The first in our patient guides, this episode was made to share with patients. Follow the key behavioral steps from morning to night as you develop a routine to stabilize the biological clock that drives bipolar moods. Learn how to use dawn simulators and blue light blockers to improve sleep and wakefulness.
Published On: 5/8/20
Duration: 20 minutes, 5 seconds
What is bipolar disorder? Is it a broken biological clock? And if it is, can the clock be fixed?
Welcome to a special edition of the Carlat Psychiatry Podcast. Today’s episode is written for patients. It’s an audio guide to social rhythm therapy for bipolar disorder. Social rhythm therapy was developed in the 1990’s by Dr. Ellen Frank at the University of Pittsburgh. It was one of the first psychotherapies to prove effective in bipolar disorder, and in the last 2 years it’s generated some interesting findings
- It treated bipolar II depression almost as well as quetiapine/Seroquel
- It reduced inflammation in the body
- It worked in a trial non-bipolar depression
But enough about the research. Let’s get into the therapy. Oh, and I’m Kellie Newsome, a psychiatric NP,
And I’m Chris Aiken, a practicing psychiatrist and the editor of the Carlat Report.
Mood stabilizers are the main treatment for bipolar disorder, but what do you do if these medications don’t work all the way? Today we’re going to teach you about a therapy for bipolar disorder that can make your medication work better. It’s called Social Rhythm Therapy, and it involves lifestyle changes that help set your biological clock.
Social rhythm therapy also involves talk therapy, and that part focuses on how bipolar disorder affects relationships and identity. To keep things simple, we’re just going to focus on the behavioral piece here.
These behavioral steps address some of the underlying biological causes of bipolar disorder. They reduce inflammation, which is thought to contribute to 1 in 3 cases of depression. People who’ve undergone this therapy also have measurable changes in their hormones. During bipolar episodes, hormones like cortisol rise up and don’t settle down, and the steps in this therapy help balance those levels so they rise and fall on a daily cycle.
This therapy changes other hormones ─ like melatonin ─ hormones that help set the biological clock. Disruptions to that biological clock are one of the leading causes of bipolar disorder, and some of the genes that cause bipolar are the same genes that program the biological clock. Medications like lithium help repair that clock, and there are specific lifestyle changes you can make that will make it run even smoother. First let’s talk about what this clock does.
KN: The biological clock is a time keeper that regulates every aspect of life. I’m not talking about a woman’s biological clock ─ the one that ticks away as we get older and no longer able to have babies. This clock keeps time on the circadian rhythm ─ the 24 hour cycle of life. And it doesn’t just tell us when to wake up and when to fall asleep. It regulates motivation, energy, alertness, digestion, appetite, muscle tone, body temperature…. Wait a minute. Did I just mention nearly every symptom of bipolar and depression?
CA: No wonder the biological clock is so tightly linked to bipolar. The connection is so strong that I prefer to call bipolar “fragile circadian rhythm disorder,” which means you have a slightly broken biological clock. To me, that captures it better than “bipolar,” which means “two poles.” Bipolar does have two poles – mania and depression ─ and some people with bipolar do cycle up and down between those poles. But for most patients, it’s the depression that dominates ─ depression is about 5 times more common than mania. And there’s other symptoms, like anxiety and concentration problems, that are just as common as the manic- and depressive- poles of bipolar.
If I told you that you had a broken biological clock, that might explain a lot. Like why your symptoms get worse when you can’t sleep. Or why your moods change with the seasons ─ because when the amount of sunlight outside changes rapidy, as it does in the Fall and Spring, it shakes up the clock and causes mood swings. By “broken clock” I mean that sometimes the clock runs fast and sometimes it runs slow, so your body doesn’t know when to be alert, when to wake up, and when to feel positive and motivated. You may be up all night starting online businesses in a manic frenzy, or in bed all day in depression.
So what would you do if you had only one clock in your house but it ran a few minutes slow? Well, you’d have to set it every day so it doesn’t drift too far off track. That’s what this therapy is all about, and the two signals that have the strongest effect on your biological clock are light and darkness. You need bright light in the morning, and darkness at night, to keep your clock running on time.
STEP ONE: BRISK AWAKENING
KN: Pay attention, because this one is the most important step in setting your clock: Get out of bed at the same time each day. If you have little motivation to change anything in your life, start here; you’ll get the biggest bang for your buck. Ideally, you would also fall asleep at the same time each night ─ but that’s far too lofty of a goal. You can force yourself to get out of bed, but you can’t force yourself to fall asleep, because when you “try” to do something it activates the energizing hormones in your body and ─ paradoxically ─ keeps you up.
Now, I want to clarify what I mean by “getting out of bed at the same time.” The time you get out of bed is when you first stand up. Standing up changes your biology ─ it gets your adrenaline pumping so your blood vessels tighten and you don’t faint from low blood pressure. It’s the first step that sets your biological clock in motion.
If you’re not a morning person, there are lots of creative ways to get out of bed. You can put your alarm across the bedroom so you have to get up to turn it off. There are alarm apps that make you perform some mental arithmetic or take pictures of things in your kitchen to turn off. But what really makes this hard is sleep inertia.
CA: Sleep inertia is a little-known but very-common symptom of depression. It means that it takes a while for your brain to wake up in the morning. Most of us have a little of this; we wake up groggy and want to hit the snooze button, but for most people it lasts no more than 15 minutes. In depression it can last 4 hours, which means you lose half your day.
There are two ways to reduce sleep inertia
- Brisk awakening. Rise out of bed quickly and immediately start some energizing activity. That’s any activity that makes you feel more alert and energetic. Some ideas:
- Open the blinds
- Take a cold shower or splash cold water on your face
- Walk outdoors for 5 minutes
- Listen to some upbeat music. Dance, gospel, exercise tunes. Anything pleasurable with a catchy melody can do ─ One research group recommends Good Vibrations by the Beach Boys or Close to me by the cure to.
- Aromatherapy ─ activating scents include mint, lemon, and geranium. Plug your diffuser into a socket timer so it turns on in the morning.
And make your bed so you can’t get back into it
The second way to improve sleep inertia is a dawn simulator.
A dawn simulator is a light that gradually turns on to create a virtual sunrise in your bedroom. This is how the brain was designed to wake up ─ to sunlight, not to a noisy alarm. What these devices do is gradually lift the brain from deep sleep into the lighter stages and onto full awakening. In contrast, a noisy alarm yanks people out of deep sleep, the brain is not prepared for this and that’s why they wake up with that groggy feeling of sleep inertia.
KN: There are dozens of dawn simulator out there. Which one do you recommend?
CA: The Wake Up light by Phillips is a good place to start. They have several models which range from $80 to $200 ─ the cheaper one works just fine it just won’t connect to your smartphone. These models have a built in full spectrum bulb. For a low cost option, try LightenUp at windhovermfg.com, for $15-20 this simple device will slowly turn on your existing bedside lamp.
Most models turn the light on steadily over 30 minutes, and you should gradually wake up over that time. If you wake up when it first turns on, move it further away from your head. If it doesn’t wake you up at all, bring it closer.
Dawn simulators make waking up easier, but they can do more than that. They help concentration and energy throughout the day, and they treat winter depression much like a lightbox can, though not as strong as a lightbox.
KN: The two techniques we’ve described ─ brisk awakening and the dawn simulator ─ have been studied for sleep inertia ─ and both of them cut its duration in half. Try them together if you have a hard time waking up in the morning.
But once you’re out of bed, how do you spend your day? Next ─ some antidepressant activities for the afternoon hours.
Depression pulls people into a cycle of avoidance ─ it says “Don’t try anything new, don’t take anything risks, don’t get up and do anything.” That voice is hard to resist, but following it just makes you more depressed and more avoidant. The way out is to do the opposite. Take risks, try something new, get creative, take on projects, get active.
It’s easy to say, “Get active” but it’s hard to do when you’re depressed. The secret is to look for activities that get you out of your head ─ after all, that’s where the depression is.
Good antidepressant activities are the ones you get fully absorbed in, where you forget your troubles and get out of your head. This is different for everyone, but might include cooking, crafts, games, sports, walking in the woods, playing music, or reading a good book. One thing I’ve noticed is that activities that involve the hands ─ like playing pool or knitting ─ work well. I suggested this to a patient recently who had constant suicidal thoughts. A week later she told me, “Dr. Aiken, I’ve not had a single suicidal thought, but I knitted 3 dozen scarves.”
KN: Getting active will help anyone with depression, but if you have bipolar disorder it also matters what time you do those activities ─ especially the ones that set your biological clock. The Germans have a word for these ─ zeitgebers ─ which means “time givers.” These are the things that give you a sense of ritual and stability.
Dr. Ellen Frank, who developed Social Rhythm Therapy, analyzed hundreds of activities that people with bipolar disorder do during the day to see which ones had a big effect on their mood stability. She narrowed it down to these four:
- The time you get up and out of bed in the morning
- The time you first start work, chores, or school
- The first time in the day that you have meaningful interactions with people
- And the time you eat dinner
CA: All of those have something in common ─ they all affect neurohormones ─ the gears that run the biological clock. Dopamine starts pumping when you start work; insulin rises when you eat dinner; and engaging with other people sets neurohormones in motion like oxytocin and vasopressin. You feel social interactions physically, particularly when they are intense. Think of the flush of love, the pounding of your heart when you’re on a first date or ─ on the other hand ─ when your boss is criticizing you. That pounding heart was your adrenaline pumping.
It’s no surprise that the things that set our biological clock have physical effects. Waking, eating, goal-directed activity, and social interactions. I might add walking and exercise in there as well, and you might find your own rituals that set your daily rhythm.
How do you know what your personal time-givers are? Look for things that help you feel motivated and energized during the day or help you wind down at night. Think about your life ─ does your mood ever get disrupted when your schedule is off? What activities give your day a sense of structure or help you feel more balanced and stable when you do them at regular times?
Once you have them down, do those things at the same time every day. The weekends and holidays are a challenge, but try to find a substitute activity that keeps you going with the same rhythm you have during the work week. For example, if you’re used to going to a work conference every day at 9am, schedule a walk with a friend or grocery shopping at 9am on weekends.
And here’s a tip. When I say “the same time everyday” I mean give or take 15 minutes. That’s about how precise the brain is around time, and that’s how regular these daily activities need to be to prevent major mood swings in the research on this therapy. In fact, the average person’s biological clock runs about 15 minutes late ─ that’s right, it’s not just people with bipolar disorder whose clocks are off. As long as there is light in the morning and darkness at night to reset the clock each day, we do good enough with that 15 minute margin of error.
One place where that margin of error tends to be high is the evening. Whether you have bipolar or not, it’s hard to fall asleep at a regular time. You’ll notice that the time you fall asleep is missing from Dr. Frank’s list of the big 4 events that set the biological clock. She was surprised by that, and when I asked her why it didn’t make the list her best guess was that it’s just too irregular and hard to control. Instead, the time you eat dinner made the list, and Dr. Frank believes that may have an indirect effect on setting the time you fall asleep.
KN: So when it comes to the evening, we are not going to emphasize falling asleep at a regular time. Instead, we’ll focus on doing things that trigger sleep at regular times. And the main thing that triggers sleep is darkness. Your own natural sleep medicine ─ melatonin ─ rises when the lights go out, and for most of human history the lights went out when the sun set, around 6-8pm. Now with tablets and smartphones and electric lights we are pushing our melatonin to the edge, and the consequences are serious, so much so that the American Medical Association lists evening light as a health hazard. Evening light has been linked to obesity, diabetes, heart disease, and cancer, as well as psychiatric illnesses like bipolar, depression, and of course insomnia.
But just as technology is causing the problem, it has also created a solution: Blue light blocking glasses. These amber tinted glasses block blue light, and it’s blue light that the brain depends on to know whether it’s day or night. When there’s no blue light, the brain will think it’s in a pitch dark room, and melatonin rises, clearing the path to sleep. It amazes me how strong this effect is. Even a small amount of light in the bedroom, like a nightlight, has enough blue light to affect the brain. People who sleep with a night light on gain more weight and are more likely to get depressed ─ because they don’t sleep as deep when the lights are on. We’re talking about quality sleep here ─ that’s more important than quality ─ and evening light breaks down the quality of sleep.
CA: Blue light blocking glasses have become popular for their health benefits, but for these to help your mood and sleep you’ll need a pair that blocks close to 100% of blue light. Uvex makes two models ─ Skyper and Ultraspec that will do the job for around $10. More comfortable ─ and more expensive ─ models are available at lowbluelights.com. I can recommend those two brands because they’ve been clinically tested and have the right specs. Outside of that there are hundreds of models and most of the ones I’ve tried don’t block enough blue light.
Put these glasses on at a regular time, about 2 hours before bed. The world will look a little yellow tinted, which is what you want at night. Think starlight, candle light: Yellow. They won’t make you tired, but they will set your clock so you’re more likely to go to bed on time and they will also deepen your sleep. When you go to bed, take them off and make sure the room is pitch dark. If you can’t sleep or have to get up at night, put them on again. When you wear them, your brain will get some of the benefits of sleep even if you can’t sleep.
In the morning, have the lights come on at a regular time. Don’t wear the blue-light blocking glasses in the daytime as that will just flip your circadian rhythm the wrong way.
KN: Just as a brisk awakening routine wakes you up in morning, a wind-down routine helps you fall asleep at night. Carve out about half an hour in the evening for some mellow, calming routines. It might include:
- Mindfulness meditation. Try Headspace, Calm, or iMindfulness apps.
- Relaxing music. Classical, ambient, or white noise all have sleep-promoting effects. One with good research behind it is weightless by Marconi union.
- Aromatherapy: lavender has the best evidence to induce sleep; other sleep-inducing scents include bergamot, chamomile, and cypress
- Stretching or muscle relaxation
- Visualize colors and shapes
- A hot bath, followed by sleeping in a colder room.
KN: Congratulations. You’ve made it through the ideal day in the life for someone with bipolar. Actually, these steps will make anyone’s mood better. Last year, researchers from New Zealand showed for the first time that Social Rhythm Therapy works for non-bipolar depression. And when I look at the schedule for a luxury resort spa like Canyon Ranch, they are doing the same things we recommended.
Here’s what you get at a resort like that:
- Wake up with the sunrise
- Morning stroll by the ocean
- Bike riding in on a forest trail
- An evening of relaxing music by the fireside, with no blue lights around
- A hot spa bath before bed
And thrown in are some healthy Mediterranean meals ─ the kind of diet that improves depression.
So yes, you can go to Canyon Ranch or Dunton Hot Springs for over $1,000 a day, or just create a mood stabilizing lifestyle in your own home for pennies on the dollar.
This episode was adapted from the 2020 book: The Depression and Bipolar Workbook, by Chris Aiken, MD.
The Carlat Report brings unbiased educational materials for mental health professionals. This is the first of our Patient Guides, which are special episodes you can share with your patients to help them get more out of their therapy. If you liked it, share it with someone, and tune in on July 6 when Greg Sazima will teach a crisis management technique: The Mindful Breather.
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