Morningness-Eveningness questionnaire in bipolar disorder

Influence of ultraviolet A1 exposures on mood states: a randomized controlled study

We investigated the effects of daily ultraviolet A1 (UV-A1, 340-400 nm) exposures on mood states (#R19055, approval on 21 October 2020). Based on our earlier findings of the influence of diurnal preference on mood, we investigated further whether diurnal preference plays a role in the influence of UV-A1 on mood states. Forty-one healthy participants aged 19-55 years were randomized to receive either UV-A1 (n = 21) or control (n = 20) exposures (violet light, 390-440 nm). The irradiations were administered on three consecutive mornings on the skin of the buttocks and middle back. Diurnal preference was assessed with the modified 6-item Morningness-Eveningness Questionnaire (mMEQ). Changes in mood were assessed with Total Mood Disturbance (TMD) score of the 40-item Profile of Mood States (POMS) before the first irradiation, immediately after each irradiation and one week after the last irradiation. Mood improved among those subjected to UV-A1 exposures compared with the controls (p = 0.031). Individuals with more pronounced morningness had mood improvement (p = 0.011), whereas those with more pronounced eveningness did not (p = 0.41). At follow-up of one week after the last irradiation the mood improvement had disappeared.

The association between chronotype profile and temporomandibular disorders among college students

BACKGROUND

Temporomandibular joint disorders (TMDs) are common in young adults, and the link between chronotype profile and TMDs is unclear.

OBJECTIVE

This study examined TMD prevalence and chronotype distribution and explored the relationship between chronotype and TMDs in young adults.

MATERIALS AND METHODS

A total of 663 students from Sichuan University completed questionnaires. Chronotype profiles were assessed using the Morningness-Eveningness Questionnaire, and TMDs were screened using the Fonseca Memory Index. To validate the findings, 68 TMD patients and 136 controls were enrolled.

RESULTS

The prevalence of TMDs was 69.7%, with significant differences among chronotype profiles. The intermediate profile was the most common chronotype. Eveningness profile was associated with higher TMDs prevalence and severity. Muscle pain and side movement difficulty scores were higher in eveningness and intermediate profiles. Female gender (OR 2.345; 95% CI 1.668-3.297) was a TMD risk factor, while morningness profile (OR 0.537; 95% CI 0.297-0.970) was protective. Validation with TMD patients and controls supported these findings, showing higher eveningness profile prevalence in the TMD groups.

CONCLUSIONS

TMDs have a high prevalence in college students, chronotype profiles shown to be associated with TMDs. Morningness is the protection factor in TMDs and PT, eveningness is a risk factor for IT.

Change in Seasonal Beliefs Mediates the Durability Advantage of Cognitive-Behavioral Therapy Over Light Therapy for Winter Depression

In treating an acute episode of winter depression, cognitive-behavioral therapy for seasonal affective disorder (CBT-SAD) and light therapy are comparably efficacious, with improvement in depression symptoms during CBT-SAD mediated by reduced seasonal beliefs (i.e., maladaptive thoughts about the seasons, light availability, and weather). Here, we tested whether the enduring benefit of CBT-SAD over light therapy following treatment is associated with offsetting seasonal beliefs during CBT-SAD. Currently depressed adults with Major Depression, Recurrent with Seasonal Pattern (N = 177) were randomized to 6 weeks of light therapy or group CBT-SAD and followedup one and two winters after treatment. Outcomes measured during treatment and at each follow-up included depression symptoms on the Structured Clinical Interview for the Hamilton Rating Scale for Depression-SAD Version and Beck Depression Inventory-Second Edition. Candidate mediators measured at pre-, mid-, and posttreatment were SAD-specific negative cognitions (Seasonal Beliefs Questionnaire; SBQ); general depressogenic cognitions (Dysfunctional Attitudes Scale; DAS); brooding rumination (Ruminative Response Scale-Brooding subscale; RRS-B); and chronotype (Morningness-Eveningness Questionnaire; MEQ). Latent growth curve mediation models found a significant positive path from treatment group to the slope of SBQ during treatment, with CBT-SAD showing larger improvements in seasonal beliefs with overall change in seasonal beliefs in the medium-effect range, and significant positive paths from SBQ slope to depression scores at the first and second winter follow-ups, indicating greater change towards more flexible seasonal beliefs during active treatment was associated with less severe depression symptoms following treatment. Estimated indirect effects (treatment group → SBQ change * SBQ change → outcome) were also significant at each follow-up for each outcome with βindirect ranging from .091 to .162. Models also found significant positive paths from treatment group to the slope of MEQ and RRS-B during treatment, with light therapy showing a greater increase in "morningness" and CBT-SAD showing a greater decrease in brooding during active treatment; however, neither construct emerged as a mediator of follow-up depression scores. Change in seasonal beliefs during treatment mediates both the acute antidepressant and long-term effects of CBT-SAD and explains lower depression severity following CBT-SAD relative to light therapy.

Dynamic modelling of chronotype and hypo/manic and depressive symptoms in young people with emerging mental disorders

There is significant interest in the possible influence of chronotype on clinical states in young people with emerging mental disorders. We apply a dynamic approach (bivariate latent change score modelling) to examine the possible prospective influence of chronotype on depressive and hypo/manic symptoms in a youth cohort with predominantly depressive, bipolar, and psychotic disorders (N = 118; 14-30-years), who completed a baseline and follow-up assessment of these constructs (mean interval = 1.8-years). Our primary hypotheses were that greater baseline eveningness would predict increases in depressive but not hypo/manic symptoms. We found moderate to strong autoregressive effects for chronotype (β = -0.447 to -0.448, p < 0.001), depressive (β = -0.650, p < 0.001) and hypo/manic symptoms (β = -0.819, p < 0.001). Against our predictions, baseline chronotypes did not predict change in depressive (β = -0.016, p = 0.810) or hypo/manic symptoms (β = 0.077, p = 0.104). Similarly, the change in chronotype did not correlate with the change in depressive symptoms (β = -0.096, p = 0.295) nor did the change in chronotype and the change in hypo/manic symptoms (β = -0.166, p = 0.070). These data suggest that chronotypes may have low utility for predicting future hypo/manic and depressive symptoms in the short term, or that more frequent assessments over longer periods are needed to observe these associations. Future studies should test whether other circadian phenotypes (e.g. sleep-wake variability) are better indicators of illness course.

The past, present, and future of sleep quality assessment and monitoring

Sleep quality is considered to be an individual's self-satisfaction with all aspects of the sleep experience. Good sleep not only improves a person's physical, mental and daily functional health, but also improves the quality-of-life level to some extent. In contrast, chronic sleep deprivation can increase the risk of diseases such as cardiovascular diseases, metabolic dysfunction and cognitive and emotional dysfunction, and can even lead to increased mortality. The scientific evaluation and monitoring of sleep quality is an important prerequisite for safeguarding and promoting the physiological health of the body. Therefore, we have compiled and reviewed the existing methods and emerging technologies commonly used for subjective and objective evaluation and monitoring of sleep quality, and found that subjective sleep evaluation is suitable for clinical screening and large-scale studies, while objective evaluation results are more intuitive and scientific, and in the comprehensive evaluation of sleep, if we want to get more scientific monitoring results, we should combine subjective and objective monitoring and dynamic monitoring.

Exploratory Study on the Associations between Lifetime Post-Traumatic Stress Spectrum, Sleep, and Circadian Rhythm Parameters in Patients with Bipolar Disorder

The present study aimed at exploring whether lifetime post-traumatic stress spectrum symptoms are associated with chronotype in patients with bipolar disorder (BD). Moreover, we explored whether the chronotype can moderate the potential associations between lifetime post-traumatic stress spectrum symptoms and rest-activity circadian and sleep-related parameters. A total of 74 BD patients were administered the Trauma and Loss Spectrum Self-Report (TALS-SR) lifetime version for lifetime post-traumatic stress spectrum symptoms, the Pittsburgh Sleep Quality Index (PSQI) for self-reported sleep quality, and the Reduced Morningness-Eveningness Questionnaire (rMEQ) to discriminate evening chronotypes (ETs), neither chronotype (NT), and morning chronotype (MT). Actigraphic monitoring was used to objectively evaluate sleep and circadian parameters. Patients classified as ET reported significantly higher scores in the re-experiencing domain, as well as poorer sleep quality, lower sleep efficiency, increased wake after sleep onset, and delayed mid-sleep point compared with both NT and MT (p-value ≤ 0.05). Moreover, ET presented significantly higher scores in the TALS-SR maladaptive coping domain than NT and lower relative amplitude than MT (p-value ≤ 0.05). Moreover, higher TALS-SR total symptomatic domains scores were significantly correlated with poor self-reported sleep quality. Regression analyses showed that the PSQI score maintained the association with the TALS total symptomatic domains scores after adjusting for potentially confounding factors (age and sex) and that no interaction effect was observed between the chronotype and the PSQI. Conclusions: This exploratory study suggests that patients with BD classified as ET showed significantly higher lifetime post-traumatic stress spectrum symptoms and more disrupted sleep and circadian rhythmicity with respect to other chronotypes. Moreover, poorer self-reported sleep quality was significantly associated with lifetime post-traumatic stress spectrum symptoms. Further studies are required to confirm our results and to evaluate whether targeting sleep disturbances and eveningness can mitigate post-traumatic stress symptoms in BD.

Can circadian rhythm predict changes in neurocognitive functioning in bipolar disorder: protocol of a 12-month longitudinal cohort study based on research domain criteria

Introduction: Bipolar disorder (BD) is a prevalent and disabling mental disorder characterized by disrupted circadian rhythms and impaired neurocognitive features, both of which fall under the major domains of Research Domain Criteria (RDoC). However, there is limited evidence regarding the interaction between circadian rhythms and long-term neurocognitive functioning. Therefore, this longitudinal cohort study protocol aims to explore whether circadian rhythm can predict changes in neurocognitive functioning over time in patients with BD.Methods: This study adopts a longitudinal cohort design, aiming to recruit 100 BD patients in either depressive or remitted states. Participants will undergo evaluations from clinical, circadian rhythm, and neurocognitive perspectives at baseline, 6-month, and 12-month follow-ups, involving questionnaires, actigraphy, and computed neurocognitive tests. We will examine both cross-sectional and longitudinal associations between participants' circadian rhythm patterns and neurocognitive functioning. Statistical analyses will employ Spearman correlation and mixed regression models.Discussion: We anticipate that circadian rhythms may serve as predictors of neurocognitive functioning changes. The findings of this study could offer supplementary insights into BD pathophysiology, potential treatment targets, and prediction.Trial Registration: This study has been registered with the Chinese Clinical Trial Registry under the registration code ChiCTR2200064922 on 21st October 2022.

The nosological status of unipolar mania and hypomania within UK Biobank according to objective and subjective measures of diurnal rest and activity

BACKGROUND

There is uncertainty whether unipolar mania is a discrete sub-type of bipolar disorder. Disrupted rest/activity rhythms are a key feature of bipolar disorder (BD) but have not been well characterised in unipolar mania/hypomania (UM). We compared subjective and objective rest/activity patterns, demographic and mental health outcomes across BD, UM and control groups.

METHODS

UK residents aged 37-73 years were recruited into UK Biobank from 2006 to 2010. BD, UM and control groups were identified via a mental health questionnaire. Demographic, mental health and subjective sleep outcomes were self-reported. Accelerometery data were available for a subset of participants, and objective measures of sleep and activity were derived.

RESULTS

A greater proportion of males met UM criteria, and more females were in the BD group. Both BD and UM groups had poor mental health outcomes vs. controls. Objectively measured activity differed between all three groups: UM had highest levels of activity and BD lowest. The UM group had shorter sleep duration compared to controls. Subjective rest/activity measures showed that both mood disorder groups (compared to controls) had later chronotype preference, more disturbed sleep and increased difficulty getting up in the morning. However, the UM group were more likely to report an early chronotype compared to BD and control groups.

CONCLUSIONS

BD and UM share features in common, but key differences support the proposition that UM may be a distinct and more clinically homogenous disorder. UM was characterised by a higher proportion of males, early chronotype, increased activity and shorter sleep duration.

The impact of lithium on circadian rhythms and implications for bipolar disorder pharmacotherapy

Bipolar disorder (BD) is characterized by disrupted circadian rhythms affecting sleep, arousal, and mood. Lithium is among the most effective mood stabilizer treatments for BD, and in addition to improving mood symptoms, stabilizes sleep and activity rhythms in treatment responsive patients. Across a variety of experimental models, lithium has effects on circadian rhythms. However, uncertainty exists as to whether these actions directly pertain to lithium's therapeutic effects. Here, we consider evidence from mechanistic studies in animals and cells and clinical trials in BD patients that identify associations between circadian rhythms and the therapeutic effects of lithium. Most evidence indicates that lithium has effects on cellular circadian rhythms and increases morningness behaviors in BD patients, changes that may contribute to the therapeutic effects of lithium. However, much of this evidence is limited by cross-sectional analyses and/or imprecise proxy markers of clinical outcomes and circadian rhythms in BD patients, while mechanistic studies rely on inference from animals or small numbers of patients . Further study may clarify the essential mechanisms underlying lithium responsive BD, better characterize the longitudinal changes in circadian rhythms in BD patients, and inform the development of therapeutic interventions targeting circadian rhythms.

Chronotypes and circadian rest-activity rhythms in bipolar disorders: a meta-analysis of self- and observer rating scales

OBJECTIVE

Chronobiological models postulate that abnormalities in circadian rest/activity rhythms (CRAR) are core phenomena of bipolar disorders (BDs). We undertook a meta-analysis of published studies to determine whether self- or observer ratings of CRAR differentiate BD cases from comparators (typically healthy controls [HCs]).

METHOD

We undertook systematic searches of four databases to identify studies for inclusion in random effects meta-analyses and meta-regression analyses. Effect sizes (ES) for pooled analyses of self- and observer ratings were expressed as standardized mean differences with 95% confidence intervals (CIs).

RESULTS

The 30 studies meeting eligibility criteria included 2840 cases and 3573 controls. Compared with HC, BD cases showed greater eveningness (ES: 0.33; 95% CI: 0.12-0.54), lower flexibility of rhythms (ES: 0.36; 95% CI: 0.06-0.67), lower amplitude of rhythms (ES: 0.55; 95% CI: 0.39-0.70) and more disturbances across a range of CRAR (ES of 0.78-1.12 for general and social activities, sleep and eating patterns). Between study heterogeneity was high (I²  > 70%) and evidence indicated a potential publication bias for studies using the Biological Rhythms Interview of Assessment in Neuropsychiatry. Meta-regression analyses suggested significantly larger ES were observed in studies using observer ratings or including BD cases with higher levels of depressive symptoms.

CONCLUSION

This meta-analysis demonstrates that BD is associated with higher levels of self- or observer-rated CRAR disturbances compared with controls. However, further studies should examine the respective performance of individual instruments when used alone or in combination, to clarify their applicability and utility in clinical practice.

Chronotype Profile, Stress, Depression Level, and Temporomandibular Symptoms in Students with Type D Personality

Background: Despite a growing interest in the types of human circadian activity, different chronotypes and personality-related issues have been rarely studied. It has already been emphasized that ‘stress personality’ is considered a risk factor for certain psychosomatic diseases and may be a temporomandibular disorders (TMDs) predictor. Therefore, an attempt has been made to analyze the chronotypes, stress levels, stress factors, and the occurrence of depression and TMDs in students with type D personalities. People with this personality trait tend to experience negative emotions more—depression, anxiety, anger, or hostility—yet may have a negative image of themselves and report somatic complaints. Aim: The aim of this study was to analyze the importance of the chronotype profile for the level of stress perceived, as well as for the occurrence of depression and TMDs in people with type D personalities. Material and Methods: The study has been conducted on a group of 220 physical therapy students. The study group G1 consisted of 110 participants with type D personalities, the control group G2 consisted of the same number of participants without the stress personality. All participants have been analyzed for the chronotype (MEQ), stress perception (PSS10), the occurrence of depression (Beck scale-BDI), the occurrence of TMDs symptoms and have completed the stress factor assessment questionnaire during the study, followed by DS14 questionnaire—a tool for assessing the prevalence of type D personality. Results: In students with type D personalities (G1), the definitely evening and evening chronotypes have been significantly more predominant than in the control group (G2). A significantly higher number of stressors and TMDs symptoms have been observed in the respondents from the G1 group than in the control group (<0.001). Univariate logistic regression analysis showed that type D personality was strongly associated with a more frequent occurrence of all TMD symptoms. Additionally, a significant influence of the evening chronotype on the occurrence of type D personality was observed. Among the potential confounding variables, female gender and a mild and moderate degree of depression have an impact on the occurrence of type D personality (p < 0.05). In the multivariate model, adjusted with the above-mentioned factors, an increased risk of the type D personality trait was found. Conclusion: The evening chronotype and type D personality may imply greater feelings of stress, greater depression, and more frequent symptoms of TMDs in young adults.

Evening chronotype as a bipolar feature among patients with major depressive disorder: the results of a pilot factor analysis

Objectives:

The bipolar spectrum concept has resulted in a paradigm shift that has affected both the diagnosis and therapy of mood disorders, with bipolarity becoming an indicator of treatment resistance in depression. Evening circadian preference has also been linked to affective disorders. The aim of our study was to confirm the relationship between the severity of depressive symptoms, bipolar features, chronotype, and sleep quality among patients with major depressive disorder.

Methods:

A group of 55 individuals who were recruited from a mental health outpatient clinic completed the following psychometric tools: a Chronotype Questionnaire comprising morningness-eveningness (ME) and subjective amplitude of the rhythm (AM) scales, the Hypomania Checklist 32 (HCL-32), the Beck Depression Inventory (BDI) and the Pittsburgh Sleep Quality Index (PSQI).

Results:

Factor analysis identified two latent components, accounting cumulatively for 58% of variables: depressive symptoms (BDI and PSQI) and bipolarity (ME, AM, and HCL-32). After rotation, ME loading in the first factor increased the result to a significant level. The correlation between the two components was very low.

Conclusions:

Evening chronotype appears to be a bipolarity-related marker, with this relationship being independent of its link to depressive symptoms and sleep quality. Eveningness and high circadian rhythm amplitude may offer promise as diagnostic, prognostic, and therapeutic predictors.

Insomnia and suicide as reported adverse effects of second-generation antipsychotics and mood stabilizers

STUDY OBJECTIVES

Insomnia and suicide ideation/behavior/death (SIB) are common in psychiatric disorders. There is evidence that clozapine and lithium have antisuicidal properties and beneficial effects on sleep. We investigated the reported odds of spontaneously reported psychiatric adverse drug reactions of insomnia and SIB in adults for second-generation antipsychotics (SGAs) and mood stabilizers compared to clozapine and lithium, respectively.

METHODS

We searched the U.S. Food & Drug Administration Adverse Event Reporting System from inception through February 2021 for which an SGA or mood stabilizer was the suspected agent of a psychiatric adverse drug reaction.

RESULTS

We investigated 10 SGAs and 5 mood stabilizers. Compared to clozapine, other SGAs were associated with a significantly increased reported odds of insomnia (reported odds ratio [rOR] = 2.41-9.70) and SIB (rOR = 1.18-2.72). Compared to lithium, there was a significantly increased reported odds of SIB (rOR = 1.17-1.70) for other mood stabilizers and odds of insomnia (rOR = 1.66) for lamotrigine. The insomnia and SIB rORs for SGAs and mood stabilizers were positively correlated.

CONCLUSIONS

Our results are consistent with evidence for antisuicidal properties of clozapine and lithium. Findings also raise the possibility of beneficial effects on sleep as one potential pathway underlying the antisuicidal properties for these agents. Future studies are needed to identify underlying biological mechanisms that contribute to these associations.

CITATION

Miller BJ, McCall WV. Insomnia and suicide as reported adverse effects of second-generation antipsychotics and mood stabilizers. J Clin Sleep Med. 2022;18(2):517-522.

Change in circadian preference predicts sustained treatment outcomes in patients with unipolar depression and evening preference

STUDY OBJECTIVES

Eveningness is associated with worse outcomes in depression. It remained unclear if eveningness could be altered with chronobiological therapy and whether such a change would predict long-term outcomes of depression.

METHODS

Data from a randomized controlled trial of 5-week adjunctive bright light therapy with a gradual advance protocol conducted in 91 adult patients with nonseasonal unipolar depression and eveningness (Morningness-Eveningness Questionnaire, score ≤ 41) was examined. "Change of eveningness" was defined by Morningness-Eveningness Questionnaire score over 41 at posttreatment week 5 and "persistent change of eveningness" was defined as maintenance of Morningness-Eveningness Questionnaire score > 41 throughout the follow-up period from week 5 to posttreatment 5 months.

RESULTS

Thirty-three participants (36%) had change of eveningness at week 5. Generalized estimating equations models showed that a change of eveningness at week 5 predicted a 2-fold increase in remission of depression over the 5-month follow up (odds ratio = 2.61 95% confidence interval 1.20-5.71, P = .016). Twenty-five participants (75.7%) had a persistent change and were more likely to achieve a remission of depression over the 5-month follow up (odds ratio = 3.18, 95% confidence interval: 1.35-7.50, P = .008).

CONCLUSIONS

One-third of the patients with depression changed their evening-preference after 5-week of chronotherapeutic treatment, and such change predicted a higher likelihood of depression remission over 5 months of follow-up.

CLINICAL TRIAL REGISTRATION

Registry: Chinese Clinical Trial Registry; Name: Adjunctive light treatment in major depressive disorder patients with evening chronotype-A randomized controlled trial; URL: https://www.chictr.org.cn/showprojen.aspx?proj=11672; Identifier: ChiCTR-IOR-15006937.

CITATION

Chan JWY, Chan NY, Li SX, et al. Change in circadian preference predicts sustained treatment outcomes in patients with unipolar depression and evening preference. J Clin Sleep Med. 2022;18(2):523-531.

Obesity and metabolic comorbidity in bipolar disorder: do patients on lithium comprise a subgroup? A naturalistic study

BACKGROUND

Bipolar disorders (BD) are associated with increased prevalence of obesity and metabolic syndrome (MetS). Nevertheless, there is a wide range in prevalence estimates, with little known about the contributions of pharmacotherapy. It has been suggested that lithium might have a more favorable metabolic profile. We hypothesized that lithium use is associated with less increased body mass index (BMI), MetS, and type II diabetes, when compared with non-lithium users (those on anticonvulsants, second-generation antipsychotics).

METHODS

Cross-sectional study of 129 patients aged 18-85 with bipolar disorder, followed at tertiary care clinics in Montreal. Patients using lithium were compared with those not on lithium, for body mass index and metabolic syndrome.

RESULTS

The prevalence of obesity and metabolic syndrome in the sample of lithium-using patients with BD was 42.4 and 35.7% respectively, with an average BMI of 29.10 (+/- 6.70). Lithium and non-lithium groups did not differ in BMI or prevalence of MetS. However, compared to the non-lithium group, lithium users had lower hemoglobin A1C (5.24 +/- 0.53 versus 6.01 +/- 1.83, U = 753.5, p = 0.006) and lower triglycerides (1.46 +/- 0.88 versus 2.01 +/- 1.25, U = 947, p = 0.020).

CONCLUSIONS

There is a high prevalence of obesity and metabolic syndrome among patients with bipolar disorder. However, this did not appear to be associated with lithium use, when compared to those not on lithium. The lithium subgroup was also associated with lower prevalence of type II diabetes. Future prospective and intervention studies with larger sample sizes are necessary to further explore the association between lithium and insulin resistance, as well as its underlying mechanisms.

Validation of the 6-item Evening Chronotype Scale (ECS): a modified version of Composite Scale Morningness

In a previous study comparing two representative chronotype questionnaires to screen for delayed sleep-phase disorder, six items from the simplified language version of Composite Scale of Morningness (CSM) have been found to be useful and effective for screening evening-type person. In this study, we reverse coded the six items from CSM and named them Evening Chronotype Scale (ECS). The primary aim of this study was to examine the psychometric properties, validity, and test-retest reliability of the ECS when administered on mood disorder patients. The secondary aim was to further examine the relationship between circadian preferences and symptoms of mood disorders. The study sample was of 472 mood disorder patients including major depressive disorder, bipolar disorder I, and bipolar disorder II. The 13-item full version CSM and 6-item ECS were externally validated by self-reported sleep time, wake time, sleep latency, depressive symptoms, hypomanic symptoms, quality of life, and impulsivity. Cronbach's alpha was calculated for the internal consistency of the ECS, and the test-retest reliability analysis was also performed. Our results suggest that the ECS is a reliable and valid instrument to assess circadian preference in mood disorder patients. First, the ECS showed moderate to good internal consistency (Cronbach's alpha = 0.727). Also, it showed external validity comparable to that of the 13-item CSM. Participants who were more evening-oriented according to the ECS slept and woke up later, took longer time to fall asleep, showed more depressive and hypomanic symptoms, and showed lower quality of life and higher impulsivity. As circadian rhythm disruption has been shown to affect the regulation of mood symptoms in patients with mood disorders, assessment of circadian preferences may be crucial in clinical settings. We suggest that ECS appears to be an easy-to-use instrument that is reliable and valid.

Effect of lithium on circadian rhythm in bipolar disorder: A systematic review and meta-analysis

OBJECTIVES

Circadian rhythm disruption is commonly reported in patients with bipolar disorder. Lithium has been suggested to have effects on the circadian clock, the biological basis of the circadian rhythm. The objective of the current review was to review systematically the existing studies on the effect of lithium on circadian rhythm in patients with bipolar disorder.

METHODS

We systematically searched the scientific literature up to September 2020 for experimental or observational studies which measured circadian rhythm in bipolar patients taking lithium (in comparison with placebo or other active treatments) and carried out a meta-analysis. Circadian rest-activity was our primary outcome, but we also collected data about sleep quality and chronotype (Morningness-Eveningness). The protocol was registered in PROSPERO (CRD42018109790).

RESULTS

Four observational studies (n = 668) and one experimental study (n = 29) were included. Results from the meta-analysis suggest a potential association between lithium and shifts towards morningness (standardized mean difference [SMD]: 0.42, 95% confidence interval [CI]: -0.05 to 0.90). One cohort study with 21 days of follow-up found that patients treated with lithium had significantly larger amplitude (0.68, 0.01 to 1.36) when compared to anticonvulsants.

CONCLUSION

This review highlights the insufficient evidence to inform us about the effect of lithium on circadian rhythm. However, we found that chronotype can be a potential target for further exploration of biomarkers or biosignatures of lithium treatment in patients with bipolar disorder. Further studies with prospective and longitudinal study design, adopting actigraphy to monitor daily circadian rest-activity changes are needed.

Diurnal preference and depressive symptomatology: a meta-analysis

Eveningness, a preference for later sleep and rise times, has been associated with a number of negative outcomes in terms of both physical and mental health. A large body of evidence links eveningness to Major Depressive Disorder (MDD). However, to date, evidence quantifying this association is limited. The current meta-analysis included 43 effect sizes from a total 27,996 participants. Using a random-effects model it was demonstrated that eveningness is associated with a small effect size (Fisher's Z = - 2.4, 95% CI [- 0.27. - 0.21], p < 0.001). Substantial heterogeneity between studies was observed, with meta-regression analyses demonstrating a significant effect of mean age on the association between diurnal preference and depression. There was also evidence of potential publication bias as assessed by visual inspection of funnel plots and Egger's test. The association between diurnal preference and depression is small in magnitude and heterogenous. A better understanding of the mechanistic underpinnings linking diurnal preference to depression and suitably powered prospective studies that allow causal inference are required.

Associations of Sleep Insufficiency and Chronotype with Inflammatory Cytokines in College Students

PURPOSE

Sleep insufficiency and circadian rhythm disturbances in college students have become prominent. Current findings show that sleep insufficiency is closely related to inflammation. Studies on the correlation between chronotype and inflammatory factors are still lacking. Therefore, this research intended to examine the relationships between sleep duration, chronotype and inflammatory cytokines in young adults, and to estimate the correlation between chronotype and inflammatory cytokines stratified by sleep duration.

PATIENTS AND METHODS

We conducted a cross-sectional study in April and May 2019. Participants were recruited from two colleges located in central China. The Pittsburgh Sleep Quality Index (PSQI) and the Morning and Evening Questionnaire-5 (MEQ-5) were administered to assess sleep duration and chronotype. Sleep duration less than 7 hours was defined as insufficient sleep. Fasting venous blood was collected to measure plasma levels of inflammatory markers including IL-1β, IL-6, TNF-α and IL-10.

RESULTS

A total of 723 participants were included in this study, with a mean age of 18.68 years (standard deviation=0.99). After adjusting for confounding factors, the results of generalized linear model showed that sleep insufficiency was positively correlated with IL-1β, TNF-α and IL-10; and evening-types (E-types) were positively associated with the levels of IL-1β and IL-6 (p<0.05). Compared to the control group (sleep sufficiency and M-types), there were positive interaction effects of sleep insufficiency and neutral-types (N-types) on the levels of IL-1β, IL-6, TNF-α and IL-10 (p<0.05). The hierarchical regression model showed that N-types and E-types were positively correlated to the levels of IL-1β, IL-6, TNF-α and IL-10 among college students with sleep insufficiency (p<0.05).

CONCLUSION

The levels of inflammatory markers were higher among college students with sleep insufficiency and E-types. N-types and E-types were positively correlated with IL-1β, IL-6, TNF-α and IL-10 among college students with sleep insufficiency.

Higher prevalence of intentional self-harm in bipolar disorder with evening chronotype: A finding from the APPLE cohort study

BACKGROUND

Patients with bipolar disorder (BD) frequently self-harm, and this is strongly associated with subsequent suicide. This study investigated the association between chronotype and intentional self-harm in patients with BD.

METHODS

Two-hundred and five outpatients with BD participated in this cross-sectional study. Each participant's chronotype was evaluated using the Morningness-Eveningness Questionnaire, dividing the scores into three types: evening, 16-41 points; intermediate, 42-58 points; and morning, 59-86 points. Intentional self-harm over the past year were self-reported by questionnaire. Propensity score for evening chronotype was estimated from age, sex, socioeconomic factors, mood symptoms, total sleep time, age at the onset of BD, psychiatric inpatient history, family history of suicide, psychiatric comorbidity, and use of lithium.

RESULTS

Thirty-six (18%) of the 205 participants reported self-harm. A substantially higher proportion of the evening chronotype group self-harmed compared to the other groups (evening, 37%; intermediate, 13%; morning 10%). In multivariable analysis adjusted for propensity score, the odds ratio (OR) for self-harming significantly increased from morning to intermediate to evening chronotype (ORs: morning, 1.00; intermediate, 1.56; evening, 3.61; P for trend = 0.038).

LIMITATIONS

This study was a cross-sectional and small sample size.

CONCLUSIONS

Although a third factors, such as personality disorder or disrupted circadian rhythm, may have influenced, these findings suggest association between chronotype and intentional self-harm in BD patients.

Inactograms and objective sleep measures as means to capture subjective sleep problems in patients with a bipolar disorder

BACKGROUND

Sleep problems are common in bipolar disorders (BDs). To objectively characterize these problems in BDs, further methodological development is needed to capture subjective insomnia.

AIM

To test psychometric properties of the Athens Insomnia Scale (AIS), and associations with actigraphy-derived measures, applying modifications in actigraphy data processing to capture features of perturbed sleep in patients with a BD.

METHODS

Seventy-four patients completed the AIS and the Quick Inventory of Depressive Symptomatology, self-report (QIDS-SR-16). Locomotor activity was continuously recorded by wrist actigraphy for ≥10 consecutive days. We computed the sleep onset/offset, the center of daily inactivity (CenDI), as a proxy for chronotype, and the degree of consolidation of daily inactivity (ConDI), as a proxy for sleep-wake rhythm strength.

RESULTS

AIS showed good psychometric properties (Cronbach's alpha = 0.84; test-retest correlation = 0.84, P<.001). Subjective sleep problems correlated moderately with a later sleep phase (CenDI with AIS rho = 0.34, P = .003), lower consolidation (ConDI with AIS rho = -0.22, P = .05; with QIDS-SR-16 rho = -0.27, P = .019), later timing of sleep offset (with AIS rho = 0.49, P = ≤.001, with QIDS-SR-16 rho = 0.36, P = .002), and longer total sleep (with AIS rho = 0.29, P = .012, with QIDS-SR-16 rho = 0.41, P = ≤.001). While AIS was psychometrically more solid, correlations with objective sleep were more consistent across time for QIDS-SR-16.

CONCLUSIONS

AIS and QIDS-SR-16 are suitable for clinical screening of sleep problems among patients with a BD. Subjective insomnia associated with objective measures. For clinical and research purposes, actigraphy and data visualization on inactograms are useful for accurate longitudinal characterization of sleep patterns.

Measuring circadian function in bipolar disorders: Empirical and conceptual review of physiological, actigraphic, and self-report approaches

BACKGROUND

Interest in biological clock pathways in bipolar disorders (BD) continues to grow, but there has yet to be an audit of circadian measurement tools for use in BD research and practice.

PROCEDURE

The International Society for Bipolar Disorders Chronobiology Task Force conducted a critical integrative review of circadian methods that have real-world applicability. Consensus discussion led to the selection of three domains to review-melatonin assessment, actigraphy, and self-report.

RESULTS

Measurement approaches used to quantify circadian function in BD are described in sufficient detail for researchers and clinicians to make pragmatic decisions about their use. A novel integration of the measurement literature is offered in the form of a provisional taxonomy distinguishing between circadian measures (the instruments and methods used to quantify circadian function, such as dim light melatonin onset) and circadian constructs (the biobehavioral processes to be measured, such as circadian phase).

CONCLUSIONS

Circadian variables are an important target of measurement in clinical practice and biomarker research. To improve reproducibility and clinical application of circadian constructs, an informed systematic approach to measurement is required. We trust that this review will decrease ambiguity in the literature and support theory-based consideration of measurement options.

Chronotypes and affective disorders: A clock for mood?

Affective disorders are often accompanied by circadian rhythm disruption and the major symptoms of mental illness occur in a rhythmic manner. Chronotype, also known as circadian preference for rest or activity, is believed to exert a substantial influence on mental health. Here, we review the connection between chronotypes and affective disorders, and discuss the potential underlying mechanisms between these two phenomena.

Using Chronobiological Phenotypes to Address Heterogeneity in Bipolar Disorder

Bipolar disorder (BD) is a neuropsychiatric mood disorder characterized by recurrent episodes of mania and depression in addition to disruptions in sleep, energy, appetite, and cognitive functions-rhythmic behaviors that typically change on daily cycles. BD symptoms can also be provoked by seasonal changes, sleep, and/or circadian disruption, indicating that chronobiological factors linked to the circadian clock may be a common feature in the disorder. Research indicates that BD exists on a clinical spectrum, with distinct subtypes often intersecting with other psychiatric disorders. This heterogeneity has been a major challenge to BD research and contributes to problems in diagnostic stability and treatment outcomes. To address this heterogeneity, we propose that chronobiologically related biomarkers could be useful in classifying BD into objectively measurable phenotypes to establish better diagnoses, inform treatments, and perhaps lead to better clinical outcomes. Presently, we review the biological basis of circadian time keeping in humans, discuss the links of BD to the circadian clock, and pre-sent recent studies that evaluated chronobiological measures as a basis for establishing BD phenotypes. We conclude that chronobiology may inform future research using other novel techniques such as genomics, cell biology, and advanced behavioral analyses to establish new and more biologically based BD phenotypes.

[The prognostic significance of biological rhythms assessment in depression]

AIM

To assess the prognostic significance of biological rhythms in depression on the example of the individual chronotype.

MATERIAL AND METHODS

One hundred patients (women 68%), aged 18-77 years, mean age 48±16, were examined before and after 8 weeks of treatment. The Morningness-Eveningness Questionnaire (MEQ) was used. Treatment response (a decrease of 50% in total MADRS scores to the 8^th week of treatment) and dynamics of depression severity (dMADRS; R) were assessed.

RESULTS AND CONCLUSION

Evening chronotype was found to be associated with poor prognosis. TCAs and SSRIs were more effective in eveningness, other antidepressants - in morningness. MEQ changes during and after treatment may reflect the resynchronizing activity of antidepressants.

Chronotype and Mental Health: Recent Advances

PURPOSE OF REVIEW

Evening chronotype is increasingly recognized as a correlate of, and perhaps a contributor to, mental illness. The current review evaluates recent evidence for the association between chronotype and mental illness and putative mechanisms underlying the association, while highlighting methodological advances and areas of research that are relatively under-examined in the literature.

RECENT FINDINGS

While evening chronotype is most consistently associated with severity of mood disorder symptoms, emerging evidence implicates evening chronotype as a transdiagnostic correlate of substance use severity, anxiety symptoms, attentional difficulties, and maladaptive behaviors such as aggression. Longitudinal studies point to the possibility that evening chronotype precedes problematic substance use, depression, and anxiety. Neural processes related to reward and affective regulation may underlie associations between evening chronotype and illness. The literature on chronotype and mental illness has evolved to (1) include associations with a broader range of psychiatric symptom profiles; (2) explore underlying mechanisms; and (3) expand on earlier research using objective measures and more sophisticated study designs. In addition to further mechanistic research, additional work is needed to examine the stability and key subcomponents of the chronotype construct, as well as more attention to pediatric and special populations. This research is needed to clarify the chronotype-mental health relationship, and to identify how, when, and what aspects of chronotype can be targeted via therapeutic interventions.