Insomnia in Bipolar Disorder: Treatment Options

Sleep problems are one of the most common side effects of bipolar disorder.

During manic episodes, less sleep is seemingly needed, which essentially ruins any semblance of a sleep schedule (1).

And during depressive episodes, almost all subjects in a study experienced either insomnia (too little sleep) or hypersomnia (too much sleep) (2).

Having low quality sleep over a long timespan leads to serious health risks, and amplifies the side effects of bipolar disorder.

What Causes Insomnia in Bipolar Disorder?

In a study of euthymic (stable mood state) patients with bipolar disorder, it was found that 70% of patients had a clinically significant sleep disturbance (3).

When comparing the patients who did have sleep issues to those who didn’t, the patients with sleep problems had:

• Higher levels of anxiety about poor sleep
• Lower daytime activity levels
• A tendency to misperceive sleep (amount and quality)

These are risk factors for insomnia in the general population as well, where sleep issues aren’t quite as common.

It's interesting to note that lithium doesn't significantly affect insomnia, as it's a common treatment method. In other words, whatever is causing sleep trouble needs to be targeted specifically, not just the bipolar disorder symptoms.

Treating Insomnia in Bipolar Disorder

In addition to sleeping better, treating sleep disturbances in bipolar disorder can also lead to improved mood and behavior overall (4).

There is still a lot of research ongoing about this topic, as there’s no single treatment method that is always the best.

Nevertheless, let’s look through some of the most commonly researched and prescribed treatment methods for insomnia in bipolar disorder.

Cognitive Behavioral Therapy for Insomnia (CBT-i)

CBT-i combines both sleep hygiene education and talk therapy to examine problematic thoughts that lead to anxiety (which then lead to sleep problems). It is by far the most effective insomnia treatment in general, not just for people with bipolar disorder.

In addition to regular sleep hygiene improvements, research suggests that adding extra emphasis on regular bedtimes and rise times can be effective (5).

One study compared CBT-i to psychoeducation (PE) (6). PE involves educating patients and their support about their conditions to better manage it. While PE does improve sleep quality, CBT-i was far more effective:

During the 6-month follow-up, the CBT-i group had fewer days in a bipolar episode relative to the PE group (3.3 days vs. 25.5 days)...and a marginally lower overall mood episode relapse rate (13.6% vs. 42.1%)

The CBT-i treatment not only improved insomnia symptoms significantly, but also improved overall mood and quality of life in the subjects.

SummaryWhile psychoeducation is a useful part of a treatment plan, CBT-i is highly effective in patients with bipolar disorder and insomnia and should be prioritized in most cases.

Sleep Medication

There are many types of sleep medication that can be used to treat insomnia. However, they often have side effects, or patients can develop tolerances to them. So while they are prescribed by doctors for insomnia if needed, medication isn’t usually more of a secondary treatment.

On top of the usual medications, there are some that are studied specifically in patients with bipolar disorder.

For example, a double-blind placebo-controlled trial of ramelteon found that it improved mood stability and sleep quality (7):

The chart above shows Pittsburgh Sleep Quality Index (PSQI), where a higher score correlates to worse sleep quality. You can use our free online PSQI calculator if you’d like to learn more. 

Home Remedies and Herbal Medicines

There’s mixed evidence whether or not herbal medicines can improve anxiety or insomnia symptoms in patients with bipolar disorder (8).

Even in studies that show positive effects from herbal medication, it’s typically not very significant. So while there aren’t typically adverse effects, home remedies aren’t sufficient to treat insomnia.

Bipolar Disorder and Trouble Waking Up

One last related topic I wanted to mention is that many people suffering from bipolar disorder also have significant sleep inertia, which refers to decreased cognitive function or disorientation for hours after waking up.

One study found that the “RISE-UP” routine, which may be prescribed as part of CBT-i, effectively reduces the duration and severity of self-reported sleep inertia (9).

The routine is a framework that outlines different activities, mainly consisting of getting a bit of activity and sun exposure in a positive environment (i.e. upbeat music, social contact).

Summary: Bipolar Disorder and Sleep Problems

It’s well established that most people with bipolar disorder suffer from sleep problems like insomnia and hypersomnia.

In those that have high levels of anxiety, these sleep issues persist even in times where their mood is relatively stable.

Like other types of insomnia, cognitive behavioral therapy modified for insomnia appears to be the most effective treatment for most. It can be combined with an emphasis on maintaining a sleep schedule and the RISE-UP routine for greater effectiveness.

In certain cases, a doctor may prescribe sleep medication at their discretion.

References

1. Sleep Disturbance in Bipolar Disorder: Therapeutic Implications
2. Sleep Disturbance in Bipolar Disorder Across the Lifespan
3. Sleep-Related Functioning in Euthymic Patients With Bipolar Disorder, Patients With Insomnia, and Subjects Without Sleep Problems
4. A test of the bidirectional association between sleep and mood in bipolar disorder and insomnia
5. Behavioral Treatment of Insomnia in Bipolar Disorder
6. Treating insomnia improves mood state, sleep, and functioning in bipolar disorder
7. A double-blind, randomized, placebo-controlled trial of adjunctive ramelteon for the treatment of insomnia and mood stability in patients with euthymic bipolar disorder
8. Clinical applications of herbal medicines for anxiety and insomnia; targeting patients with bipolar disorder
9. Rise and shine: A treatment experiment testing a morning routine to decrease subjective sleep inertia in insomnia and bipolar disorder