Ideas on Improving the Quality of Sleep?
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Q:  Ideas on Improving the Quality of Sleep?

Dr. Phelps,

I'm having a lot of issues with sleep quality.  I have BPII, and it is relatively mild for me (based on the hundred or so folks I've met in a support group).

My issue is this: the quality of my sleep is poor.  I often wake up around 2 or 3 am (I go to bed regularly at 10 pm).

I have very vivid dreams (sometimes scary, sometimes not), which occasionaly give me that waking sleep feeling (I'm asleep, but feels like I'm awake).  The dreams feel very real, and continue once I'm back to sleep.

I discontinued wellbutrin about 6-8 weeks ago, and the doc incr eased my lamictal (was at 200 mg, now at 400 mg).

I'm not having any depression, and don't seem to be having hypomania nearly as much (used to take a lot more Xanax XR, but that need decreased a lot after going off the wellbutrin).  I have hypnotics (ambien and lunesta - the lunesta doesn't work that great for me, but ambien does), which I'm using less than before (I can usually get back to sleep now, but the dreams start all over again).

And I often have music in my head that doesn't stop when I awake during the bad nights,and continues once back asleep.

Any ideas on why I can try to improve the quality of sleep? - it leaves me worn out the next day (but the hypomania is much less)

Signed:  Poor Sleep in Seattle

Dear SeattleSleeper -- 
Sometimes poor sleep, quite like the pattern you describe, is part of the bipolar problem (and, sometimes is is not; for example, people with rough childhoods or exposure to life-threatening situations can have a degree of alertness that causes sleep problems like this). If it's part of the bipolar problem, then it is often accompanied by other signs that the bipolar problem is not fully controlled: usually some evidence of cycling of mood and energy, even though that can be pretty subtle.  And thus my usual response to the sleep problem, especially when it is clear that there are other signs of bipolar symptoms not yet fully controlled, is to increase the mood stabilizer a bit more -- rather like your doctor has done, except that (as she would likely agree) Lamictal is not the greatest anti-manic-symptom agent out there. It is good against cycling, though, so over time this step might be enough. 

Perhaps even more powerful is the tapering off Wellbutrin you recently finished.  That alone might be enough to lead to improved sleep, although I would have expected you'd be seeing the full benefits of that step right about now (6-8 weeks out).  

So, if those two steps don't do it, you'd first want to make sure you've optimized your exercise program and timing; and looked for a cognitive/behavioral therapy program that could teach you "mindfulness" (not all CBT therapists have this newer emphasis) and breathing-based relaxation techniques; and then consider a small addition of a mood stabilizer known to help sleep. Quetiapine is famous for this but has some notable side effect risks that make this a non-trivial step (possible weight gain, glucose increases, cholesterol increases -- and once in a while it seems to have the opposite effect, increasing energy, though I think that frequency must be less than 1/100). Very low-dose lithium can also do this, perhaps with lower risk (watch thyroid though). And Depakote probably deserves to be on that list too, especially for a guy (in women I think it's more complicated), but the well-known interaction with lamotrigine (Lamictal) makes that a more complicated thing to add in your case. These are all just ideas to discuss with your doctor, who I suspect has already been thinking along these lines).  Good luck with all that. 

Dr. Phelps

Published October, 2005


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