may need to be modified or temporarily stopped.
- Rather than plunging headlong into sleep restriction, you’ll start by simply regularizing your hours in bed. Pick an average bedtime and a wake up time and observe them every day, including on weekends. This will involve setting an alarm clock to wake you up in the morning, and possibly setting it again in the evening to remind you of when to start winding down. Start your wind-down routine—take your shower, put on your pajamas, do relaxation exercises—an hour before bedtime.
- After 1 or 2 weeks, you’ll calculate your sleep efficiency.* If it’s 85%–90%, all you need to do to keep your sleep on track is continue with the same sleep schedule.
- If your sleep efficiency falls below 85%, your therapist may recommend sleep restriction. However, because mild sleep deprivation could trigger a manic episode, the authors of the Sleep Medicine Clinics paper have written that “Minimum time in bed during sleep restriction should likely be no lower than 6.5 hours.”
- Your therapist may also ask that you refrain from going to bed until you’re sleepy and observe the 15- to 20-minute rule (see above). But if doing these things is overstimulating or arouses intense anxiety, these aspects of therapy may need to be revised or simply dropped.
A clinical trial is under way in Norway to see if CBT-I improves the sleep quality and helps stabilize the mood of participants with bipolar disorder and insomnia. The results will help clarify for whom and in what situations it’s likely to work. For now, the answer to whether insomnia in bipolar disorder can be successfully treated with CBT-I is “maybe.”
* Calculate your sleep efficiency (SE) at the end of each week. SE = total sleep time ÷ planned sleep time X 100.
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