Q:  Feeling Very Flat & Exhausted:  Natural Remedies & Acute Insomnia

Dear doctor Phelps,

I was diagnosed with BP-II a few years ago; I tried various meds including Valproate, Seroquel, and Serzone but could not stay on any on them due to adverse side-effects and total emotional numbness (I am a professional artist and I found it impossible to work and take meds in the same time). I am trying to keep myself sane by doing yoga, eating healthy food, and cutting off all sugars in my diet. 

My question is: could you give me an advice how to manage depressions which manifest themselves as 1-2 weeks periods of very flat mood combined with profound  exhaustion?  The problem is that during such times I am unable to do anything at all. I am not desperate but VERY, VERY flat, slightly sad, exhausted without a reason, and
completely oblivious to the world (this 'flat depressions' are new to me. Until recently my 'usual depressions' were very dark but not as disabling as these 'new').

And one more question: do you know any herbal or 'natural' remedies other than Valerian and Melatonin which could help with acute insomnia during hypomanic
periods?

Regards,
Anna
 

Dear Ms. Anna -- 
Noting that you describe both depression phases and also hypomanic periods, we can probably safely conclude you're still having mood "cycling": that is, still having cyclic changes in mood and energy.  If so, then one of my favorite approaches is to focus on the cycling, not the depressions (Part 1 of your question) or the hypomania (Part II of your question). For that, you can use any mood stabilizer -- which leaves you free to look for one that does not have this flat/exhausted effect. Here's a list of mood stabilizers, tabulated by evidence of effectiveness: sort of like a menu. You've already had quite a few, perhaps most, but one way to sort among them is to look for those which also have antidepressant effects, since it sounds like that's your dominant symptom. 

I hope this logic makes sense: target the cycling (because targeting the depression can lead to an antidepressant which can lead to continued cycling) but look for the tools which also have as much antidepressant clout as you can get without an antidepressant per se. See this list of eight such tools (some not sufficient by themselves but useful to take the pressure off the medication choices). You'll note that omega-3 fatty acids are on there, and there is a recent study suggesting that they really do work in this "antidepressant" role in bipolar disorder (as you'll see discussed on my fish oil page). 

As for a non-pharmacologic approach to sleep, there is a great one -- but it is not what you think. For people who have difficulty sleeping due to cycling, particularly rapid cycling bipolar disorder, there is one very important non-pharmacologic approach to know about. In fact, nearly everyone in that situation should be using it, or some version of it. And it doesn't cost money; and it doesn't have any risks. Wow, sounds pretty good right? Okay, now for the really hard part: you have to give up being a night owl even when you're not hypomanic. It's been called "dark therapy" and is described on my website; I'll give you the link in a second. This approach has not been widely tested; usually something with this little evidence for benefit wouldn't even be on my map. But because it has no cost or risk and is within reach for nearly everyone, I think it's worth knowing about.  You just have to get in the dark much earlier than you probably do now, and stay there -- for what at first will seem like a long time.  Make sure you discuss this whole thing with your doctor and make sure she/he is okay with the idea. Here's the link for more on Dark Therapy. 

And finally, to actually answer your question: well, there's tryptophan, sort of. In the United States this is still unavailable as a prescription medication (we used it for a few years back around the mid-1990's for a sleep medication. As you probably know, tryptophan is a regular old amino acid, a regular dietary feature. It's also the molecule from which serotonin is built (a mere two-step conversion, in fact); and serotonin is clearly involved somehow in regulating sleep. But the prescription tryptophan caused a nasty reaction in several people called "eosinophilic myalgia", an allergic reaction of sorts. Later it was thought that this came from a compound in the pill, but not from the tryptophan itself; and yet the last time I looked, about a year ago, the United States Food and Drug Administration (FDA) was still concerned that the eosinophilic myalgia might have been from the tryptophan itself so they still haven't allowed it to be released for use in a different pill formulation). However, I understand that people can somehow get it over the internet (what can't you get?) from Canada, where it's apparently routinely used as far as I can tell, and elsewhere. That doesn't mean the FDA is wrong about their safety concerns, of course. Rather complicated story, isn't it? 

Dr. Phelps

Published March, 2006