Bipolar Disorder, Insomnia and Suicide
For many years now, I have advised on the treatment of many well-known people with all sorts of problems and illnesses. I always admire people who reveal that they have suffered from a problem in the hope of helping other sufferers.
The actor Stephen Fry has recently described his struggles with bipolar disorder and why he suddenly abandoned a play in London after developing stage fright. You may have seen him playing Jeeves to Hugh Laurie’s Wooster, or in the Blackadder shows.
Stephen was once described as a man with a “Brain the size of Kent.” He said that he became so knowledgeable because of terrible insomnia, which kept him up nights: he used the time to read enormous numbers of books. He also described a suicide attempt and a very serious plan to kill himself.
Though I’ve not examined Stephen, I can now explain several things to you:
1. Bipolar disorder is not uncommon, and is rather more common in highly creative people. That being said, we must not romanticize an illness that carries a substantial mortality. The illness is frequently misdiagnosed, and when it is, there is an ever-present risk of suicide, as well as a host of other medical problems.
2. Anxiety disorders occur in 80-90% of people struggling with bipolar disorder, and stage fright is one of these anxiety states
3. Stephen may not have had insomnia as much as a reduced need for sleep, which is a classic symptom of one type of bipolar disorder. People with insomnia cannot sleep and usually go through the day feeling un-rested. People with a reduced need for sleep not only stay awake, but don’t get tired until they have been up for days at a time. Doing something like reading lots of books at night is another classic symptom.
Stephen Fry has just made a documentary for the BBC in which he talks about bipolar disorder with Carrie Fisher, Richard Dreyfuss and Robbie Williams.
They all deserve our gratitude for speaking out, telling their stories, and hopefully helping alleviate some of the stigma of mental illness, and helping more people get the diagnosis and treatment that they need.
Thank you Stephen!
P.S. There has recently been a rumor going round that your humble reporter was the model for Hugh Laurie’s Golden Globe award-winning portrayal of Dr. Gregory House. I don’t know where it started, but there’s absolutely no truth in this vile calumny. I’m never irritable or curmudgeonly…
Technorati tags: Stephen Fry Bipolar disorder Stigma Hugh Laurie Blackadder Gregory House
Sleep, Weight, Insulin Resistance and Diabetes
I am often asked why there seem to be such close links between food and mood. Not just comfort eating, or the sudden shock of lots of carbs when we need an energy jolt, but why drugs that alter mood so often alter appetite?
You will probably not know this, gentle reader, but I only learned of it from reading scholarly papers. Apparently many people report that using marijuana makes them very hungry. On the other hand, cocaine and amphetamine affect not just the metabolism, but also appetite. The link has to do with the evolutionary development of feeding behaviors with the motivation to find food and to be satisfied by it.
Another link that has interested me for many years is the connection between metabolism and sleep. We have always presumed that this link has to do with hibernation: even humans have maintained some hibernation responses.
There is extremely good evidence that there is an inverse relationship between the number of hours that you sleep and an increase in your weight. There have been a great many studies on this, but one of the best was published by a group of researchers from the Mood and Anxiety Disorders Program, at the National Institute of Mental Health, the Psychiatric University Hospital, Zurich, Switzerland; University of Pittsburgh School of Medicine and the Department of Psychosocial Medicine, Zürich University Hospital, Switzerland in the Journal Sleep in 2004.
A report from the BBC concerning a study presented to the American Thoracic Society International Conference in San Diego provides yet more evidence of this link between sleep and weight. Researchers from Case Western Reserve University in Ohio, followed nearly 70,000 women for 16 years. They found that women who slept five or fewer hours a night were a third more likely to put on at least 33lbs (15kg) than sound sleepers during that time. It also found that compared with women who slept for seven hours a night. lighter sleepers were 15% more likely to become obese (have a Body Mass Index (BMI) of 30 or more. {BMI is calculated by dividing your weight in kilograms by the square of your height in meters}).
Previous studies, some of which I have reported before, have shown that after just a few days of sleep restriction, the hormones that control appetite cause people to become hungrier. However the women in the study appeared to eat less. I say “appeared to,” since the use of personal evaluations of food intake are notoriously inaccurate.
In dozens of countries arond the world, I am regarded as an authority in the fields of endocrinology, metabolism and nutrition. But when a group of us tried to estimate our daily intake and compare it with meticulous diaries, we discovered that we – a group of internationally renowned experts – were off by around 500 calories per day.
All kinds of explanations have been advanced, from people who didn’t sleep getting up and binge eating; to the effects of sleep-deprived people craving high carbohydrate, high fat food; to insomnia being a result of anxiety or depression that releases hormones that cause us to lay down fat in our tummies.
For all kinds of complex biochemical reasons, I have always felt that a lack of sleep would lead to an increase in insulin resistance, that may cause an increase in the deposition of fat in key regions of the body.
Some new research suggests that I may have been right on this one. A group based at Yale University School of Medicine, in New Haven, Connecticut has just published a report that should be of interest to all of us, and in particular you multi-tasking insomniacs out there.
The investigators studied a cohort of men from the Massachusetts Male Aging Study who did not have diabetes at baseline (1987–1989) and who were followed until 2004 to look for the development of diabetes mellitus. They came to the conclusion that BOTH very short and extra long sleep durations increase the risk of developing diabetes, independent of confounding factors.
The take home message?
If you do not get 7-8 hours sleep each night, you are vulnerable to a great many problems, and perhaps the biggest of all is the risk of weight gain, insulin resistance and diabetes mellitus.
I do not recommend using sleeping tablets unless absolutely necessary, and then for just a few days at a time. Instead follow all the sleep strategies that I have talked about in earlier blog entries.
During a recent visit to Danville, Virginia, I was delighted to learn that one of the non-pharmacological approaches that I have found helpful – putting a cold compress on the abdomen – was used by General Stonewall Jackson who used this very technique that I had to learn by going all the way to China.
The bottom line? Before your sleep gets disrupted by being overweight and you develop sleep apnea, try some simple sleep hygiene, and a few of these novel techniques.
Technorati tags: Insulin Insulin resistance Insulin resistance syndrome insomnia alternative medicine resilience
Modafinil and ADD
The Washington Post has just reported that the FDA has turned an application from the Pharmaceutical Company Cephalon to have modafinil approved for use in children with ADD, because of worries about a potentially serious skin reaction called Stevens-Johnson syndrome .
This is a real shame: we need more options for treating children and adults with ADD, and although I am a huge proponent of non-pharmacological methods of treatment, the fact is that a lot of people simply do not respond to the methods that we currently have available, and some do not even respond to the medications that are available.
Modafinil had looked very promising: in December 1998 the FDA approved modafinil under the brand name Provigil for treating adults with sleepiness associated with narcolepsy. Its main mechanism of action is to inhibit the reuptake of dopamine in key regions of the brain, effectively increasing the amount of dopamine available. It has been used off-label for excessive daytime sleepiness and last year a study form the University of Pennsylvania indicated that it might help some cocaine addicts fight their cravings. It is an open secret that a great many students and academics have been using it for years to enable them to study and work longer. I remember an article from someone who was due to lecture in India, immediately after his arrival from the United States. He admitted to taking modafinil to help him get through the ordeal.
The application to use modafinil in ADD is not dead. The FDA has said that they want a 3000 patients study to assess the risk of Stevens-Johnson syndrome, and the company will discuss that with them. But it will inevitably mean delays.
Some Suggestions for Dealing with Insomnia
“I seem not to have the shut down switch in my brain.” She is worried about taking medications, and wonders if there is anything else that she can do to help herself.
It is always unwise to make specific recommendations about someone without seeing them face-to-face, and the evaluation of a problem like this will normally take several hours. But the points that she raises have a great deal of relevance for so many people that I thought that a few comments would be helpful and equip everyone reading this with some information to discuss with their healthcare providers.
As usual, I think that it is a good idea to look at the question from the multiple dimensions of physical, psychological, social, subtle and spiritual. They are all inter-related, so dividing them up is simply a convenient way to help us think through the problem.
Before we do anything, we have to try and find out why someone has problems with sleep, and that may need investigations up to and including a sleep study.
The first thing is that my correspondent is female and likely either menopausal or perimenopausal. That is important, because as most women know, hormones have potent effects on sleep. It is not just that uncomfortable hot flashes can wake a person; it is also a direct effect of estrogen and probably of some of the releasing hormones in the hypothalamus. Hormone replacement therapy alone, does help some women but by no means all. Even at the physical level we see the general principle that there is rarely one cause for one problem. Typical menopausal sleep disturbances include a difficulty in falling asleep, and around 20% of menopausal women report that they sleep less than six hours a night. There is also some degradation in what we call sleep efficacy and an increase in deep slow wave sleep. Estrogen has effects on nasal mucosa, and when estrogen levels fall obstructive sleep apnea is more likely to occur. A major physical and psychological issue is that insomnia may become a learned habit that can persist even in the face of the best treatments.
This leads me to the second dimension, and that is psychological. The writer of the letter mentioned that she couldn’t turn off her thoughts. You would be amazed at how frequently I have been asked to consult on someone with a sleep problem and the individual has never been asked the question, “What is it that stops you falling asleep?” I have seen countless people prescribed sleeping tablets, when the real problem was anxiety or some other nasty problem that needed to be tackled first. In a moment I am going to make some suggestions that will try and help with both sleep and the ruminations and anxieties that may be contributing to its disturbance. Similarly, I have known a great many people whose sleep problems were the result of relationship difficulties or of something as simple as one person being a night owl and the other an early morning riser.
I always start with some simple sleep hygiene:
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Stress management
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Exercise a couple of hours before retiring
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Keeping mentally stimulated until it is time for bed
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Don’t go to bed until you are tired
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No caffeine, alcohol or nicotine after 6pm. (Preferably, of course, no nicotine ever!!) {Remember that many over the counter painkillers contain caffeine, as does chocolate}
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There are some specific dietary recommendations for helping with sleep, and I shall write about those on a future occasion
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Try to keep the bedroom atmosphere relaxing, and establish a sleep ritual
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If you cannot sleep, get up and do something relaxing: struggling to go to sleep is virtually impossible.
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Always get up at the same time in the morning, to try and re-set your brain, and as soon as you get up, be exposed to as much bright light as possible.
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Start by lying on your left side for 5-10 minutes and then roll onto your right side. This appears to work by exploiting the so-called nasal cycle, which I shall write more about on a future occasion.
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Still on the subject of the nose, one of the reasons that aromatherapy can be helpful, is because smell is unique amongst our senses, in that it is the only one that is not filtered by the thalamus. The regions of the brain that respond to smells are also directly related to some of the memory centers. The result is that smells can evoke memories extremely rapidly. You will probably have had the experience of smelling a perfume or cologne and instantly remembering someone who wore it in the past. This close linkage of smell and memory has enormous survival advantages: the smell of a predator can cause us to respond extremely rapidly. We can also use this knowledge to our advantage. Lavender has been used as a sleep aid for centuries. You can try putting a few drops of lavender oil on a cloth on your night-stand. Or you can use an electric diffuser or aromatherapy lamp. When I was growing up, we grew lavender and would put sprigs of it in the bed linens. It certainly seemed to help.
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Some people have found that melatonin can be very helpful, and it is readily available. Discuss it with your health care provider.
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Here is an old trick from traditional Chinese medicine. If you cannot sleep, soak a washcloth in cold water, lie down and put it on your abdomen for about ten minutes. I was taught that this works by pulling excess energy out of your head and neck down into the abdomen. There’s not a shred of scientific evidence that the technique works, but it does surprisingly often.
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If people who are good at visualization, some have reported great success by creating a picture of a warm, calm and relaxing place. And not just a picture, but also a five senses experience. It has to be personal, and perhaps even a place to go back to on a regular basis. When I first learned to do hypnotherapy I was put into a light trance by one of my teachers. To this day, more than 25 years later I can still vividly recall the experience of being told that I was drowsing on a grassy knoll on a warm summer’s day on the Downs of Southern England, and actually feeling that I was there. I can still evoke the memory at will and I’ve made it more detailed over time. If you are a visualizer, try that.
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Another technique that I learned from an early teacher, is to review the day backwards. Remembering what you did immediately before going to bed, and before that and so on. A simpler and often effective technique is just to start slowly counting backwards from 100.
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Herbs: There are three that are widely used, and for which there is some research base. There is good evidence that the herb Valerian can induce drowsiness, and it is widely used – even by doctors – in France and Germany. An important point about valerian is that it is poorly absorbed and chemically and thermally unstable. So it needs to be kept cool, and used fairly soon after it is prepared. As with all herbs, Valerian has side effects and can interact with prescription medications and alcohol, so it really is essential to discuss its use with your health care provider. The same goes for the other two widely used herbs: Hops and Passionflower.
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There is some evidence, though it’s not that strong, that taking a combined calcium/magnesium supplement (500mg calcium and 250-500mg magnesium) an hour before bed helps some people.
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I recommend massaging your facial muscles before lying down to sleep. Not only does this reduce muscle tension, but also the face is covered in acupuncture points, and so that may be another reason why it can help.
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Do not read or watch television in bed, but listen to a little calming music before retiring.
I do hope that will help you in your discussions with your health care provider. And I am always interested in hearing other suggestions, particularly if there is some research to back them up.
Technorati tags: Insomnia, menopause, herbal medicine, sleep hygiene, insomnia remedies, women’s health
Sleep and Mood
The interaction between sleep and mood is fascinating, complex and supremely practical.
I have received a couple of queries and comments. Let me start with one from a physician:
“I have a question about sleep disorders. My patients seem to suffer from this even after their depression is better.”
This is an extremely interesting issue.
Every healthcare student has been taught about the sleep disturbances that may occur in association with mood disorders. The classic problems in depression are early morning wakening, difficulty in getting off to sleep and sometimes waking in the early hours. Some others will sleep for very long periods, and there has been speculation that this may be a form of hibernation behavior. People with abnormally elevated mood can often stay awake for days at a time. There is also the well-known problem of seasonal affective disorder, in which the long winter nights can cause depression. Fortunately the depression is often relieved by the use of a light box.
Many experts now consider that the disturbances of sleep are often the primary problem, which then cause depressed or elevated mood. This is actually not a new idea: one of the old fashioned treatments for depression was sleep deprivation and many of us who have worked all night have experienced the mildly manic symptoms of sleep deprivation. On early morning rounds at the hospital I commented that it was easy to tell if some of the residents had been working all night, even before they presented their reports. The giggling, high energy and disturbances in thought patterns were not at all what one sees when someone is tired.
It is not just the sleep deprivation, but also light. It is well known that people suffering with bipolar disorder are more likely to get manic episode in the spring and early summer, as the amount of ambient light increases. It is the converse of the seasonal affective disorder problem.
So what often happens is that antidepressant medications do indeed help with the depressed mood, but the underlying sleep problem takes much longer to correct itself. This is also one of the reasons why people who have seen their mood improve on treatment still have cognitive problems that can go on for months after the mood symptoms have been corrected. It is probably a combination of sleep deprivation and also the impact of corticosteroids that can rise in some sufferers causing transient damage to some key regions of the brain.
It would be nice if we could modulate people’s sleep/wake cycles and thereby treat the mood problems directly, but at the moment, despite the enormous advances in pharmacological treatments of sleep problems, we are still not able to do that reliably.
Technorati tags: Sleep, Mood, bipolar disorder, Depression,
Thinking and Sleep
There is an important article in a recent issue of the Journal of the American Medical Association (Effects of Sleep Inertia on Cognition Adam T. Wertz; Kenneth P. Wright Jr; Joseph M. Ronda; Charles A. Czeisler JAMA. 2006;295:163-164.)
The study by a team at the Brigham and Women’s Hospital in Boston and the University of Colorado examined the phenomenon of sleep inertia: how long it takes for someone to wake up and think effectively, and to compare that with thinking after a person has been awake for 24 hours. For most of the first three years after I graduated from medical school, I worked on what was then known as a “one in two” on-call roster: every other night and every other weekend. Fortunately that inhumane system was abandoned some years ago, but it was not uncommon to be up and working for three straight days at the weekends, and we all became absolute experts on sleep and how to handle sleep deprivation. The problem was that if we did manage to get a few minutes sleep, there was always the chance of being awoken and being asked immediately to perform important tasks that would require very high levels of thinking and analysis. The results of this new study will not be a surprise to anyone who has done night work, or anyone who has been out all night burning the candle at both ends.
The study participants had had six nights of monitored sleep lasting eight hours per night, they were given a performance test that involved adding randomly generated, two-digit numbers. Based on the results of this test, the researchers concluded the subjects exhibited the most severe impairments to their short-term memory, counting skills and cognitive abilities from sleep inertia within the first three minutes after awakening. The most severe effects of sleep inertia generally dissipated within the first 10 minutes, although its effects were often detectable for up to two hours.
The study follows other research that has looked at the effects of going without sleep for over 24 hours, and found that the cognitive impairments were roughly the same as being drunk. Yet in the Colorado experiments, the cognitive skills of test subjects were worse upon awakening than after extended sleep deprivation: In a nutshell, the effects of sleep inertia may be as bad as or worse than being legally drunk. The most likely explanation is that certain areas of the brain take longer to "wake up".
Previous research has shown that the prefrontal cortex, which is responsible for executive functions: planning, problem solving, complex thought and emotional control, is one of the brain regions that takes longer to come "on-line" following sleep.
What should be the conclusions from these studies?
1. Ideally, nobody should be doing anything really important for 15 to 30 minutes after they wake up.
2. If you are asleep, it’s a much bigger transition to go from that to being awake, rather than staying awake, even for a long time, because then you will be aware that you are drowsy.
3. The study did not examine emotion and motivation, and that may come in to play. If you are asleep in a hotel and the fire alarms go off, you may well be able to wake up and think very well and very quickly for a few minutes, but then you brain plays “catch-up,” and you will once again we groggy and cognitively impaired.
As a young doctor, there was no option: I had to wake up fast and be able to think straight. So I just did it, and fortunately the quality of my decisions seemed to be fine when older and wiser physicians checked them the next morning. Though I am VERY pleased not to have to work like that any more!
