Why sleep is important to your quality of life
Sleeping and being awake are two sides of the same coin. Better sleep can improve your physical health and cognitive function (i.e., thinking, remembering and planning), as well as help balance your moods and feelings (emotion regulation).1 For people with bipolar disorder, the link between sleep and better health is especially important because poor sleep can also be involved in increased bipolar symptoms and relapse.2
Compared to being awake, sleep is a time when we are unaware of things going on around us. The body rests and mends itself and the brain processes memories of the day so they can be remembered later.3 Sleep is important for mental and physical health, but this doesn’t mean that you should worry too much about a bad night’s sleep. Like exercise and other lifestyle factors in health, long-term habits matter more than individual events. Developing and keeping good sleep habits can have long-term benefits. Below, you will be introduced to some important strategies for improving sleep. But first, it’s useful to understand a bit about how sleep works.
There is no single correct amount of sleep for everyone. Although the average adult needs and wants about 8 hours of sleep a night, there is a wide range in the amount of sleep a particular person needs. The time at which we prefer to go to bed also differs across people—morning types (known as larks) sleep and wake relatively early, while evening types (or owls) sleep and wake relatively late. People usually become more owlish in adolescence (causing problems with getting up for school) and more larkish in middle age. People with bipolar disorder tend to be owls.
There are three main factors that determine when, and how well, we sleep. Ask most people, and they’ll guess that we sleep because we’re tired. Like hunger increases the longer a person hasn’t eaten, drive for sleep increases with hours awake. But this is only one of three factors that influence when we sleep, and all three can be targeted to improve sleep.
The second factor influencing sleep is the brain’s internal clock – if you’ve ever worked shift work or had jet lag, you know that it’s hard to go to bed when the body doesn’t think it’s time to sleep. No matter how tired, a person just doesn’t sleep well if their internal clock thinks it’s time to be awake.
One way to improve sleep is by training your internal clock to provide a strong signal to sleep and wake up around the same times each day (called regularizing or synchronizing your internal clock). Strengthening your internal clock is important for people with bipolar disorder, because having an unstable internal clock is linked to symptoms of both mania and depression. You can strengthen your internal clock by training it into a regular daily routine (a bit like training a pet to expect food at a certain place and time).
The third factor influencing sleep is arousal at bedtime. This means that if you are calm, quiet and relaxed at bedtime, you will sleep better than if you go to bed feeling very excited or stressed. The feeling of being tired but unable to sleep is very distressing. Trying your best to relax at bedtime and teach your body to associate your bedroom with sleep can be very helpful.
But, even if you know about these factors, sleep can still be a challenge. During depressive episodes of bipolar disorder, the majority of people have problems with insomnia (falling and staying asleep at night) and hypersomnia (waking up or getting out of bed in the morning). In contrast, during manic and hypomanic episodes, people usually feel a decreased need for sleep and sleep can be short and interrupted. Insomnia also commonly occurs in manic and hypomanic episodes. Even when people with bipolar disorder are not having full-blown episodes, they commonly report problems with their sleep. One research study found that the reports about sleep problems from people who live with bipolar disorder were as wide-ranging and severe as the problems reported by people being treated for sleep disorders . So, it may help you to remember that problems with sleep originate with the illness, and aren’t a personal trait or flaw.
Lastly, changes in sleep are not just symptoms of bipolar disorder – they are one of the causes of bipolar disorder symptoms.
Improving sleep can improve your mood, and monitoring for sleep changes can help people make the changes needed to prevent relapse. People with bipolar disorder typically experience early warning signs of their manic and depressive episodes, and people have better outcomes if they can identify these early warning signs and make the changes needed to manage them. Importantly, changes in sleep are almost always seen as an early warning sign for developing episodes of mania or depression. Being mindful of sleep is a very important part of staying well with bipolar disorder.
How you can take action
The good news is that there are a lot of things you can do to improve your sleep habits. Most of the research evidence about these simple strategies comes from years of research into Cognitive Behavioural Therapy for Insomnia (CBT-I). CBT-I works extremely well! In fact, it’s the first-line treatment for insomnia, and is even preferred over medication in many cases.5
CBT-I is a therapy that aims to help people develop good sleep habits that can help to facilitate good sleep and to minimize insomnia and hypersomnia. Recent use of CBT-I for people with bipolar disorder who have also been diagnosed with insomnia shows that it can be used safely and effectively. Interestingly, this early research seems to show that strengthening your internal clock by regularizing your wake time across 7 days of the week may be the most powerful strategy for improving sleep.6
We’ve talked about the three controllable factors that determine when and how well we sleep: being tired, the internal clock, and arousal levels at bedtime. Now let’s look at the best strategies for improving these factors. For detailed advice about how to apply the skills described in the next section you should read The Bipolar Workbook: Tools for Controlling Your Mood Swings written by M. R. Basco and published in 2006.
Learning new behaviours takes some effort – the assistance of a healthcare professional will be helpful in bedding down these new habits. One of the best-known ways of improving sleep (a strategy called sleep opportunity restriction) is not discussed here. It requires close monitoring, and if you are interested, your healthcare provider will be able to assist you further in finding out if it’s right for you and implementing it.
There are strategies you can take to strengthen your sleep drive. After a poor night’s sleep, it’s tempting to use naps and stimulants (like coffee) to get through the day. This is a perfectly understandable strategy, but it can become a vicious cycle if continued for more than a day or two.
To make sure you’re sleepy at bedtime, it’s important to try your best to both avoid daytime napping and to minimize stimulant use. Caffeine in coffee, tea, energy drinks and sodas, nicotine, or energizing drugs will decrease your sleep drive if used after midday. It’s also important to know that while alcohol can help people fall asleep, it disturbs sleep during the night. Also, there are more effective ways to relax in the evening than by having a few drinks, as we’ll discuss later.
Successful psychological treatments for depression encourage plenty of daytime activity (some of these types of treatments are called behavioural activation and activity scheduling), which has positive effects on sleep as well as mood and motivation.7 Increased daytime activity is a good sleep strategy for people with bipolar disorder, but one important warning must be added – because of the risk of mania, be mindful of over-stimulation. Monitoring activity and mood levels is important in bipolar disorder generally, and needs to be used when dealing with sleep problems.8
You can train your internal clock. One of the most powerful strategies for improving your sleep is to have a regular wake-up time every day – this includes weekends! The brain’s internal clock needs to be set every day, and it gets the information on how to set itself from our activity and exposure to light. With a reliable wake-up time throughout the week, your internal clock can create a steady 24-hour pulse and can work better when it tries to set you to sleep again about 16 hours after waking up.9
For many people, a wake up time of around 7:30 AM is a good goal; however, lifestyle and other factors might make a wake time of 8:30 AM or even 9:00 AM more appropriate for some people with bipolar disorder. It’s important to get out of bed as soon as you wake up, even if you feel that you haven’t had enough sleep. Many people find that gentle exercise (especially outdoors) upon waking up improves mood; it’s also very good for your internal clock.
The internal clock also benefits from regular timing of other daily activities. The most important ones to keep in mind are socializing, eating and exercising. It may be surprising to hear that sleep at night depends strongly on the regularity of a person’s daytime activities. Some lifestyles help you keep regular daily activities (e.g., a 9-to-5 job), others challenge regularity (e.g., night shifts, on-call jobs). As well, some life events can be predicted to disturb regularity (e.g., a new baby or a holiday): you can plan for these events and be aware that they will impact your daily routines so that you will be better able to make changes and even possibly keep some of your routines intact.10
There are three main things you can do to decrease arousal and increase relaxation at bedtime: develop a pre-sleep routine, don’t let stress or excitement follow you to bed and associate your bed and bedroom with sleep.
First, develop a relaxing pre-sleep routine. In the 2 or 3 hours before bed, avoid stimulation. Emotional stimulation arises from intense discussions with partners and housemates, stimulating television, music or Internet surfing. Stimulation from light can really disturb sleep at night, and is an easy thing to stay away from before bed. To do this, keep room lighting to a minimum and avoid the light from screens – especially close-up screens like laptops, smartphones and tablets. Physical stimulation comes from exercise close to bedtime.
If you have a cat, you may have noticed that cats prepare for sleep by calmly circling around and clawing the couch – we humans also benefit from rituals around bedtime. Develop a routine around sleep so that your body learns that bedtime is coming. Some people have a habit of an evening drink (milk or chamomile tea may aid sleep), others have routines around their pets or closing up the house for the night.
Second, manage stress and excitement that can interfere with sleep. It’s just not usually possible to solve big problems after dark. When we’re tired and under-resourced, molehills inevitably turn into mountains. To improve sleep, it’s important to address concerns and anxieties before the sun sets. Practicing meditation or progressive muscle relaxation before bedtime can help you to relieve residual stress from the day. If any concerns do arise around bedtime, a strategy to effectively get them off your chest is to write them down to take care of the next day.
For people with bipolar disorder, excitement and stimulation are very important to manage in the evening. It can be tempting to pursue new ideas and projects into the night, but it’s useful to remind yourself that these things can wait: if it’s really a good idea, it will still be a good idea in the morning.
If you have worries about sleep itself, these should be actively addressed with your healthcare professional. Some people have distressing associations with sleep and bed – careful discussion with your healthcare professional can help you to form more beneficial and realistic thoughts about sleep.
Third, try to associate your bed with rest and relaxation, rather than productivity. Spending hours in bed tossing and turning, watching Game of Thrones or writing the great novel of the 21st Century can associate the thought of the bedroom with hyperarousal. It is an extremely useful sleep habit to only use your bed for sleep, but it is also okay to use it for sex and brief reading, if these are calming activities for you.
Finally, to make the bedroom a good place to sleep, it should be cool and quiet (try foam earplugs and a fan), dark (try a sleeping mask, good blinds or curtains), and disconnected from the social world (try removing the TV from your bedroom or not taking phone calls in bed).