Dr. Phelps,

I know we have already been in contact, but I really want to know (and maybe there's not enough research, but I figured the question might help others too) about this:

The question is, if someone is in the throes of either mixed mania or a manic episode, and they haven't been sleeping enough for weeks, so as to start the kindling process, how long would it take for them to slow it down merely by sleeping "enough", and what would be "enough"?  Would it be a few days at 12 hours a day  (i.e. like the dark therapy) as your report on psycheducation.org suggests, or if that wasn't possible, or the subject wasn't willing to try that, or would getting 8 hours for say, a couple of weeks be "enough" or would it just simply not work altogether because they need the extended time at one sitting?  The reason I ask is my husband has been wearing his yellow glasses for 1 1/2 weeks but the mania does not seem to be subsiding much--he is still irritable and charged up at night.  In fact, he has gone back on a low dose of the antipsychotic as a last-ditch effort.  That too, helps him sleep, but  doesn't seem to quell the mania because the dose isn't high enough.  The glasses, however, are working in terms of what they promised because when he puts them on, he is asleep within 1/2 hour--he can't do that without medication usually.  However, this still only gives him 7-8 hours sleep per night because once he comes home at 7 or 8 o'clock, sometimes 9 o'clock if he sees his therapist after work (he has a rather long commute as a to the city nearby) he does not want to go immediately to bed but rather play on the computer, etc. and enjoy his hobbies a  bit. Feel free to edit this if you want to use it.  Thanks for your help again.



Dear Ms. H. --

Generally I avoid trying to comment on issues previously addressed, lest the exchange turn into some form of sustained communication that could be interpreted by someone as a "treatment relationship", which without some face-to-face contact is far outside the standard of care in psychiatry.

In this case, I can at least comment on your reference to the use of the "yellow lenses". For readers who have not run across this idea before, or the idea of "dark therapy", Ms. H. is referring to concepts described in my essays about darkness as a therapy for rapid cycling, and the tentative conclusions at the end of an essay entitled Bipolar Disorder: Light and Darkness -- Treatment Implications.

A case series report of my first 20 patients' experience with these yellow lenses, which can create a physiologic darkness even in an electrically lit environment (shown in one key experiment already: Kayumov) has been accepted for publication, but until that comes out, there is no direct evidence whatsoever in the literature supporting the idea of using these lenses. If someone were to believe that these glasses could treat rapid cycling, or even treat mania, and on that basis was to avoid using tools which have already been demonstrated to be effective treatments for these conditions, that would be most unfortunate. It is crucial that my ideas not interfere with accepted and effective treatments. These glasses, if used at all, cannot replace anti-manic treatments such as antipsychotics. The latter should not be "last-ditch" but rather first line until the symptoms are controlled.

Now I am aware that people really like the idea of using these glasses as a "natural" treatment, of sorts (as natural as it can be to put a pair of plastic lenses on your head at night). And I am also aware that people often really dislike the antipsychotic medications because of how they feel when taking them, even if they are manic symptoms are fairly well controlled by these medications. So I can understand how your husband might have come to use these approaches in the order that you describe, but as you can gather, I would like to emphasize that he should be working closely with his psychiatrist and not using my theoretical treatment as an alternative.

As for your question though: how long does it take when someone is in a mixed or manic state, for improved sleep alone to bring their symptoms under control? As you can imagine, we have relatively little data on this because usually people are being treated with an anti-manic medication, not just sleep alone. However, many of us in psychiatry have learned over the years to pay close attention to how many hours of sleep people are getting, as a marker of their improvement. On that basis, I think it might be fair to say that in general, until people are sleeping more than six hours per night I am quite concerned that we are not going in the right direction (or at least not fast enough). Then, when people are sleeping around eight hours a night, one often begins to see a fairly clear improvement. In some people, even within days there is a dramatic reduction in symptoms. Although I cannot recall a specific research study on this, I think it is the general impression in my field that for most patients with a significant mania, it can take several weeks thereafter for a complete return to a non-manic state. Indeed, in some people it can seem to take months to reach that point, with a relatively rapid improvement at first but then a very slow taper of the last symptoms to disappear and then a slow recovery of full social function. 

This may even be borne out by the graph to which you referred, of the patient who received "dark therapy" at the NIMH (whose dramatic response to this treatment is quite dramatic, worth a look). Notice that although his sleep improves almost immediately, and his symptoms show a dramatic reduction very quickly as well (within the first week or two, estimated from the graph), there is a subsequent very slow but fairly steady reduction in cycling that takes nearly a year or two really smoothed out.

I hope that addresses your question somewhat. Please suggest again, as I'm sure you have done already, that your husband discuss with his psychiatrist how to more directly and acceptably (to your husband) address his symptoms. Good luck with all that.

Dr. Phelps 



Published July, 2007