(52) Bipolar Disorder

I have sleep apnea in addition to bipolar disorder. What should I do?

The relation between bipolar disorder and insomnia is well established. During the manic phase of the illness, the resulting high energy leads to a decreased need for sleep. During the depressive phase, the reverse is often the case, with low energy and increased sleep, although in depression with typical vegetative symptoms, low energy is often associated with an inability to stay asleep, also known as middle insomnia. It is also well known that sleep deprivation can lead to or exacerbate an underlying mood disorder. Sleep deprivation can occur for many reasons. Anxiety in anticipation of an upcoming stressful event can often lead to trouble falling asleep and, if prolonged, could precipitate either a manic or depressive episode. Jet lag has also been known to precipitate mood disorders.

The most common causes of insomnia are medical causes. These causes are the most important to recognize and treat as these may not only precipitate a mood disorder but also render treatment of the mood disorder ineffective. Chief among these medical conditions is sleep apnea. Sleep apnea affects 2% of the 30- to 60-year-old male population and half as many of the female population.

Apnea is defined as a cessation of breath that lasts at least ten seconds. Additionally there may be episodes known as hypopnea. This is defined as a significant reduction in airflow lasting at least ten seconds and usually associated with a decline in a person’s oxygen level.

People are considered to have sleep apnea if they have more than ten apneas and hypopneas per hour of sleep (commonly referred to as the apnea-hypopnea index, or AHI). This can only be diagnosed using a test known as polysomnography in a sleep lab. Polysomnography meas-ures multiple factors associated with sleep, including brain waves through electroencephalography (EEG) that measure the various stages of sleep, respiratory rates and other vital signs, pulse oximetry that measures oxygenation, and motor activity.

Sleep apnea is generally classified into three types: central, obstructive, and mixed, with the latter two being much more common. Central sleep apnea occurs when the brain neglects to send signals to the chest muscles ordering them to breathe. Central sleep apnea is a neurological condition-there is no “mechanical” obstruction involved, as is the case with obstructive sleep apnea (OSA). OSA, the most common form of sleep apnea, occurs when a breathing effort is initiated but air is blocked from entering the lungs because the rear of the throat collapses and blocks the airway. Mixed apnea occurs when both central and obstructive elements are demonstrated by polysomnography. Thus there is limited or delayed inspiratory effort, and subsequently, when efforts are initiated the apnea persists because the upper airway is blocked. The consequence of sleep apnea is that sleep is disrupted with frequent awakenings that may not necessarily be perceived by the sleeper. Sleep is therefore of poor quality. The reason most people are not aware of this is because they do not fully wake up but instead spend an inordinate amount of time in Stage 1 light sleep and much less in Stage 3 or 4 (restful or deep sleep) and REM (dream) sleep. The result is that people complain of very poor sleep no matter how many hours they “sleep” in bed and feel they need to nap throughout the day. This not only leads to problems with mood but also can increase the risk of cardiac disease, affect memory, cause headaches, lead to weight gain, and cause impotency.

Risk factors for sleep apnea include obesity (up to one-third of obese individuals have OSA), a large neck, recessed chin, male gender, structural abnormalities with the upper airway, smoking, and alcohol use. If your sleeping partner notices loud snoring followed by periods of silence, you should seek a medical evaluation for the condition. Risk factors also point to treatment. Weight loss and avoidance of alcohol and tobacco are the most obvious first-line approaches. An ear, nose, and throat doctor (also known as an otolaryngologist or ENT) evaluation may be indicated in order to determine if there is a structural abnormality that can be surgically repaired.

Finally, continuous positive airway pressure, known as CPAP, is the treatment of choice. This includes a pump and a mask that essentially forces the airway open to allow more ease of breathing. Patients often initially complain of the mask and noise associated with this treatment and, as a result, compliance is often a problem.

However, with time one can adjust to these initial difficulties. The results CPAP provides in terms or morbidity and mortality are well worth the effort.

Scott’s comments:

I was recently diagnosed with sleep apnea. My prescribed treatment was CPAP, and I’ve been on CPAP therapy now for about 3-4 months. My moods are now more stable, as I’ve not been sleep deprived. I found that the CPAP therapy can help return my general mood to a baseline that is closer to my perception of “normal.”

What is the relation between thyroid problems and bipolar disorder?

Thyroid dysfunction is associated with mood disorders with symptoms of hypothyroidism able to mimic depression and of hyperthyroidism able to mimic mania. People with an overactive thyroid may exhibit marked anxiety and tension, emotional liability, impatience and irritability, distractible over activity, exaggerated sensitivity to noise, and fluctuating depression with sadness as well as problems with sleep and the appetite. In extreme cases psychosis can develop. Cases of hyperthyroidism induced mania are rare, however. People with underactive thyroid may exhibit depressed mood, anxiety, inattentiveness, slowing of thought, weakness, poor memory, and sleep difficulties with psychosis in more extreme cases. Again, the incidence of thyroid dysfunction in depressed patients is low, more likely being present in treatment-resistant depression. It has been postulated that a surplus of thyroid hormone could lead to mania by promoting the action of catecholamines at central receptor sites, and, conversely, low thyroid levels could diminish the use of norepinephrine in times of stress, leading to depression. Tests for thyroid dysfunction should be given, as it is simple to test and if present, treatment of the thyroid dysfunction may resolve the mood disorder.

People with bipolar disorder often have abnormal thyroid gland function, with women more likely to be afflicted than men. Because too much or too little thyroid hormone alone can lead to mood and energy changes, thyroid levels should be carefully monitored by a physician. Interestingly, a high prevalence of thyroid hypofunction has been found in bipolar patients, being estimated to occur in almost one out of every ten bipolar patients not being treated with certain mood-stabilizing medications (that cause thyroid dysfunction). Although not common, there have been cases of mania reported secondary to hypothyroidism as well. Several studies have shown a higher incidence of hypothyroidism in patients with rapid-cycling bipolar disorder than in nonrapid cyclers. Thyroid treatment of hypothy-roidism in rapid cyclers has been shown to decrease the severity and frequency of manic and depressive episodes, and high-dose thyroid hormone has been used to treat refractory rapid cycling in the absence of measurable thyroid deficiency. Hypothyroidism may induce or contribute to the induction of rapid cycling in bipolar illness. Long-term lithium use can cause hypothyroid function, which may account for some depressive episodes that occur during treatment. This is usually reversible unless antithyroid antibodies have developed. Lithium-induced thyroid dysfunction is more likely to occur in women. Treatment with lithium is often continued with thyroid supplementation provided.

I was put on steroids for treatment of a medical condition. I ended up in the emergency room after several sleepless nights, confused, disoriented, and hallucinating. I was given an antipsychotic medication and was told that I needed to keep taking it because I was bipolar. I have never had a mental illness in my life. Was it just due to the steroids, or do I now have a new condition?

Steroids make up a large family of chemical compounds including hormones, body constituents, and drugs such as sterols, cardiac glycosides, androgens, estrogens, corticosteroids, bile acids, sterols, and precursors of vitamin D and cholesterol. Almost no function in the body occurs without the involvement of one of these compounds. Most steroids prescribed as medicine are used to reduce inflammation. Inflammation causes pain and swelling and can lead to other symptoms as well. Allergic reactions, autoimmune diseases, or other inflammatory diseases such as chronic obstructive pulmonary disease or emphysema are treated with steroids in order to reduce their symptoms. Steroids have multiple effects on the body aside from their anti-inflammatory effects. They can cause the “fight or flight” response through activation of the sympathetic nervous system. This effect causes various physiological changes in the body such as an increase in blood flow to the muscles, an increase in heart rate and blood pressure, and a state of hyper-alertness. This hyper-alertness can have psychiatric effects: from a general fear response to frank paranoia including delusions and hallucinations, insomnia, and mood swings from depression to mania. Prednisone is the most commonly prescribed medication in this family, and the psychiatric effects appear to be based on three factors: the dose, the change in rate of the dose over time, and finally the length of time receiving the medication. Euphoria and anxiety tend to be the most common mild psychiatric side effects followed by frank mania and depression, with depression more common upon rapid withdrawal of the medication.

Studies have shown that in patients with no psychiatric history, measuring only severe psychiatric disturbances resulting from prednisone found a rate of about 2%, with increasing rates to as high as 20% as dosage increases. Some of the most commonly known names of corticosteroids include:

• Cortisone and Hydrocortisone

• Flonase

• Lanacort

• Prednisone

• Nasonex

Corticosteroids are used in the treatment of a variety of medical conditions including:

• Asthma

• Emphysema

• Crohn’s disease

• Bursitis

• Tendonitis

• Ulcerative colitis

• Hives

• Insect bites

• Nasal allergies

• Eczema

• Psoriasis

The management of steroid-induced mania and/or psychosis is the same as if one had bipolar disorder, which includes both mood-stabilizing medication and/or antipsychotic medication. No evidence currently supports the notion that chronic steroid use causes bipolar disorder; however, there are cases of steroids unmasking a previously undiagnosed bipolar disorder. How often this happens is unclear but it is much rarer than steroid-induced mania or psychosis.

The difference between these two conditions is more in terms of the difference in the length of time one needs to be on psychotropic medication. If the condition is merely steroid induced it will eventually resolve with the discontinuation of steroids, and the patient will be able to come off psychotropic medication as well. If it is bipolar disorder, eliminating the steroids will not eliminate the underlying condition and long-term psychotropic medication will be necessary. If you have steroid-induced mania or bipolar disorder it is critical to inform the doctor the next time you require steroid treatment. Studies have shown that adequate prophylaxis with a mood stabilizer or antipsychotic can prevent future episodes.

Terms:

Hypopnea – abnormally slow, shallow breathing.

Prophylaxis – the prevention of disease.