Special Situations Sleep

Disturbed sleep is a common, and pathophysiologically important component of bipolar disorder. Persons with bipolar disorder often escalate their interest, elation and energy levels in the evening hours, into the early hours of the next day. It is important to counsel patients regarding this diurnal phase disturbance, but medications are often needed. No systematic studies have been conducted regarding comparative benefits of various strategies. Benzodiazepines are most commonly employed. Benzodiazepines vary along dimensions of speed of onset and half-life. It is best to tailor the drug in a trial-and-error fashion to the patient's unique sleep problems. Some patients may have side effects from benzodiazepines, principally carryover sedation, or less frequently disinhibition of affect and action. In such instances, alternative medications can be used. Despite lack of direct testing for insomnia, gabapentin, at doses of 100 to 400 mg, is often helpful for sleep induction. Although sedative antidepressants are often employed for insomnia, they are to be discouraged due to risks of mood destabilization.

Mood stabilizers can often be prescribed fully or largely at bedtime, and thereby have their sedative properties facilitate sleep. This can be a useful strategy for lithium, divalproex, atypical antipsychotics, and topiramate, but rarely for carbamazepine.

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