Author: IntraBalance

Bipolar, burnout, and 2 hours of sleep a night: How Bill found peace

Posted on July 24, 2025 by IntraBalance - Sleep Health

I just read The Borrowed Life of Frederick Fife. Have you read it?

Such a fun and heartwarming novel. It was written by Anna Johnston, a physician who worked in a nursing home, and was inspired by her grandparents.

I won’t spoil it, but I loved the above quote on sleep.
Sleep disturbances are a core feature of many medical conditions, including bipolar disorder.

It’s the “S” in the DIGFAST mnemonic for mania.*

Sleep issues in bipolar disorder aren’t limited to acute episodes of mania, hypomania, or depression.

You can also see persistent sleep issues during euthymic (interepisode) periods, showing up in a variety of ways, including chronic insomnia, hypersomnia, or irregular sleep-wake patterns.

Circadian rhythm disturbances, including delayed sleep phase, are also common, and are associated with greater mood instability and functional impairment.

That’s why stabilizing sleep is a key preventive strategy in bipolar disorder.

This week, I have a video for you that’s a little different.
It’s an interview with Bill Fitzgerald, also known as The Accidental Life Coach, and a patient with bipolar disorder in Ireland.

He shares his raw and inspiring journey of living with bipolar disorder and trauma, overcoming chronic insomnia, and rebuilding his life from the inside out.

Bill and I share an Irish connection, as we’re both UCC (University College Cork)alums – I went to med school in Cork, Ireland.

Here are some tips to get you started:

During mania or hypomania, the hallmark sleep change is a reduced need for sleep (not insomnia). People sleep significantly less without feeling tired.

During depression, you can see insomnia or hypersomnia. Hypersomnia is more common in bipolar depression than in unipolar depression. That’s a diagnostic pearl most people miss.

PSG (polysomnogram) and actigraphy show increased sleep onset latency (time to fall asleep) and increased REM density across all illness stages.

We also see more obstructive sleep apnea, restless leg syndrome in people with bipolar disorder…yet these may go undiagnosed.

Sleep changes are often early warning signs.

Trouble falling asleep or sleeping too much can show up weeks to months before a depressive episode.

Decreased need for sleep often precedes mania.

If you’re treating bipolar disorder, or managing it yourself or with a loved one, addressing sleep is vital.

It’s one of the most powerful tools we have for preventing relapse and protecting stability.

To see what that looks like in real life, listen to Bill’s story here.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.

P.S. DIGFAST is a mnemonic to remember the symptoms of mania. It stands for: Distractibility, Impulsivity, Grandiosity, Flight of ideas, Activity increased, Sleep decreased, and Talkativeness

References:
1. Kaplan KA. Sleep and sleep treatments in bipolar disorder. Curr Opin Psychol. 2020 Aug;34:117-122. doi: 10.1016/j.copsyc.2020.02.001. Epub 2020 Feb 13. PMID: 32203912.

2. Lewis KJS, Richards A, Karlsson R, et al. Comparison of Genetic Liability for Sleep Traits Among Individuals With Bipolar Disorder I or II and Control Participants. JAMA Psychiatry. 2020;77(3):303–310. doi:10.1001/jamapsychiatry.2019.4079

3. Palagini L, Miniati M, Caruso D, Massa L, Novi M, Pardini F, Salarpi G, Pini S, Marazziti D, Etain B, Riemann D. Association between affective temperaments and mood features in bipolar disorder II: The role of insomnia and chronobiological rhythms desynchronization. J Affect Disord. 2020 Apr 1;266:263-272. doi: 10.1016/j.jad.2020.01.134. Epub 2020 Jan 22. PMID: 32056887.

What It’s REALLY Like to Have Bipolar Insomnia (and Come Out the Other Side)

Posted on July 22, 2025 by IntraBalance - Sleep Health

In this episode, join Dr. Nishi Bhopal as she interviews Bill Fitzgerald, the ‘Accidental Life Coach,’ who shares his powerful journey of overcoming bipolar disorder. Bill provides an in-depth account of his experiences with panic attacks, insomnia, and being diagnosed with bipolar one. He talks about the various therapies and modalities that have aided him, from EMDR and reiki to grounding techniques and meditation. Bill emphasizes the importance of holistic approaches in mental health treatment, and offers valuable advice for health practitioners and individuals dealing with mental health crises. Don’t miss this inspiring and informative story that sheds light on the vast array of tools available for mental wellness.

How to taper off benzodiazepines

Posted on July 22, 2025 by IntraBalance - Sleep Health

During med school, I lived by my “First Aid for the USMLE” book series.

Over a decade later, I still use some of the acronyms and mnemonics…10 points to Gryffindor if you remember SIGECAPS.* 🙂

Dr. Harvinder Singh MD, founder of Psychiatry Education Forum, joined me on YouTube this week and reminded me of this one: Out The Liver (OLT).

Do you know that one?

Here’s a refresher: All benzodiazepines are metabolized by the liver, and the metabolites are eliminated by the kidneys.

Some benzos don’t have active metabolites, and take a simpler route through the liver…they skip the usual oxidative metabolism and go straight to glucuronidation. 👇

Those are the “OLT” (Out The Liver) benzos:
‣ Oxazepam
‣ Lorazepam
‣ Temazepam

Why does this matter? Because this pathway doesn’t rely heavily on liver function, making these meds safer choices for older adults or people with liver issues (Peng et al, 2022). Plus, they don’t produce active metabolites, so they’re gentler on the kidneys too.

I don’t recommend long-term use of benzodiazepines because of the side effects including a high potential for misuse and physical dependence.

So how do you safely come off of them? Dr. Singh provided us with a masterclass on benzodiazepine tapering this week, based on the 2025 ASAM (American Society of Addiction Medicine) guidelines.

If you’re a clinician it’s a must watch, I learned so much from it. If you’re not a clinician, but are taking benzodiazepines or know somebody who is, this is must-have information.

This talk is jam-packed with high yield information, including:
‣ How long it takes to become dependent on benzos (it happens much faster than you think!)
‣ How to assess withdrawal risk
‣ The number 1 mistake people make with tapering
‣ Dr. Singh’s first step in tapering – it will change how you think about benzo tapers
‣ A tapering table to help you decide how to taper
‣ When you should switch to a long acting benzo, which 3 long acting benzos to choose, and who should NOT be switched to long acting
‣ Tapering pace and how to start
‣ The 2 adjuncts recommended by the ASAM guidelines to support a taper
‣ Managing sleep disturbances during a taper

And so much more…

Watch it here and bookmark the link, because you’ll want to refer back to it again and again. https://www.youtube.com/watch?v=eCzUoh5Cx_A&t=1s

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.

References:
1. Peng L, Morford KL, Levander XA. Benzodiazepines and Related Sedatives. Med Clin North Am. 2022 Jan;106(1):113-129. doi: 10.1016/j.mcna.2021.08.012. PMID: 34823725.

Mastering Benzodiazepine Tapering: Insights from ASAM Guidelines

Posted on July 14, 2025 by IntraBalance - Sleep Health

In this episode, we dive deep into the intricacies of tapering patients off benzodiazepines with Dr. Nishi Bhopal and a special guest, a board-certified psychiatrist Harvinder Singh MD. Learn about the latest guidelines from the American Society of Addiction Medicine (ASAM), risk-benefit assessments, patient-centered approaches, and the pitfalls and best practices for successful tapering. This video is packed with valuable information for healthcare providers, offering both practical advice and theoretical knowledge to optimize patient care in the realm of benzodiazepine tapering. Watch to gain insights into managing dependency, withdrawal, and ensuring patient collaboration through evidence-based strategies.

How Sleep Issues Cause Glaucoma, Dry Eyes & More

Posted on July 9, 2025 by IntraBalance - Sleep Health

Join host and optometrist Dr. Neda Gioia in this insightful episode as she delves into the interconnections between sleep and eye health. Discover the pillars of eye health from a functional medicine perspective, addressing modifiable risk factors like nutrition, stress management, exercise, and sleep. Learn about the impact of sleep disorders, particularly obstructive sleep apnea, on eye conditions such as dry eye and glaucoma. Dr. Gioia also provides valuable insights into functional medicine, nutritional advice, and the importance of personalized patient care. This episode is essential for healthcare professionals looking to enhance their understanding of holistic eye care and its systemic interactions.

How sleep affects your eye health

Posted on July 9, 2025 by IntraBalance - Sleep Health

I was getting my hair and makeup done at the Psychiatric Times studio in New Jersey before filming a segment on narcolepsy, when the makeup artist asked, “Wow, you have amazing lashes! Do you use a serum?”

I laughed, “Well… it’s just my glaucoma medicine.”

Because of a family history of glaucoma, I’m on latanoprost eye drops to keep my eye pressures down, and the main side effect is excessive eyelash growth.

Fun fact: it has similar ingredients to Latisse, the eyelash growth serum.

When my intraocular pressure started creeping up, I also got myself tested for sleep apnea.

As a sleep doc, I know the link between sleep apnea and glaucoma…but unfortunately, sleep apnea screening isn’t yet routine in glaucoma care.

We don’t usually connect sleep and eye health. But we should.
In this week’s conversation, I spoke with Dr. Neda Gioia (pronounced “Joya”), optometrist and functional medicine practitioner, about the surprising and under-discussed link between sleep quality and vision.

It turns out your sleep habits may play a much bigger role in eye disease than we realize.

How Sleep Affects Eye Health

Poor sleep increases oxidative stress and systemic inflammation, both of which are risk factors for:

- Dry eye disease
- Glaucoma
- Retinal degeneration

Untreated sleep issues like sleep apnea can worsen eye health. Yet, there isn’t enough collaboration between eye doctors and sleep specialists.
The eye’s tiny blood vessels are vulnerable to inflammation, acting like a “canary in the coal mine” for systemic problems.

Dr. Gioia takes a functional medicine approach to eye care…getting curious about nutrition, sleep, stress, and even trauma.

She’s not just treating symptoms; she’s looking under the hood to see why inflammation is there in the first place, and addressing it with her 5 Pillars of Eye Health.

It’s a refreshing and fascinating expansion of the current model of eye care – certainly not one that I’ve experienced in my personal healthcare journey.

What You Can Do Right Now

For clinicians:

Ask about sleep duration, timing, and quality
Consider sleep evaluations for patients with chronic eye conditions
Remind your patients to get regular eye exams

For you:

Get your yearly eye exam…and consider a sleep study if you have high eye pressures
Prioritize sleep just as you would your blood pressure or diet…it’s all connected

Dr. Gioia explains:

- The link between sleep apnea and glaucoma
- The impact of blue light on eye health
- Specific nutrition tips for the eyes (I’m definitely going to start incorporating these)
- Pillars of Eye Health
- The dry eye and sleep connection
- Insomnia, shift work, and eye health

And a lot more…

Yoga Nidra for Sleep

Posted on June 26, 2025 by IntraBalance - Sleep Health

You may have heard the buzz around Non-Sleep Deep Rest (NSDR), popularized recently by neurobiology professor Andrew Huberman.

While he’s not a sleep specialist, there is evidence for NSDR which is rooted in an ancient yogic practice called Yoga Nidra, often described as “aware sleep.”

Yoga Nidra is a guided, supine practice that induces delta brainwave activity, seen in deep sleep (stage 3 sleep), while you stay awake.

It’s especially helpful for reducing stress and improving sleep quality, with evidence supporting its use in insomnia, PTSD, and anxiety.

That’s why, in our practice, we blend CBT-I (Cognitive Behavioral Therapy for Insomnia), ACT (Acceptance and Commitment Therapy), and Yoga Nidra. This combination allows us to address both the behavioral and emotional barriers to restful sleep.

CBT-I remains the gold standard for chronic insomnia and I do recommend it.

But in real-world practice, CBT-I alone isn’t always enough. For patients with high arousal, sleep-related anxiety, or trauma histories, it can feel too rigid or triggering, sometimes leading to dropout or poor adherence.

That’s why, in our practice, we blend CBT-I, ACT (Acceptance and Commitment Therapy), and Yoga Nidra. This combination allows us to address both the behavioral and emotional barriers to restful sleep.

This week, I’m joined by Lauren Ziegler, sleep coach and yoga therapist teacher to discuss how yoga nidra works for insomnia. Click here or watch the video below.

What the Evidence Says

RCTs show Yoga Nidra improves both subjective and objective sleep parameters, including sleep latency, total sleep time, and sleep efficiency.

It helps reduce psychological and physiological arousal, two of the biggest perpetuating factors in chronic insomnia.

Early findings also suggest benefits in post-sleep refreshment, cognitive clarity, and emotional regulation…key for daytime functioning.

Who benefits?

Patients with insomnia, especially with high cognitive or physiological arousal
People who have “failed” meditation
Those tapering off sleep aids and looking for alternatives
Those who struggle with implementing CBT-i

One of the clients in our sleep program was initially skeptical, but found Yoga Nidra so effective it helped him sleep more deeply, feel calmer, and even reduce his use of sleeping pills.

How to Introduce It in Clinical Practice

You don’t need to be a yoga teacher to recommend it. Just frame it as a guided rest practice that’s low-effort, low-risk, and deeply restorative.

“You don’t have to clear your mind, just lie down and listen.”
“Even five minutes can help.”
“This isn’t about trying to sleep. It’s about letting the nervous system soften.”

Next Steps

Yoga Nidra is simple, accessible, and research-backed. For many of our patients, it’s the first time they experience what deep rest actually feels like.

Watch the YouTube conversation with Lauren to learn more.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.

References:

1. Alghosi M, Sharifi M, Namavari S, Rajamand N, Bamorovat F, Norouzi N, Alimoradi M, Konrad A. The effect of chronic yoga interventions on sleep quality in people with sleep disorders: a scoping review. Front Neurol. 2025 Apr 29;16:1566445. doi: 10.3389/fneur.2025.1566445. PMID: 40365457; PMCID: PMC12071090.

2. Datta K, Bhutambare A, V L M, Narawa Y, Srinath R, Kanitkar M. Improved sleep, cognitive processing and enhanced learning and memory task accuracy with Yoga nidra practice in novices. PLoS One. 2023 Dec 13;18(12):e0294678. doi: 10.1371/journal.pone.0294678. PMID: 38091317; PMCID: PMC10718434.

3. Sharpe E, Butler MP, Clark-Stone J, Soltanzadeh R, Jindal R, Hanes D, Bradley R. A closer look at yoga nidra- early randomized sleep lab investigations. J Psychosom Res. 2023 Mar;166:111169. doi: 10.1016/j.jpsychores.2023.111169. Epub 2023 Jan 29. PMID: 36731199; PMCID: PMC9973252.

4. Sharpe E, Tibbitts D, Wolfe B, Senders A, Bradley R. Qualitative Impressions of a Yoga Nidra Practice for Insomnia: An Exploratory Mixed-Methods Design. J Altern Complement Med. 2021 Oct;27(10):884-892. doi: 10.1089/acm.2021.0125. Epub 2021 Jul 15. PMID: 34265219; PMCID: PMC10772320.

How Yoga Nidra Can Improve Sleep

Posted on June 17, 2025 by IntraBalance - Sleep Health

In this episode, discover the secrets to falling asleep faster and reducing sleep anxiety through the transformative practice of Yoga Nidra. Join us as renowned sleep coach and Yoga Nidra specialist Lauren Ziegler explains the intricacies behind this ancient practice and its modern applications for insomnia relief. We explore the physiological benefits, differences from traditional meditation, and practical tips for implementation. Perfect for healthcare providers looking to recommend new, effective therapies to their patients or individuals seeking deeper, more restful sleep. Learn about our integrative sleep coaching program combining CBTI, ACT, and Yoga Nidra for comprehensive support. Don’t miss out on this insightful conversation that could revolutionize your approach to sleep therapy!

Does cannabis help sleep?

Posted on June 12, 2025 by IntraBalance - Sleep Health

Exploring Cannabis in Medicine: Insights with an Internal Medicine Doctor

Cannabis for medical issues wasn’t on the radar when I was in med school. Now it’s everywhere…the local coffee shop offers CBD shots for your morning espresso and medical cannabis has become mainstream.

Even my dog gets CBD treats PRN anxiety.

You may be getting more and more questions about cannabis in clinic…but most of us were never taught about medicinal cannabis in training.

This week I sat down with Dr. Janice Makela MD, an internal medicine and palliative care doc with training in cannabis-based care, to unpack the practical, clinical side of cannabis.

In our conversation, Dr. Makela shares what every clinician should know before saying yes or no to cannabis as part of a treatment plan.

The endocannabinoid system (ECS) helps regulate pain, sleep, metabolism, and immune response. Dr. Makela points out that we learned about the renin-angiotensin system in med school, but there’s no training on the ECS.

She makes the case that understanding the ECS is foundational, not fringe, especially if we want to evaluate cannabis objectively in modern practice.

Clinical Pearls

Chronic Pain

Cannabis can modulate pain pathways through CB1 receptors. Some patients reduce their opioid burden with its use, but it’s not one-size-fits-all.

PTSD

For some, cannabis reduces nightmare frequency and intensity. However, there isn’t enough data to recommend treating patients with it.

Dementia

Low doses may reduce agitation in geriatric populations. Dr. Makela shared some clinical pearls on dosing.

Cannabis is not benign, but it’s also not going away.

Risks and Red Flags

While anxiety and insomnia are two of the most common reasons patients turn to cannabis, the response is highly formulation- and person-dependent.

It can both help and harm. Be careful in people with underlying trauma, addiction histories, or schizophrenia-spectrum vulnerabilities.

What About Sleep?

While people feel like they sleep better, the data tells a murkier story, with increased light sleep, reduced REM, and potential disruption of architecture over time, depending on the formulation.

Patients with chronic non-cancer pain are most likely to experience benefit from cannabinoids for sleep disturbances.

Where Do We Go From Here?

Dr. Makela believes cannabis in medicine could eventually take a place like digitalis or morphine: powerful when used wisely, dangerous when not.

That’s why education matters to help clinicians think critically, communicate clearly, and meet patients where they are.

I don’t recommend medical cannabis in my practice because I don’t have adequate training in how to prescribe it appropriately. However, I’m open to having conversations with patients about it and pointing them in the right direction when they need more information.

If you’ve been curious about how to bring cannabis into the conversation with patients, or when to leave it out entirely, this interview is worth your time.

Take a listen and let me know what stood out to you.

Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.

References:
AminiLari M, Wang L, Neumark S, Adli T, Couban RJ, Giangregorio A, Carney CE, Busse JW. Medical cannabis and cannabinoids for impaired sleep: a systematic review and meta-analysis of randomized clinical trials. Sleep. 2022 Feb 14;45(2):zsab234. doi: 10.1093/sleep/zsab234. PMID: 34546363.

Bhagavan C, Kung S, Doppen M, John M, Vakalalabure I, Oldfield K, Braithwaite I, Newton-Howes G. Cannabinoids in the Treatment of Insomnia Disorder: A Systematic Review and Meta-Analysis. CNS Drugs. 2020 Dec;34(12):1217-1228. doi: 10.1007/s40263-020-00773-x. Epub 2020 Nov 26. PMID: 33244728.

Morin CM, Buysse DJ. Management of Insomnia. N Engl J Med. 2024 Jul 18;391(3):247-258. doi: 10.1056/NEJMcp2305655. PMID: 39018534.

Sznitman SR, Meiri D, Amit BH, Rosenberg D, Greene T. Posttraumatic stress disorder, sleep and medical cannabis treatment: A daily diary study. J Anxiety Disord. 2022 Dec;92:102632. doi: 10.1016/j.janxdis.2022.102632. Epub 2022 Sep 16. PMID: 36182689.

Velzeboer R, Malas A, Boerkoel P, Cullen K, Hawkins M, Roesler J, Lai WW. Cannabis dosing and administration for sleep: a systematic review. Sleep. 2022 Nov 9;45(11):zsac218. doi: 10.1093/sleep/zsac218. Erratum in: Sleep. 2023 Mar 9;46(3):zsad008. doi: 10.1093/sleep/zsad008. PMID: 36107800.

Exploring Cannabis in Medicine: Insights with an Internal Medicine Doctor

Posted on June 10, 2025 by IntraBalance - Sleep Health

Join us for an eye-opening conversation with Dr. Janice Makela as we dive deep into the medical use of cannabis. Dr. Makela shares her extensive knowledge on the benefits, risks, and applications of cannabis for sleep, pain, and anxiety management. Discover the science behind the endocannabinoid system, the differences between THC and CBD, and explore how cannabis can be integrated into medical practice. Perfect for doctors and healthcare professionals looking to expand their understanding of this increasingly relevant topic.