Question Re. Time of Day and the Illness
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Q:  Question Re. Time of Day and the Illness

After years and years of refractory depression, and after educating myself, I realized that I was bipolar. I have no euphoric or expansive mania though. I am now on Lithium. I am proceeding slowly because the first time I took it, I developed Hashimoto and hypothyroidism at 600 mgs. I am now on 450, do show a therapeutic level, but may proceed to the 600 mgs, as I am still both agitated and depressed. I take it at night. My question has to do with the time of the day and my illness. I wake up every single day, without exception, wishing I did not wake up and had died. I wake up scared of the day to come, despondent, teary. I start telling myself that things will be better as the day proceeds. They usually do get better, either from seeing friends or family or working or exercising. But why must I wake up feeling like this and needing some three hours to get out of bed? I don't have bad dreams. I don't wake up like this depending on what happened the day before or what is to happen. I just always have to "recover" from sleep. I am not on anything else but the Lithium, Synthroid in the morning (75mcg), and 30 mgs of Inderal (20 at night, 10 in the morning) for migraine prophylaxis. What happens while we sleep? Can we fix it?

Dear F --
You raise a very interesting question, although I understand that this is not just a matter of "interesting" to you, is a matter of trying to improve your quality of life -- a lot!  Unfortunately, your experience is extremely common.  Mornings being worse than the late afternoon and evening, in people with depression, is extremely well recognized as a pattern.  It was characterized decades ago by mood researchers.

Unfortunately, despite being recognized all that time, we still don't really know exactly what the basis of this phenomenon is, or how to adjust treatment accordingly.  Generally we just press ahead with antidepressant treatments, including those which are not antidepressants per se (and therefore do not run a less risk of making bipolar disorder worse; here is a list of nine "antidepressants which are not antidepressants.")

Nevertheless, what we do know is that sleep can make depression worse -- at least too much sleep; or sleep at the wrong times relative to your usual circadian rhythm.  For example, as you have probably read, sleep deprivation can cause manic symptoms to emerge.  One of the most common triggers of a manic episode is somehow going without enough sleep for a night or two.  What is less well understood, by the general public, is dead the mirror image seems also to be true: getting too much sleep can move some people, particularly those with bipolar depression, and the direction of becoming even more depressed.

Ironic, isn't it?  A change in sleep can lead to the emergence of a symptom pattern which makes that change in sleep even more pronounced (huh?): sleep deprivation can lead to mania which leads to a dramatic decrease in sleep; and likewise, it appears that sleep access can lead to depression which leads to a dramatic increase in sleep (at least in some people).

The good news in all this is that some people can respond to treatment interventions designed to shift their sleep pattern.  Sometimes simply getting up at a regular hour, oftentimes one that is much earlier than your body would want to do, and actually directly decreased depression symptoms.  I know, this might seem like last thing you want to do.  Mornings are the worst.  Why should you get up early, to have more morning?  Similarly, often in this pattern, late evenings are the best.  Why should you try to miss out on those few good hours of the day by going to sleep earlier (in order to be able to get up, on a regular basis, earlier).  Nevertheless, despite sounding like a really dumb idea, this intervention has helped some people.  Talk with your psychiatrist about whether this approach might be useful for you.

Finally, sometimes these sleep interventions are best when combined with a shift in light exposure.  Again, talk with your psychiatrist about this.  It involves using forms of light therapy, including a dawn simulator and/or a light box; and for some people, there may be a point in using some form of "dark therapy" as well.

Dr. Phelps

Published November, 2008

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