Our circadian system is what allows our body to maintain a 24-hour cycle of activity. At night we sleep, during the day we are alert, and each specific time of the day we have increased activity of certain organs and hormones. These rhythms are generated internally in our brain (suprachiasmatic nuclea) but are kept in check by external clues (called Zeitgebers) such as light and darkness, activities, meals, social clues, etc. When the circadian system is in balance, we feel healthy, energetic, and sleep well. When out of balance we start to see many problems.
What happens to our circadian system in bipolar disorder?
In bipolar disorder it appears that this system has instability. Recent research in has shown associations between problematic genes regulating our circadian rhythm (ARNTL and PER3) and bipolar disorder. Essentially this means the internal regulation is weak and susceptible to both internal and external influences. Left unprotected, changes in circadian rhythms may precede mood episodes. Sometimes you may notice a few days of early waking before a manic or hypomanic mood. Or you may notice that a late morning of sleep will lead to a depressed mood. Furthermore, once the mood episode starts, the patients behavior seems to self-propagate the circadian imbalance such as hiding under the covers when depressed or staying out late and dancing when manic. Therefore, maintaining crisp control of circadian rhythms is very important for both acute and long-term management of bipolar disorder.
What can you do about it?
Since the internal clock may be broken we can amplify external clues to keep it on time. Here are some ideas to help keep your rhythms set.
Light is the most potent external regulator of circadian rhythms and manipulations of it are very important in maintain stable mood. Bright light therapy is well known for seasonal affective disorder but works equally as well for bipolar disorder. Dr. Janikula finds that bright light therapy is a potent antidepressant and, when used correctly, is a simple mood stabilizer. Dr. Janikula recommends the light box by Apollo Health because of ease of use. He has found the blue light works better than other light boxes and its small size makes it perfect for travel. There are several important factors to think about with bright light therapy listed below.
1. Usually works best when used in the morning for 30 minutes.
2. The light needs to be positioned above your head, as blue light receptors are located on the bottom of your eye.
3. With bipolar disorder, bright light therapy should always be used with dark therapy to prevent switching to hypomania/mania.
4. Retinal risk is unknown but estimated as small, but a good antioxidant supplement containing lutein should be used.
Darkness is also very important to setting rhythms and most patients with bipolar are very sensitive to artificial light. Evening artificial light often confuses the brain and the body does not have the normal hormonal responses that accompany darkness. There are several case reports of rapid-cycling bipolar patients who dramatically stabilized when put in a dark room 10-14 hours a night. You can shut of all your lights at 8-9 PM (very inconvenient) or you can wear a simple pair of glasses. A company called LowBlueLights.com manufactures a type of glasses that block blue light and trick your brain into thinking it is dark. Dr. Janikula finds most patients notice improvement in sleep quality and mood stability when wearing these glasses 2-3 hours before they go to bed. In rapid-cycling patients he finds it imperative to successful control.
Dr. Janikula often starts difficult to manage cases with early morning light therapy and dark therapy in the form of glasses in the evening. He has seen amazing results with this method and feels it is essential to long term care. Dr. Janikula (and all other doctors at Fountainhead Clinic) has no affiliation with these companies, he just finds them effective.
Other important lifestyle factors that regulate circadian rhythms are timing of meals and exercise. Regular meal timing is critical and missed meals or delayed meals often lead to mood changes. Exercise timing is also important and Dr. Janikula often finds morning exercise has more mood stabilizing effects than afternoon or evening exercise.
Dr. Janikula will sometimes use other treatments to regulate circadian rhythms such as physiological doses of hydrocortisone, B12 injections, and melatonin supplementation.