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Expert Q&A

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Can keeping a routine help control bipolar symptoms?

Asked by H, Rural Northeastern United States

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I have a diagnosis of brittle bipolar disorder. Most peer-reviewed literature tells me that setting up concrete routines (daily, work, home, etc.) is a good way to help control symptoms. Is this true? Is it an important tool or just speculation? How can I work with my employer/coworkers to limit my symptoms with routines?

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear H,

The quick answer to your question is: Yes I think it is true that routines help control bipolar symptoms. It's more than speculation, but as with almost all things psychiatric, my take on the studies is that establishing routines isn't the cure-all that it is sometimes touted to be. I don't need to tell you that bipolar disorder is too difficult to succumb to any single type of "magic bullet."

The idea of using routines to control symptoms grows out of all sorts of data showing that our daily bodily rhythms of sleep and wake, as well as body temperature and hormones, markedly affect our moods. This field is known as chronobiology and it has created one of the most underestimated sets of data in all of psychiatry.

Like all creatures, humans exist in time and are profoundly affected by it. If we watched ourselves closely we'd see that we have more energy at some times in the day and far less at others, that we think more clearly in the morning and less so right after lunch and that we tend to feel more emotionally well at one time or another on average. These are known as circadian effects. Many people also recognize that their moods and energies mutate with the seasons, with the most typical pattern being increased well-being and energy in spring and summer and more tiredness and depression during the gray days of winter. Most of us have the biological flexibility to adjust to these patterns, but not so for people with bipolar disorder. You used the word "brittle" to describe your condition, and it is a very accurate descriptor of how vulnerable people with bipolar disorder can be to changes in their human or natural environments.

Whereas people with "regular old depression" tend to be highly vulnerable to psychological stress, one way of thinking about bipolar disorder is that it is a condition of extreme sensitivity to the circles of time. Days and nights and springs and falls are registered as stressors that provoke symptoms in folks with bipolar disorder. This is especially clear with sleep. Overwhelming data show that sleep disruption is the surest and fastest way to induce a manic episode. Even missing an hour or two of sleep is enough to set vulnerable people off into an episode. So anything that disrupts sleep is very likely to worsen symptoms, leading eventually to the types of rapid changes in mood that are known as "rapid cycling" and that represent such an ominous sign for the long-term prognosis of bipolar disorder.

So the most important element of establishing routines is to make sure that one's sleep is as regular as possible. But this is easier said than done. Alcohol disrupts sleep, so if you are serious about this you should stop drinking, and avoid caffeine after lunch. Stressors disrupt sleep, so it becomes important to devise a lifestyle that is sustainable, but that is as stress free as possible. Travel becomes a problem. I've seen more than one patient over the years who had a first manic episode after an international flight. A study from 20 years ago found that flying from west to east is more likely to induce manias than flying from east to west. We all know about jet lag, but for people with bipolar disorder the circadian disruption that manifests as jet lag can be quite dangerous.

I have personally had great luck with using routines (or more formally "chronotherapy") to help people with bipolar disorder. One of the sickest patients I ever cared for was able to completely turn her life around by committing deeply to establishing very strict routines that helped stabilize her sleep. She went from being completely catatonic to teaching at a university. I don't have space in this brief blog to go into details of how to employ chronotherapy, but these can be easily found online or in books. As a start, however, many people find it useful to begin carefully recording their sleep patterns to see for themselves how sleep disruption is associated with their symptoms getting better or worse. Seeing this with one's own eyes is often a very effective way to engender a commitment to really work on getting as much regular sleep as possible. Once this begins to happen most people will find their symptoms improving, which is itself an inspiration to keep at it.

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