Q:  Can Melatonin Aid in a Sleep Schedule? : Vitamin, Mineral Supplements & Hair Loss, Fatigue

Dear Doctor,

I have been diagnosed with bp-ll on lamictal 100mg and lorazepam 2mg hs for difficulty getting off to sleep. My two questions are

:1)does melatonin help in bipolar disorder in maintaining a good sleep schedule by inducing timely sleep? can it replace lorazepam in long term?

2)I have hair loss and weakness/fatigue all the time.  Can vitamin-mineral supplements (ABCPLUS) help with that?( u mentioned  that in one of your patients a vitamin supplement caused heart rhythm changes ,is that a serious concern with all supplements)

Thanks for your time and informative site on bipolar-ll disorders.
 

Dear A' --

Lamotrigine (Lamictal) is a very good medication for bipolar II, one of my most standard options. But, as you may have learned, and as you can see from your experience, this medication is not known to be able to help people fall asleep. When using this medication alone, it is not uncommon to see people still having that problem.

There are numerous reasons to have difficulty falling asleep ("initial insomnia"), so I would not presume to be able to address all of them. However, there is a fascinating science story around one of the most common reasons for this problem, namely a mismatch between your biological clock and your intended sleep time. In other words, problems of "circadian rhythm" are commonly associated with an initial insomnia. If your clock is not trying to make your body fall asleep until midnight, and you are trying to fall asleep at 10, you can easily lie there for a couple of hours waiting to fall asleep. Most people with this pattern also have difficulty getting up in the morning, as their clock is not ready to really wake them up from sleep until perhaps 8 a.m., when they are trying to get up at 6 a.m., for example.

Again, there might be other explanations. But if these circadian rhythm problem described above is at least part of the problem, then anything which helps move the clock earlier, so that your body does indeed want to fall asleep earlier, should help. This can be done without medications at all. Theoretically, getting up earlier and getting into bed earlier showed promote this clock change. Yet some people with mood disorders seem not to respond to these maneuvers. It's as though their clock keeps wanting to drift in the opposite direction: staying up later and getting up later. I think this might be particularly true for people who have winter depressions ("seasonal affective disorder").

Melatonin, you are correct, it is theoretically capable of helping "pull" your biological clock toward an earlier sleep time. A research laboratory up the road from me in Portland, Oregon, under the direction of Dr. Al Lewy, is one of the institutions leading the study of this area. Dr. Lewy and his colleagues use a very small dose in the late afternoon, between 0.3 and 0.5 mg. The goal is not to induce sleep, but rather to move the clock. This does not work for everyone, and indeed there are some people who will worsen (particularly in terms of depression) with this approach. (Reference for the curious, although you must be very curious and very scientific minded, because this is a very difficult paper: Lewy, PNAS). 

Dr. Lewy and I have discussed an alternative approach which he believes is equivalent to his melatonin approach, at least in theory (because my approach has not been tested).  This uses a sort of artificial darkness as a means of pulling the clock toward an earlier sleep hour. That approach is described on my webpage about Light and Darkness in Bipolar Disorder. This essay ends up describing the use of a pair of amber tinted lenses to produce a physiologic darkness. It is a neat trick if it works. We just don't have the research on that yet.  Neither melatonin nor the amber lenses can necessarily be relied upon to replace lorazepam, which might be playing a minor role in mood stabilizing independent of its effect on sleep, so you should definitely be carefully checking with your psychiatrist about any changes there.

2. Hair loss is a known side effect of lamotrigine (a reader here at Bipolar World helped me learn that, as I had not seen it in my patients at that point, although I have since). How to fix it is not so well understood. We would have to extrapolate from what has worked for hair loss can be used by other similar medications, such as another anti-seizure medication, Depakote. For that, selenium and zinc have been shown to be useful, at least anecdotally. One person wrote me about using biotin for this. You can find the references on my page about hair loss and Depakote.

Thank you for your interesting question.

Dr. Phelps