From the Guidelines
Treatment for bipolar disorder with significant sleep disturbances should prioritize a combination of mood stabilizers and targeted sleep interventions, with a focus on cognitive behavioral therapy for insomnia (CBT-I) and sleep hygiene measures, as supported by the American College of Physicians guideline 1. The goal is to improve sleep quality and alleviate distress or dysfunction caused by the disorder, while also addressing the underlying mood disorder. Key interventions include:
- Mood stabilizers such as lithium (600-1200 mg/day), valproate (750-1500 mg/day), or second-generation antipsychotics like quetiapine (300-800 mg/day) or olanzapine (5-20 mg/day) to stabilize mood.
- Targeted sleep interventions, including low-dose quetiapine (25-100 mg at bedtime) or trazodone (25-100 mg at bedtime), and in some cases, short-term use of benzodiazepines like lorazepam (0.5-2 mg) or non-benzodiazepine hypnotics like zolpidem (5-10 mg), as recommended by the American Academy of Sleep Medicine 1.
- Sleep hygiene measures, including maintaining consistent sleep-wake times, avoiding caffeine after noon, limiting screen time before bed, and creating a comfortable sleep environment.
- Cognitive behavioral therapy for insomnia (CBT-I) to provide additional benefit, as it is a multimodal cognitive behavioral therapy targeted specifically to insomnia, consisting of a combination of cognitive therapy, behavioral interventions, and educational interventions 1. Regular monitoring of medication effects and side effects is crucial, as is adjusting treatment based on the specific phase of bipolar disorder (manic, depressive, or mixed), and considering the recommendations from the clinical guideline for the evaluation and management of chronic insomnia in adults 1.
From the Research
Treatment Options for Sleep Disturbances in Bipolar Disorder
- Sleep problems are highly prevalent in bipolar disorder and can be highly impairing and distressing, making them an important therapeutic focus 2.
- The treatment of sleep disturbances in bipolar disorder may include medication approaches, psychological interventions, light therapies, and sleep deprivation 3.
- Established and emerging treatments for various sleep disturbances are available, with emphasis on applications for light therapy and adapted cognitive behavioral therapy 4.
- Cognitive-behavioral intervention strategies can be effectively and appropriately applied by clinical psychologists and psychotherapists to address sleep problems in bipolar disorder 2.
Importance of Addressing Sleep Disturbances
- Sleep disturbances can exert a negative impact on overall course, quality of life, and treatment outcomes in bipolar disorder 5.
- The presence of sleep disturbance is associated with functional impairment and may attenuate response to treatment 4.
- Sleep deprivation can trigger manic relapse and have an adverse impact on emotion regulation 3.
Available Therapies
- Light therapy and adapted cognitive behavioral therapy are emerging treatments for sleep disturbances in bipolar disorder 4.
- Mood stabilizers, such as lithium, valproate, and lamotrigine, are commonly used in the treatment of bipolar disorder, but may not directly address sleep disturbances 6.
- Antipsychotic agents, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine, may be used in the treatment of bipolar disorder, but some are associated with weight gain 6.