Temporal relation between sleep and mood in patients with bipolar disorder

Extra dimensions in all aspects of life-the meaning of life with bipolar disorder

Living with Bipolar Disorder (BD) greatly affects the whole life; still the meaning of it is poorly explored from the perspective of the individuals actually living with it. The aim of this study is thus to explore the existential meaning of life with BD. Ten persons, six women and four men, (aged 30–61), diagnosed with BD were interviewed. A reflective lifeworld perspective based on phenomenological philosophy was used. The findings show that living with BD entails experiencing extra dimensions in all aspects of life, expressed in terms of a magnitude and complexity beyond that which is perceived as pertaining to normal life. The essential meaning of the phenomenon is further described by its constituents: “a specific intensity”, “a struggle to understand”, “an illness that is intertwined with one's whole being”. Living with BD means more for the individual than having episodes of depression and mania and must therefore be understood from a holistic perspective. Adequate care for persons with BD, therefore, includes places for safe and profound reflecting about existential issues, such as identity, trust and self-confidence. The present study recommends the caring services to change their ways to explain and talk about the BD illness.

Comparison of sleep/wake parameters for self-monitoring bipolar disorder

BACKGROUND

Psychosocial interventions may teach patients with bipolar disorder to successfully detect warning signs of relapse. These interventions often include ongoing self-monitoring of sleep. We previously reported that a change in sleep duration (sleep plus bedrest) of >3 h may indicate that a mood change is imminent. This analysis further investigated whether sleep duration, sleep onset or sleep offset was the most useful sleep/wake parameter to monitor for an oncoming mood change.

METHODS

101 adult outpatients receiving treatment as usual recorded mood, sleep and medications every day on a home computer for a mean of 265+/-103 days. A daily time series of mood, sleep duration (sleep plus bedrest), sleep onset and sleep offset was constructed for each patient. After applying an ARIMA (0,1,1) filter, a cross correlation function was used to analyze the temporal relationship between the residuals for lags of +/-7 days.

RESULTS

Less frequent significant correlations were found between a change in either sleep onset or sleep offset and mood, than between sleep duration and mood. Patients with a significant correlation between sleep duration and mood included 86% of those with a significant correlation between sleep onset or sleep offset and mood. Mean sleep duration when euthymic was long (> or =8 h in 89% of patients, > or =9 h in 51% of patients).

LIMITATIONS

Self-reported data, naturalistic study, and computer access required.

CONCLUSIONS

Self-monitoring of sleep duration is recommended for patients with bipolar disorder. Better understanding of the long sleep duration of euthymic patients is required.

Sleep Disturbance in Bipolar Disorder Across the Lifespan

The aim of this article is to highlight the importance of the sleep-wake cycle in children, adolescents, and adults with bipolar disorder. After reviewing the evidence that has accrued to date on the nature and severity of the sleep disturbance experienced, we document the importance of sleep for quality of life, risk for relapse, affective functioning, cognitive functioning, health (sleep disturbance is implicated in obesity, poor diet, and inadequate exercise), impulsivity, and risk taking. We argue that sleep may be critically important in the complex multifactorial cause of interepisode dysfunction, adverse health outcomes, and relapse. An agenda for future research is presented that includes improving the quality of sleep measures and controlling for the impact of bipolar medications.

Longitudinal Predictors of Bipolar Spectrum Disorders: A Behavioral Approach System (BAS) Perspective

We review longitudinal predictors, primarily psychosocial, of the onset, course, and expression of bipolar spectrum disorders. We organize our review along a proximal - distal continuum, discussing the most proximal (i.e., prodromes) predictors of bipolar episodes first, then recent environmental (i.e., life events) predictors of bipolar symptoms and episodes next, followed by more distal psychological (i.e., cognitive styles) predictors, and ending with the most distal temperament (i.e., Behavioral Approach System sensitivity) predictors. We then present a theoretical model, the Behavioral Approach System (BAS) dysregulation model, for understanding and integrating the role of these predictors of bipolar spectrum disorders. Finally, we consider the implications of the reviewed longitudinal predictors for future research and psychosocial treatments of bipolar disorders.

Onset of mania after CPAP in a man with obstructive sleep apnea

BACKGROUND

This short report presents the case of a man with chronic anergy and mild depressive symptoms probably due to obstructive sleep apnea (OAS).

METHOD

The patient was treated with continuous positive airway pressure (CPAP).

RESULT

He developed a first manic episode at an atypical age simultaneously with the beginning of treatment.

DISCUSSION

Several possible connections between affective syndromes, OAS, and CPAP treatment are proposed and discussed relating to current literature.

Sleep functioning in relation to mood, function, and quality of life at entry to the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

BACKGROUND

Sleep disturbance in bipolar disorder can be both a risk factor and symptom of mood episodes. However, the associations among sleep and clinical characteristics, function, and quality of life in bipolar disorder have not been fully investigated.

METHODS

The prevalence of sleep disturbance, duration, and variability, as well as their associations with mood, function, and quality of life, was determined from 2024 bipolar patients enrolled in the National Institute of Mental Health Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

RESULTS

Analyses indicated that 32% of patients were classified as short sleepers, 38% normal sleepers, and 23% long sleepers. Overall, short sleepers demonstrated greater mood elevation, earlier age at onset, and longer illness duration compared to both normal and long sleepers. Both short and long sleepers had greater depressive symptoms, poorer life functioning, and quality of life compared to normal sleepers.

DISCUSSION

Short sleep duration in bipolar disorder was associated with a more severe symptom presentation, whereas both short and long sleep duration are associated with poorer function and quality of life compared to normal sleep duration. Sleep disturbance could be a trait marker of bipolar disorder, though longitudinal assessments are warranted to assess potential causal relations and the longer-term implications of sleep disturbance in bipolar disorder.

Convergent functional genomics of genome-wide association data for bipolar disorder: comprehensive identification of candidate genes, pathways and mechanisms

Given the mounting convergent evidence implicating many more genes in complex disorders such as bipolar disorder than the small number identified unambiguously by the first-generation Genome-Wide Association studies (GWAS) to date, there is a strong need for improvements in methodology. One strategy is to include in the next generation GWAS larger numbers of subjects, and/or to pool independent studies into meta-analyses. We propose and provide proof of principle for the use of a complementary approach, convergent functional genomics (CFG), as a way of mining the existing GWAS datasets for signals that are there already, but did not reach significance using a genetics-only approach. With the CFG approach, the integration of genetics with genomics, of human and animal model data, and of multiple independent lines of evidence converging on the same genes offers a way of extracting signal from noise and prioritizing candidates. In essence our analysis is the most comprehensive integration of genetics and functional genomics to date in the field of bipolar disorder, yielding a series of novel (such as Klf12, Aldh1a1, A2bp1, Ak3l1, Rorb, Rora) and previously known (such as Bdnf, Arntl, Gsk3b, Disc1, Nrg1, Htr2a) candidate genes, blood biomarkers, as well as a comprehensive identification of pathways and mechanisms. These become prime targets for hypothesis driven follow-up studies, new drug development and personalized medicine approaches.

Ambulatory Assessment

Convergent experimental data, autobiographical studies, and investigations on daily life have all demonstrated that gathering information retrospectively is a highly dubious methodology. Retrospection is subject to multiple systematic distortions (i.e., affective valence effect, mood congruent memory effect, duration neglect; peak end rule) as it is based on (often biased) storage and recollection of memories of the original experience or the behavior that are of interest. The method of choice to circumvent these biases is the use of electronic diaries to collect self-reported symptoms, behaviors, or physiological processes in real time. Different terms have been used for this kind of methodology: ambulatory assessment, ecological momentary assessment, experience sampling method, and real-time data capture. Even though the terms differ, they have in common the use of computer-assisted methodology to assess self-reported symptoms, behaviors, or physiological processes, while the participant undergoes normal daily activities. In this review we discuss the main features and advantages of ambulatory assessment regarding clinical psychology and psychiatry: (a) the use of realtime assessment to circumvent biased recollection, (b) assessment in real life to enhance generalizability, (c) repeated assessment to investigate within person processes, (d) multimodal assessment, including psychological, physiological and behavioral data, (e) the opportunity to assess and investigate context-specific relationships, and (f) the possibility of giving feedback in real time. Using prototypic examples from the literature of clinical psychology and psychiatry, we demonstrate that ambulatory assessment can answer specific research questions better than laboratory or questionnaire studies.

Nocturnal sleep panic and depression: relationship to subjective sleep in panic disorder

BACKGROUND

Patients with panic disorder (PD) often complain of sleep disturbances. PD patients have high co-morbid depression and almost 65-70% reports a history of nocturnal panic attacks. It is possible that both nocturnal-sleep panic attacks and depression contribute to sleep disturbances in PD patients. However, the individual and interactive effects of nocturnal-sleep panic attacks and lifetime depression on subjective sleep in PD are unknown.

METHODS

The National Institute of Mental Health Panic Disorder Questionnaire (NIMH-PQ) was administered to 773 individuals who met DSM-IV criteria for PD. All of these subjects completed queries related to nocturnal-sleep panic attacks, lifetime depression, difficulty sleeping, and sleep duration.

RESULTS

We examined difficulty in sleeping and sleep duration in four subgroups [PD without nocturnal panic attacks or lifetime depression (NP-D-), PD with nocturnal panic attacks (NP+D-), PD with lifetime depression (NP-D+), and PD with both nocturnal panic attacks and lifetime depression (NP+D+)]. Significantly greater proportions of NP+D+ subjects reported difficulty sleeping compared to other three subgroups. In addition, the NP+D+ patients reported significantly decreased subjective sleep durations compared to the other three subgroups. Using < or = 5h as a criteria for severe sleep restriction, approximately 20% of the NP+D+ patients, compared to 9.2%, 9.6%, and 2.5% in the NP+D-, NP-D+, NP-D- subgroups, respectively, reported sleeping 5h or less. 8.2% of panic disorder patients reported excessive sleeping per sleeping period.

CONCLUSIONS

A high percentage of panic disorder individuals report subjective sleep disturbances. Not surprisingly, an unusually high prevalence of patients with nocturnal panic attacks or depression have sleep problems and 92.3% of patients with both nocturnal panic attacks and depression report striking extremes in sleep duration or insomnia. Thus, nocturnal-sleep panic attacks and depression are independently as well as interactively associated with increased sleep disturbances in panic disorder. Although these findings are expected, they underscore the importance of assessing sleep functions, including over-sleeping, in panic disorder patients.

Only half of bipolar I and II patients report prodromal symptoms

BACKGROUND

Learning to detect prodromal symptoms is a key element of psychosocial treatment of bipolar disorder (BD). However, previous studies have described only prodromes of manic and depressive phases of BD I patients, while information on prodromes in BD II, or other phases is lacking.

METHODS

The Jorvi Bipolar Study included 191 in- and outpatients with DSM-IV BD (90 BD I, 101 BD II) in any acute phase of illness at baseline. The prevalence, type and duration of preceding prodromes were investigated using open-ended questions. The effects of type I or II disorder, index phase, socio-demographic factors, comorbidity, illness history and other correlates on report and duration of prodromes were investigated.

RESULTS

Prodromes were reported by 45.0% of BD I and 50.0% of BD II patients. The first prodromal symptom was usually mood congruent, but sometimes non-specific for mood or a symptom of anxiety; the median duration was 30.5 days. No differences between BD I and II, or between patients who did and those who did not report prodromes were found. Only Axis I comorbidity associated with longer prodromes, but not independently after adjusting for age, gender and type of phase.

LIMITATIONS

The study was cross-sectional. Reporting prodromes depends on patients' insight which was likely affected by a sub-acute phase at time of interview.

CONCLUSIONS

Only half of ordinary, secondary care bipolar patients are able to report prodromes. The chronic and fluctuating course of illness, and sometimes short time interval to full episode may limit the potentials of prodrome-based interventions.

Diagnosis and treatment in the early illness phase of bipolar disorders

The combination of a long undetected illness and significant psychosocial impairment renders early identification and intervention a vital role in bipolar disorders. Early detection forms the basis for adequate education and for treatment from the beginning. Several lines of evidence indicate that the characterization of early phases in the development of bipolar disorders is feasible. Risk factors for the development of bipolar disorders have been established and a manic prodrome has been characterized that is sufficiently long to allow recognition and, potentially, intervention. Centers specifically focussing on early detection and prevention of bipolar disorders need to be established. More research in this field is warranted including both groups of symptomatic subjects and symptom-free persons, with and without a positive family history.

The roles of melatonin and light in the pathophysiology and treatment of circadian rhythm sleep disorders

Normal circadian rhythms are synchronized to a regular 24 h environmental light-dark cycle, and the suprachiasmatic nucleus and the hormone melatonin have important roles in this process. Desynchronization of circadian rhythms, as occurs in chronobiological disorders, can produce severe disturbances in sleep patterns. According to the International Classification of Sleep Disorders, circadian rhythm sleep disorders (CRSDs) include delayed sleep phase syndrome, advanced sleep phase syndrome, non-24 h sleep-wake disorder, jet lag and shift-work sleep disorder. Disturbances in the circadian phase position of plasma melatonin levels have been documented in all of these disorders. There is compelling evidence to implicate endogenous melatonin as an important mediator in CRSD pathophysiology, although further research involving large numbers of patients will be required to clarify whether the disruption of melatonin secretion is a causal factor in CRSDs. In this Review, we focus on the use of exogenous melatonin and light therapy to treat the disturbed sleep-wake rhythms seen in CRSDs.

Phenomic, convergent functional genomic, and biomarker studies in a stress-reactive genetic animal model of bipolar disorder and co-morbid alcoholism

We had previously identified the clock gene D-box binding protein (Dbp) as a potential candidate gene for bipolar disorder and for alcoholism, using a Convergent Functional Genomics (CFG) approach. Here we report that mice with a homozygous deletion of DBP have lower locomotor activity, blunted responses to stimulants, and gain less weight over time. In response to a chronic stress paradigm, these mice exhibit a diametric switch in these phenotypes. DBP knockout mice are also activated by sleep deprivation, similar to bipolar patients, and that activation is prevented by treatment with the mood stabilizer drug valproate. Moreover, these mice show increased alcohol intake following exposure to stress. Microarray studies of brain and blood reveal a pattern of gene expression changes that may explain the observed phenotypes. CFG analysis of the gene expression changes identified a series of novel candidate genes and blood biomarkers for bipolar disorder, alcoholism, and stress reactivity.

Complicated grief and impaired sleep in patients with bipolar disorder

OBJECTIVES

To examine the relationship of sleep disturbance with complicated grief (CG) in patients with bipolar disorder (BD).

METHODS

Adults with DSM-IV BD were asked if they ever experienced significant loss and, if so, completed the Inventory of Complicated Grief. Subjective sleep disturbance was assessed with the Pittsburgh Sleep Quality Index (PSQI). The association of CG with sleep disturbance was assessed in univariate t-tests, and in multivariate analyses controlling for the presence of anxiety disorder comorbidity and current bipolar recovery status.

RESULTS

Individuals with CG had significantly higher mean PSQI scores (10.9 versus 7.9, p = 0.003) than those without CG. Further, within the group of BD participants who had experienced a significant loss, those with CG had significantly poorer sleep (p = 0.01). CG remained significantly associated with greater sleep impairment after adjustment for comorbid anxiety disorder and bipolar mood state. This additive impairment in sleep with CG comorbidity was evident for four of the PSQI component scales: sleep quality, sleep duration, sleep efficiency and sleep disturbance.

CONCLUSIONS

Our data indicate a significant association of CG with poor sleep in individuals with BD. Disturbed sleep may be a mechanism by which CG increases the burden of illness in BD.

Bipolar disorder: causes, contexts, and treatments

Bipolar disorder is a chronic and often devastating illness that may go undiagnosed because of its complex and diverse presentation. Clinicians can provide psychological treatments, in conjunction with pharmacotherapy, that can reduce the frequency, severity, and duration of manic and depressive episodes. Because bipolar disorder is characterized by high degrees of comorbidity and high rates of medical complications, the clinician will frequently need to implement other treatments targeted to comorbid conditions, such as panic, generalized anxiety, substance abuse, and personality disorders. This article introduces the issue of Journal of Clinical Psychology: In Session devoted to the treatment of bipolar disorder. We describe the cognitive styles and personal vulnerabilities that pose greater risk for bipolar disorder. Three evidence-based psychological treatments (interpersonal social rhythm therapy, family-focused treatment, and cognitive-behavioral therapy) and current pharmacological treatments are examined and illustrated. Finally, we review the effectiveness and practice implications of a variety of treatments for this severe and underresearched disorder.

Sleep and circadian rhythms in mood disorders

OBJECTIVE

Self-reported sleep disturbances are present in over 80% of patients with depression. However, sleep electroencephalography (EEG) findings, based on overnight polysomnography have not always differentiated depressed patients from healthy individuals.

METHOD

The present paper will review the findings on sleep EEG studies in depression highlighting how recent technological and methodological advances have impacted on study outcomes.

RESULTS

The majority of studies, including our own work, do indicate that sleep homeostasis and sleep EEG rhythms are abnormal in depression, but the sleep disturbances were strongly moderated by gender and age. Melancholic features of depression correlated significantly with low slow-wave activity in depressed men, but not in depressed women. Women with depression showed low temporal coherence of sleep EEG rhythms but the presence or absence of melancholic features did not influence correlations.

CONCLUSION

Diagnostic classification schemas and clinical features of depression may influence sleep EEG findings, but gender may be a more important consideration.

Prodromal symptoms to relapse in bipolar disorder

In a cyclical and recurring illness such as bipolar disorder, prodrome detection is of vital importance. This paper describes manic and depressive prodromal symptoms to relapse, methods used in their detection, problems inherent in their assessment, and patients' coping strategies. A review of the literature on the issue was performed using MEDLINE and EMBASE databases (1965-May 2006). 'Bipolar disorder', 'prodromes', 'early symptoms', 'coping', 'manic' and 'depression' were entered as key words. A hand search was conducted simultaneously and the references of the articles found were used to locate additional articles. The most common depressive prodromes are mood changes, psychomotor symptoms and increased anxiety; the most frequent manic prodromes are sleep disturbances, psychotic symptoms and mood changes. The manic prodromes also last longer. Certain psychological interventions, both at the individual and psychoeducational group level, have proven effective, especially in preventing manic episodes. Bipolar patients are highly capable of detecting prodromal symptoms to relapse, although they do find the depressive ones harder to identify. Learning detection, coping strategies and idiosyncratic prodromes are elements that should be incorporated into daily clinical practice with bipolar patients.

Psychotherapy through the phases of bipolar disorder: Evidence for general efficacy and differential effects

The obstacle facing pharmacotherapy for bipolar disorder is that almost half of the patients do not achieve recovery over the duration of treatment. Although the reason for this disappointing clinical outcome remains unclear, structured psychotherapy has helped to fill these gaps in the treatment of bipolar disorder. Psychoeducation, family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy have all received attention in the research literature. In this review, by assessing the outcomes from randomized control trials across the phases of bipolar disorder, we demonstrate that psychotherapy is an effective adjunctive treatment. We also show that the use of psychotherapy for bipolar disorder has differential results depending on when and under what conditions it is administered.

Sleep in mood disorders

Sleep disturbances are among the most common symptoms in patients who have acute episodes of mood disorders, and patients who have mood disorders exhibit higher rates of sleep disturbances than the general population, even during periods of remission. Insomnia and hypersomnia are associated with an increased risk for the development or recurrence of mood disorders and increased severity of psychiatric symptoms. Sleep electroencephalogram recordings have identified objective abnormalities associated with mood disorders, providing insight into the neurobiologic relationships between mood and sleep. Future studies will continue to investigate this association and potentially improve treatment of sleep and mood disorders.