The effect of mood on sleep onset latency and REM sleep in interepisode bipolar disorder

Methods for REM Sleep Density Analysis: A Scoping Review

Rapid eye movements (REM) sleep density is the parameter proposed to explain the variability in the amount of eye movements during REM sleep. Alterations in REM sleep density have been proposed as a screening criterion for individuals with depression and other mental health conditions, but its accuracy has not been properly evaluated. The lack of consensus and the variability of the methods used to score it reduces the external validity of the results, hindering an adequate analysis of its diagnostic accuracy and clinical applicability. This scoping review aimed to identify and quantify the methods used to score REM sleep density, describing their main characteristics. A literature search was conducted in PubMed, Scopus, PsycInfo, and Web of Science. Only studies with objective measures for REM sleep density analysis in individuals with depression were considered eligible. The final sample comprised 57 articles, covering 64 analyses of REM sleep density. The relative frequency methods were the predominant measurement parameter for analyzing REM sleep density across studies. The most frequently adopted REM estimation unit was the number of REM events followed by mini-epochs containing REM. The most common unit of measurement were frequency/time measures. The results demonstrate that there is no consistency in the methods used to calculate REM sleep density in the literature, and a high percentage of studies do not describe their methods in sufficient detail. The most used method was the number of REM episodes per minute of REM sleep, but its use is neither unanimous nor consensual. The methodological inconsistencies and omissions among studies limit the replicability, comparability, and clinical applicability of REM sleep density. Future guidelines should discuss and include a specific methodology for the scoring of REM sleep density, so it can be consensually implemented in clinical services and research.

Good sleep is a mood buffer for young women during menses

STUDY OBJECTIVES

We sought to elucidate the interaction between sleep and mood considering menstrual cycle phase (menses and non-menses portions of the cycle) in 72 healthy young women (18-33 years) with natural, regular menstrual cycles and without menstrual-associated disorders. This work fills a gap in literature of examining mood in context of sleep and menstrual cycle jointly, rather than individually.

METHODS

Daily subjective measures of sleep and mood, and date of menses were remotely, digitally collected over a 2-month period. Each morning, participants rated their sleep on the previous night, and each evening participants rated the extent of positive and negative mood for that day. Objective sleep was tracked with a wearable (ŌURA ring) during month 2 of the study. Time-lag cross-correlation and mixed linear models were used to analyze the significance and directionality of the sleep-mood relationship, and how the interaction between menstrual cycle status and sleep impacted mood levels.

RESULTS

We found that menstrual status alone did not impact mood. However, subjective sleep quality and menstrual status interacted to impact positive mood (p < .05). After a night of perceived poor sleep quality, participants reported lower positive mood during menses compared to non-menses portions of the cycle, while after a night of perceived good sleep quality participants reported equivalent levels of positive mood across the cycle.

CONCLUSIONS

We suggest that the perception of good sleep quality acts as a mood equalizer, with good sleep providing a protective buffer to positive mood across the menstrual cycle.

Effects of red light on sleep and mood in healthy subjects and individuals with insomnia disorder

Introduction

This study aimed to determine the influence of red light on objective sleep and the relationship between mood and sleep among individuals with insomnia disorder (ID).

Method

57 individuals with insomnia symptoms and 57 healthy participants were randomly divided into three groups (red- and white-light groups, and the black control group), which received different light treatments for 1 h before bedtime. The emotions and subjective alertness of participants were evaluated using Positive and Negative Affect Schedule scales (PANAS) and Karolinska Sleepiness Scale (KSS), their sleeping data were recorded using polysomnography (PSG).

Result

The negative emotion scores were higher in the healthy subject-red light (HS-RL) group than in the HS-white light (WL) and HS-black control (BC) groups (p < 0.001). The anxiety and negative emotion scores were higher in the ID-RL group than in the ID-WL and ID-BC groups (p = 0.007 and p < 0.001, respectively). The KSS scores were lower in the RL group than in the WL and BC groups for both HS and ID group (both p < 0.001). The SOL was shorter in the HS-RL group than in HS-WL group (p = 0.019). Compared with the HS-BC group, the HS-RL group had an increase in microarousal index (MAI) and N1% (p = 0.034 and p = 0.021, respectively), while the total sleep time (TST) and sleep efficiency (SE) decreased (p = 0.001 and p < 0.001, respectively). Compared with the ID-WL group, the SOL was shorter in the ID-RL group (p = 0.043), while TST, SE, number of microarousals (NMA), and numbers of cycles of REM period were increased (p = 0.016, p = 0.046, p = 0.001, and p = 0.041, respectively). Compared with the ID-BC group, the ID-RL group had increases in the SOL, WASO, and the numbers of cycles and NMA in REM period (p = 0.038, p = 0.005, p = 0.045, and p = 0.033, respectively), and a decrease in SE (p = 0.014). The effects of ID-WL (vs. ID-RL group) and ID-BC (vs. ID-RL group) on SOL were mediated by negative emotions (mediating effects were - 37.626 and - 33.768, respectively).

Conclusion

Red light can increase subjective alertness, anxiety, and negative emotions in both healthy subjects and people with ID, which can affect sleep directly or indirectly via the mediating effect of negative emotions.

The Role of Emotion Dysregulation in the Relationship Between Sleep Disturbances and PTSD Symptom Severity

ABSTRACT

Emotion dysregulation is implicated in the development, maintenance, and treatment of sleep disturbances and posttraumatic stress disorder (PTSD) separately. However, few studies have assessed interactions among these variables. To address this gap, this study examined whether the associations of sleep quality and sleep quantity with PTSD severity were stronger at higher levels of negative and positive emotion dysregulation in a community sample of 199 trauma-exposed individuals. This study found that both poorer sleep quality and lower sleep quantity were associated with greater PTSD severity at low to average (but not high) levels of negative emotion dysregulation. Positive emotion dysregulation did not moderate the relationships between sleep quality or quantity and PTSD severity. Exploratory additive multiple moderation analyses showed significant associations between poorer sleep quality and lower sleep quantity with greater PTSD severity at low to average levels of negative emotion dysregulation, coupled with any level of positive emotion dysregulation. Findings inform theoretical perspectives on the sleep-PTSD relationship and clinical applications of targeting emotion dysregulation in the treatment of sleep disturbances and PTSD symptoms for trauma-exposed individuals.

Pre-sleep affect predicts subsequent REM frontal theta in nonlinear fashion

Pre-sleep affect is thought to influence sleep, but associations with both sleep architecture and the electroencephalographic (EEG) power spectrum are mixed. In this pre-registered study, we assessed negative valence and arousal 1 h pre-sleep in 52 adults drawn from the community, then recorded one night of polysomnography (PSG) in participants' own homes. Pre-sleep affect was not associated with nonrapid eye movement (NREM) or rapid eye movement (REM) sleep architecture parameters, but we did observe inverted U-shaped relationships between both negative valence and arousal and REM frontal theta power, such that theta power was highest at moderate negative valence and arousal, and lowest at either affective extreme. When entered into a model together, both valence and arousal accounted for independent variance. Secondary analyses revealed a similar quadratic association with pre-sleep positive valence, suggesting a nonspecific effect of pre-sleep valence on REM frontal theta. Robustness checks confirmed that effects were not explained by homeostatic sleep pressure or sleep timing. Our results suggest that mixed findings in the literature may reflect different ends of a quadratic function, underscoring the importance of assessing how different components of pre-sleep affect relate to sleep.

[Hypersomnia in mental disorders]

Hypersomnia is a group of diseases that share the main symptom - excessive daytime sleepiness, not caused by disturbances in nocturnal sleep or circadian rhythms. Excessive daytime sleepiness is present in 15.6% of adults in the world, a Russian study showed a prevalence of 39.2%. It is associated with a wide range of comorbidities, including obesity and mental disorders, on the other hand, the presence of hypersomnia increases the likelihood of mental illness. People with hypersomnia are more likely to take medications, have a decreased quality of life, spend more health care resources, and more often receive social benefits. The heritability is estimated to be about 40% for sleep duration and 17% for excessive daytime sleepiness. Hypersomnia in mental disorders is secondary. It most often occurs in patients with depression or bipolar disorder. To assess the severity of daytime sleepiness, self-observation and objective methods, including the multiple sleep latency test, actigraphy, polysomnography, are used. In the differential diagnosis of hypersomnia in psychiatric disorders, it is necessary to make a differential diagnosis with hypersomnia caused by taking medications or other substances and insufficient sleep syndrome. The etiology of prolonged sleep in psychiatric disorders is complex, and includes biological and psychological causes. The relationship between self-reported hypersomnia and sleep actually obtained is still unclear. Results of daily polysomnography show a significant increase in time in bed during the day and night (clinophilia). Therapy of hypersomniac syndromes should be done taking into account the etiology of the disease. In cases of secondary nature, the main efforts should be directed to the treatment of the underlying mental disorder causing somnolence.

People with passive sleep delay have more severe depression and sleep problems than those with active sleep delays-a cross-sectional study after the COVID-19 pandemic

Objective

This study was designed to investigate the effect of different types of sleep delay in depression and sleep characteristics after the pandemic. Meanwhile, risk factors for depression were also explored.

Methods

The survey was conducted in Wuhan from March 1 to May 30, 2021, and participants were recruited through a snowball process. A total of 1,583 people with sleep delays responded to the invitation, of which 1,296 were enrolled. Participants filled out a questionnaire including social demographics, sleep characteristics, Social Support Rating Scale (SSRS), Pittsburgh Sleep Quality Index (PSQI) and Patient Health Questionnaire-9 (PHQ-9).

Results

There were no significant differences in sex, social support and level of education between the two types of sleep delay (p = 0.961, p = 0.110, p = 0.090), but the average age of the passive sleep delay group was higher (p = 0.015). And most people with active sleep delay were caused by the use of electronic devices (73.6%), while most people with passive sleep delay were caused by work or study tasks (73.2%), with a significant difference between the two groups (p < 0.001). People who actively delayed sleep had more regular sleep (p < 0.001), better sleep quality and longer sleep duration (p < 0.001, p < 0.001). In addition, although they delayed sleep more frequently (p < 0.001), they had significantly lower depression degree than people who passively delayed sleep (p < 0.001).

Conclusions

Passive sleep delays, usually caused by work or study, has higher levels of depression and more adverse sleep behaviors than active sleep delay. The findings help further understand the effects of delayed sleep and provide insight for people with delayed sleep to evaluate their own condition. Future studies are required to standardize and accurately classify sleep delay and further explore it.

Sleep and affect: A conceptual review

Everyday experience suggests that sleep and affect are closely linked, with daytime affect influencing how we sleep, and sleep influencing subsequent affect. Yet empirical evidence for this bidirectional relationship between sleep and affect in non-clinical adult samples remains mixed, which may be due to heterogeneity in both construct definitions and measurement. This conceptual review proposes a granular framework that deconstructs sleep and affect findings according to three subordinate dimensions, namely domains (which are distinct for sleep and affect), methods (i.e., self-report vs. behavioral/physiological measures), and timescale (i.e., shorter vs. longer). We illustrate the value of our granular framework through a systematic review of empirical studies published in PubMed (N = 80 articles). We found that in some cases, particularly for sleep disturbances and sleep duration, our framework identified robust evidence for associations with affect that are separable by domain, method, and timescale. However, in most other cases, evidence was either inconclusive or too sparse, resulting in no clear patterns. Our review did not find support for granular bidirectionality between sleep and affect. We suggest a roadmap for future studies based on gaps identified by our review and discuss advantages and disadvantages of our granular dimensional framework.

Sleep characteristics of Iranian people and their effects on daytime functioning: a population-based study

Sleep characteristics vary between populations. Detrimental sleep habits have cognitive consequences leading to daytime functioning debilitation. Until now no study has been done to investigate sleep characteristics in Iran thoroughly. In this study, we aimed to evaluate Iranians’ sleep characteristics and their association with daytime functioning. We conducted a population-based study from January 2017 to May 2019 on people more than 18 years old who lived in 11 urban destricts and 3 rural areas of Tehran, Iran. We randomly selected the participants using a multistage random stratified clustered sampling method. We obtained the participants’ demographic and anthropometric characteristics and details of bedtime, sleep duration, sleep onset latency, wake-up time and sleep impact on daytime functioning. Logistic regression model was used to assess the relationship between sleep characteristics) and daytime functioning. In total, 1830 people with a mean age of 40.83 years participated in the study. The gender distribution of the participants was even, and 70.98% of them were married. After adjusting for age and sex, the following three factors had a significant impact on daytime functioning: bedtime, sleep onset latency, and sleep duration. (OR = 1.12, P < 0.038, OR = 1.01, P < 0.011, and OR = 0.99, P = 0.01, respectively). We also found that longer sleep onset latency (P = 0.004) and shorter sleep durations (P = 0.029) significantly interfere with daytime functioning. Iranians’ sleep characteristics, especially their sleep duration and sleep onset latency, are associated with their daytime function. Interventions on people’s sleep hygiene are warranted to promote healthier sleep behaviors among Iranians, considering the high impact of current sleep characteristics on their daily lives.

External Auditory Stimulation as a Non-Pharmacological Sleep Aid

The increased demand for well-being has fueled interest in sleep. Research in technology for monitoring sleep ranges from sleep efficiency and sleep stage analysis to sleep disorder detection, centering on wearable devices such as fitness bands, and some techniques have been commercialized and are available to consumers. Recently, as interest in digital therapeutics has increased, the field of sleep engineering demands a technology that helps people obtain quality sleep that goes beyond the level of monitoring. In particular, interest in sleep aids for people with or without insomnia but who cannot fall asleep easily at night is increasing. In this review, we discuss experiments that have tested the sleep-inducing effects of various auditory stimuli currently used for sleep-inducing purposes. The auditory stimulations were divided into (1) colored noises such as white noise and pink noise, (2) autonomous sensory meridian response sounds such as natural sounds such as rain and firewood burning, sounds of whispers, or rubbing various objects with a brush, and (3) classical music or a preferred type of music. For now, the current clinical method of receiving drugs or cognitive behavioral therapy to induce sleep is expected to dominate. However, it is anticipated that devices or applications with proven ability to induce sleep clinically will begin to appear outside the hospital environment in everyday life.

Do Daytime Activity, Mood and Unit Tumult Predict Nighttime Sleep Quality of Long-Term Care Residents?

Based on the premise that stressors can have a cumulative effect on people with dementia throughout the day that contributes to negative consequences later in the day, we examined if daytime activity, unit tumult, and mood were associated with sleep quality. A convenience sample of 53 long-term care (LTC) residents participated in this correlational study. Objective sleep quality was measured using actigraphy, and comorbid illness and level of dementia were control variables. Half of the sample had a sleep efficiency that was less than 80% and was awake for more than 90 min at night. Comorbid illness, negative mood at bedtime, and daytime activity level accounted for 26.1% of the variance in total sleep minutes. Census changes and the use of temporary agency staff were associated with poor sleep. Findings suggest daytime activity, mood at bedtime, and unit tumult should be considered when designing and testing interventions to improve sleep quality.

Self-reported suboptimal sleep and receipt of sleep assessment and treatment among persons with and without a mental health condition in Australia: a cross sectional study

BACKGROUND

Poor sleep and poor mental health go hand in hand and, together, can have an adverse impact on physical health. Given the already disproportionate physical health inequities experienced by people with a mental health condition worldwide, the need to consider and optimise sleep has been highlighted as a means of improving both physical and mental health status. Sleep recommendations recently developed by the United States' National Sleep Foundation incorporate a range of sleep parameters and enable the identification of 'suboptimal' sleep. Among community-dwelling persons with and without a 12-month mental health condition in Australia, this study reports: [1] the prevalence of 'suboptimal' sleep and [2] rates of sleep assessment by a health care clinician/service and receipt of and desire for sleep treatment.

METHODS

A descriptive study (N = 1265) was undertaken using self-report data derived from a cross-sectional telephone survey of Australian adults, undertaken in 2017.

RESULTS

Fifteen per cent (n = 184) of participants identified as having a mental health condition in the past 12 months. Across most (7 of 8) sleep parameters, the prevalence of suboptimal sleep was higher among people with a mental health condition, compared to those without (all p < 0.05). The highest prevalence of suboptimal sleep for both groups was seen on measures of sleep duration (36-39% and 17-20% for people with and without a mental health condition, respectively). In terms of sleep assessment and treatment, people with a mental health condition were significantly more likely to: desire treatment (37% versus 16%), have been assessed (38% versus 12%) and have received treatment (30% versus 7%).

CONCLUSIONS

The prevalence of suboptimal sleep among persons with a mental health condition in Australia is significantly higher than those without such a condition, and rates of assessment and treatment are low for both groups, but higher for people with a mental health condition. Population health interventions, including those delivered as part of routine health care, addressing suboptimal sleep are needed.

Sleep quality and emotional reactivity cluster in bipolar disorders and impact on functioning

Objective:

Bipolar disorders (BD) are characterized by sleep disturbances and emotional dysregulation both during acute episodes and remission periods. We hypothesized that sleep quality (SQ) and emotional reactivity (ER) defined clusters of patients with no or abnormal SQ and ER and we studied the association with functioning.

Method:

We performed a bi-dimensional cluster analysis using SQ and ER measures in a sample of 533 outpatients patients with BD (in remission or with subsyndromal mood symptoms). Clusters were compared for mood symptoms, sleep profile and functioning.

Results:

We identified three clusters of patients: C1 (normal ER and SQ, 54%), C2 (hypo-ER and low SQ, 22%) and C3 (hyper-ER and low SQ, 24%). C1 was characterized by minimal mood symptoms, better sleep profile and higher functioning than other clusters. Although highly different for ER, C2 and C3 had similar levels of subsyndromal mood symptoms as assessed using classical mood scales. When exploring sleep domains, C2 showed poor sleep efficiency and a trend for longer sleep latency as compared to C3. Interestingly, alterations in functioning were similar in C2 and C3, with no difference in any of the sub-domains.

Conclusion:

Abnormalities in ER and SQ delineated three clusters of patients with BD and significantly impacted on functioning.

Internalizing symptoms and sleep outcomes in urban children with and without asthma

STUDY OBJECTIVES

This study examines associations between internalizing symptoms and sleep in a sample of urban children with and without asthma, whether asthma status moderates these associations, and whether associations differ by ethnic group.

METHODS

Participants were Latino, African American (AA), and non-Latino white (NLW) urban 7- to 9-year-olds with (n = 259) and without (n = 122) persistent asthma. Teacher-reported internalizing symptoms (anxiety, depressive, and somatic) were assessed using the Behavioral Assessment System for Children-2. Sleep duration, variability in sleep duration, and sleep onset latency were assessed with actigraphy.

RESULTS

Depressive symptoms were associated with variability in sleep duration and shorter sleep onset latency; somatic symptoms were associated with variability in sleep duration. In Latino children, depressive symptoms were associated with shorter sleep onset latency. In AA children, anxiety, depressive, and somatic symptoms were associated with variability in sleep duration; somatic symptoms were related to variability in sleep duration in NLW children. The association between internalizing symptoms and sleep outcomes did not differ by asthma status. However, asthma status was a significant moderator when examining these associations by ethnic group: among AA children, depressive symptoms were significantly related to variability in sleep duration only in children with asthma, whereas in NLW children, somatic symptoms were related to variability in sleep duration only in children without asthma.

CONCLUSIONS

Targeting specific internalizing symptoms and sleep outcomes may be beneficial in the development of interventions tailored for urban children with and without asthma from specific ethnic groups.

How does music aid sleep? literature review

With the growth of interest in using music to treat insomnia, there is a need to collect and evaluate the literature. This paper reviews disparate literature and assesses the various kinds of assertions and hypotheses made by researchers about music's efficacy in assisting sleep. Six main researcher proposed reasons (RPR) for how music aids sleep were identified in the literature: (1) relaxation, where music encourages physiological or psychological relaxation; (2) distraction, where music acts as a focal point to distract from inner stressful thoughts; (3) entrainment, synchronization of biological rhythms to beat structures in music; (4) masking, obscuring noxious background noise with music; (5) enjoyment, listening to preferred, emotionally relatable or pleasant music; and (6) expectation, individuals cultural beliefs around music. We evaluated each RPR in terms of the evidence available in the extant literature. Masking RPR was identified as having support for improving sleep. Relaxation, distraction and enjoyment RPR had mixed levels of support. Expectation RPR had possible support. Entrainment had mixed possible support. The paper discusses interactions between RPRs, and a call is made to turn research attention to sequencing the RPRs and possible RPR mediators, with relaxation being a likely mediator of several RPRs.

Sleep alterations in pediatric bipolar disorder versus attention deficit disorder

Bipolar disorder (BD) and attention deficit/hyperactivity disorder (ADHD) share numerous clinical features, which can make the differential diagnosis challenging. Studies conducted in adults suggest that patients with BD and ADHD have different sleep patterns. However, in pediatric populations, data on these potential differences are scant. The present preliminary study was conducted to identify potential differences in sleep alterations among youths diagnosed with BD or ADHD compared to healthy controls (HC). A total of 26 patients diagnosed with BD (n = 13) or ADHD (n = 13) were compared to 26 sex- and age-matched HC ([HC_BD], n = 13, and [HC_ADHD], n = 13). All participants underwent polysomnography. The mean duration of stage N2 sleep was shorter in the BD group than in controls (HC_BD). The BD group also had higher (non-significant) REM density (REMd) scores than controls while mean REMd scores were lower in the ADHD group versus controls. Compared to the ADHD group, the BD group presented a shorter N2 stage, a longer first REM sleep duration (R1), and greater REMd. According to our findings, these three variables-N2 stage, REMd, and R1-appear to differentiate patients with BD from those with ADHD and from HC.

Sleep spindles in bipolar disorder - a comparison to healthy control subjects

OBJECTIVE

Bipolar disorder is a severe mental disorder for which currently no reliable biomarkers exist. It has been shown that patients with schizophrenia but not with unipolar depression have a reduced density of fast sleep spindles during N2 sleep. The aim of this study was to assess fast sleep spindle density in euthymic patients with bipolar disorder.

METHODS

Patients with bipolar disorder (n = 24) and healthy control subjects (n = 25) were assessed using all-night polysomnography. Sleep spindles within stage N2 sleep were identified by visual inspection and subdivided into fast (>13 Hz) and slow (≤13 Hz) spindles. All spindles were subsequently characterised by density, frequency, amplitude, duration and coherence.

RESULTS

Euthymic patients with bipolar disorder were found to have a reduced density and a lower mean frequency of fast spindles. Slow spindle density and frequency did not differ between groups. There were no differences regarding amplitude, duration or coherence.

CONCLUSIONS

A reduction in fast spindle density during N2 sleep points towards thalamic dysfunction as a potential neurobiological mechanism of relevance in bipolar disorder. In addition, a reduced sleep spindle density could be interpreted as a common endophenotype shared with schizophrenia but not unipolar depression and may - if replicated - be of utility in early recognition and risk stratification.

You'll feel better in the morning: slow wave activity and overnight mood regulation in interepisode bipolar disorder

BACKGROUND

Sleep disturbances are prominent correlates of acute mood episodes and inadequate recovery in bipolar disorder (BD), yet the mechanistic relationship between sleep physiology and mood remains poorly understood. Using a series of pre-sleep mood inductions and overnight sleep recording, this study examined the relationship between overnight mood regulation and a marker of sleep intensity (non-rapid eye movement sleep slow wave activity; NREM SWA) during the interepisode phase of BD.

METHODS

Adults with interepisode BD type 1 (BD; n = 20) and healthy adult controls (CTL; n = 23) slept in the laboratory for a screening night, a neutral mood induction night (baseline), a happy mood induction night, and a sad mood induction night. NREM SWA (0.75-4.75 Hz) was derived from overnight sleep EEG recordings. Overnight mood regulation was evaluated using an affect grid pleasantness rating post-mood induction (pre-sleep) and the next morning.

RESULTS

Overnight mood regulation did not differ between groups following the sad or happy inductions. SWA did not significantly change for either group on the sad induction night compared with baseline. In BD only, SWA on the sad night was related to impaired overnight negative mood regulation. On the happy induction night, SWA increased relative to baseline in both groups, though SWA was not related to overnight mood regulation for either group.

CONCLUSIONS

These findings indicate that SWA disruption may play a role in sustaining negative mood state from the previous night in interepisode BD. However, positive mood state could enhance SWA in bipolar patients and healthy adults.

Sleep disturbance may impact treatment outcome in bipolar disorder: A preliminary investigation in the context of a large comparative effectiveness trial

BACKGROUND

Bipolar patients experience sleep disturbances during and between mood episodes. Yet the impact of sleep on treatment with different medications has not been fully explored. The purpose of this paper is to explore the potential impact of poor sleep at baseline on outcomes in a randomized effectiveness trial of quetiapine and lithium.

METHODS

The Bipolar CHOICE study was a 6-month, parallel group, multisite randomized controlled trial. Participants with bipolar disorder (N = 482; 59% female and age 18-70 years) received quetiapine or lithium. Patients were allowed to also receive adjunctive personalized treatments, which were guideline-informed, empirically-based medications added to treatment as needed. Medication changes were recorded as necessary clinical adjustments (NCA). Fisher's exact tests, mixed-regression models, and Mann-Whitney U tests were used to assess demographic and clinical characteristics as well as whether sleep disturbance would predict outcomes.

RESULTS

63% of patients had baseline sleep disturbance. Individuals with sleep disturbance had worse bipolar illness severity, greater severity of depression, mania, anxiety, irritability, and psychosis, were less likely to have sustained response (17% vs. 29%; adjusted RR: 0.55, 95% CI: 0.38-0.78, p = 0.0006) and had more NCAs (median 0.71 vs. 0.59, p = 0.03).

LIMITATIONS

Our findings were limited by how we defined sleep disturbance, and by how severity of sleep disturbance was assessed with one item with a non-sleep specific measure.

CONCLUSIONS

Baseline sleep disturbance was associated with more severe bipolar symptoms and worse 6-month outcomes. Further research is warranted on improving sleep in bipolar disorder, especially the role of psychosocial interventions.

Reconsidering Emotion Dysregulation

This article aims to review the concept of emotion dysregulation, focusing on issues related to its definition, meanings and role in psychiatric disorders. Articles on emotion dysregulation published until May 2016 were identified through electronic database searches. Although there is no agreement about the definition of emotion dysregulation, the following five overlapping, not mutually exclusive dimensions of emotion dysregulation were identified: decreased emotional awareness, inadequate emotional reactivity, intense experience and expression of emotions, emotional rigidity and cognitive reappraisal difficulty. These dimensions characterise a number of psychiatric disorders in various proportions, with borderline personality disorder and eating disorders seemingly more affected than other conditions. The present review contributes to the literature by identifying the key components of emotion dysregulation and by showing how these permeate various forms of psychopathology. It also makes suggestions for improving research endeavours. Better understanding of the various dimensions of emotion dysregulation will have implications for clinical practice. Future research needs to address emotion dysregulation in all its multifaceted complexity so that it becomes clearer what the concept encompasses.

Positive and Negative Affect as Links Between Social Anxiety and Depression: Predicting Concurrent and Prospective Mood Symptoms in Unipolar and Bipolar Mood Disorders

The co-occurrence of social anxiety and depression is associated with increased functional impairment and a more severe course of illness. Social anxiety disorder is unique among the anxiety disorders in sharing an affective profile with depression, characterized by low levels of positive affect (PA) and high levels of negative affect (NA). Yet it remains unclear how this shared affective profile contributes to the covariation of social anxiety and depressive symptoms. We examined whether self-reported PA and NA accounted for unique variance in the association between social anxiety and depressive symptoms across three groups (individuals with remitted bipolar disorder, type I [BD; n = 32], individuals with remitted major depressive disorder [MDD; n = 31], and nonpsychiatric controls [n = 30]) at baseline and follow-ups of 6 and 12 months. Low levels of PA, but not NA, accounted for unique variance in both concurrent and prospective associations between social anxiety and depression in the BD group; in contrast, high levels of NA, but not PA, accounted for unique variance in concurrent and prospective associations between social anxiety and depression in the MDD group. Limitations include that social anxiety and PA/NA were assessed concurrently and all measurement was self-report. Few individuals with MDD/BD met current diagnostic criteria for social anxiety disorder. There was some attrition at follow-up assessments. Results suggest that affective mechanisms may contribute to the high rates of co-occurrence of social anxiety and depression in both MDD and BD. Implications of the differential role of PA and NA in the relationship between social anxiety and depression in MDD and BD and considerations for treatment are discussed.

The Current Status of the Ketogenic Diet in Psychiatry

BACKGROUND

The ketogenic diet (KD) has been used in treatment-resistant epilepsy since the 1920s. It has been researched in a variety of neurological conditions in both animal models and human trials. The aim of this review is to clarify the potential role of KD in psychiatry.

METHODS

Narrative review of electronic databases PubMED, PsychINFO, and Scopus.

RESULTS

The search yielded 15 studies that related the use of KD in mental disorders including anxiety, depression, bipolar disorder, schizophrenia, autism spectrum disorder (ASD), and attention deficit hyperactivity disorder (ADHD). These studies comprised nine animal models, four case studies, and two open-label studies in humans. In anxiety, exogenous ketone supplementation reduced anxiety-related behaviors in a rat model. In depression, KD significantly reduced depression-like behaviors in rat and mice models in two controlled studies. In bipolar disorder, one case study reported a reduction in symptomatology, while a second case study reported no improvement. In schizophrenia, an open-label study in female patients (n = 10) reported reduced symptoms after 2 weeks of KD, a single case study reported no improvement. In a brief report, 3 weeks of KD in a mouse model normalized pathological behaviors. In ASD, an open-label study in children (n = 30) reported no significant improvement; one case study reported a pronounced and sustained response to KD. In ASD, in four controlled animal studies, KD significantly reduced ASD-related behaviors in mice and rats. In ADHD, in one controlled trial of KD in dogs with comorbid epilepsy, both conditions significantly improved.

CONCLUSION

Despite its long history in neurology, the role of KD in mental disorders is unclear. Half of the published studies are based on animal models of mental disorders with limited generalizability to the analog conditions in humans. The review lists some major limitations including the lack of measuring ketone levels in four studies and the issue of compliance to the rigid diet in humans. Currently, there is insufficient evidence for the use of KD in mental disorders, and it is not a recommended treatment option. Future research should include long-term, prospective, randomized, placebo-controlled crossover dietary trials to examine the effect of KD in various mental disorders.

REM-Enriched Naps Are Associated with Memory Consolidation for Sad Stories and Enhance Mood-Related Reactivity

Emerging evidence suggests that emotion and affect modulate the relation between sleep and cognition. In the present study, we investigated the role of rapid-eye movement (REM) sleep in mood regulation and memory consolidation for sad stories. In a counterbalanced design, participants (n = 24) listened to either a neutral or a sad story during two sessions, spaced one week apart. After listening to the story, half of the participants had a short (45 min) morning nap. The other half had a long (90 min) morning nap, richer in REM and N2 sleep. Story recall, mood evolution and changes in emotional response to the re-exposure to the story were assessed after the nap. Although recall performance was similar for sad and neutral stories irrespective of nap duration, sleep measures were correlated with recall performance in the sad story condition only. After the long nap, REM sleep density positively correlated with retrieval performance, while re-exposure to the sad story led to diminished mood and increased skin conductance levels. Our results suggest that REM sleep may not only be associated with the consolidation of intrinsically sad material, but also enhances mood reactivity, at least on the short term.

Affective Disruption from Social Rhythm and Behavioral Approach System (BAS) Sensitivities: A Test of the Integration of the Social Zeitgeber and BAS Theories of Bipolar Disorder

The Behavioral Approach System (BAS)/Reward Hypersensitivity Theory and the Social Zeitgeber Theory are two biopsychosocial theories of bipolar spectrum disorders (BSD) that may work together to explain affective dysregulation. The present study examined whether BAS sensitivity is associated with affective symptoms via a) increased social rhythm disruption in response to BAS-relevant life events, or b) greater exposure to BAS events leading to social rhythm disruption and subsequent symptoms. Results indicated that high BAS individuals were more likely to experience social rhythm disruption following BAS-relevant events. Social rhythm disruption mediated the association between BAS-relevant events and symptoms (hypothesis a). High BAS individuals experienced significantly more BAS-relevant events, which predicted greater social rhythm disruption, which predicted greater levels of affective symptoms (hypothesis b). Individuals at risk for BSD may be sensitive to BAS-relevant stimuli, experience more BAS-relevant events, and experience affective dysregulation due to the interplay of the BAS and circadian rhythms.

Happiness increases distraction by auditory deviant stimuli

Rare and unexpected changes (deviants) in an otherwise repeated stream of task-irrelevant auditory distractors (standards) capture attention and impair behavioural performance in an ongoing visual task. Recent evidence indicates that this effect is increased by sadness in a task involving neutral stimuli. We tested the hypothesis that such effect may not be limited to negative emotions but reflect a general depletion of attentional resources by examining whether a positive emotion (happiness) would increase deviance distraction too. Prior to performing an auditory-visual oddball task, happiness or a neutral mood was induced in participants by means of the exposure to music and the recollection of an autobiographical event. Results from the oddball task showed significantly larger deviance distraction following the induction of happiness. Interestingly, the small amount of distraction typically observed on the standard trial following a deviant trial (post-deviance distraction) was not increased by happiness. We speculate that happiness might interfere with the disengagement of attention from the deviant sound back towards the target stimulus (through the depletion of cognitive resources and/or mind wandering) but help subsequent cognitive control to recover from distraction.

Hypersomnia subtypes, sleep and relapse in bipolar disorder

BACKGROUND

Though poorly defined, hypersomnia is associated with negative health outcomes and new-onset and recurrence of psychiatric illness. Lack of definition impedes generalizability across studies. The present research clarifies hypersomnia diagnoses in bipolar disorder by exploring possible subgroups and their relationship to prospective sleep data and relapse into mood episodes.

METHOD

A community sample of 159 adults (aged 18-70 years) with bipolar spectrum diagnoses, euthymic at study entry, was included. Self-report inventories and clinician-administered interviews determined features of hypersomnia. Participants completed sleep diaries and wore wrist actigraphs at home to obtain prospective sleep data. Approximately 7 months later, psychiatric status was reassessed. Factor analysis and latent profile analysis explored empirical groupings within hypersomnia diagnoses.

RESULTS

Factor analyses confirmed two separate subtypes of hypersomnia ('long sleep' and 'excessive sleepiness') that were uncorrelated. Latent profile analyses suggested a four-class solution, with 'long sleep' and 'excessive sleepiness' again representing two separate classes. Prospective sleep data suggested that the sleep of 'long sleepers' is characterized by a long time in bed, not long sleep duration. Longitudinal assessment suggested that 'excessive sleepiness' at baseline predicted mania/hypomania relapse.

CONCLUSIONS

This study is the largest of hypersomnia to include objective sleep measurement, and refines our understanding of classification, characterization and associated morbidity. Hypersomnia appears to be comprised of two separate subgroups: long sleep and excessive sleepiness. Long sleep is characterized primarily by long bedrest duration. Excessive sleepiness is not associated with longer sleep or bedrest, but predicts relapse to mania/hypomania. Understanding these entities has important research and treatment implications.

A profile approach to impulsivity in bipolar disorder: the key role of strong emotions

OBJECTIVE

Bipolar disorder has been associated with elevated impulsivity - a complex construct subsuming multiple facets. We aimed to compare specific facets of impulsivity in bipolar disorder, including those related to key psychological correlates of the illness: reward sensitivity and strong emotion.

METHOD

Ninety-one individuals diagnosed with bipolar I disorder (inter-episode period) and 80 controls completed several well-validated impulsivity measures, including those relevant to reward (Fun-seeking subscale of the Behavioral Activation System scale) and emotion (Positive Urgency and Negative Urgency scales).

RESULTS

Bipolar participants reported higher impulsivity scores than did controls on all of the impulsivity measures, except the Fun-seeking subscale of the Behavioral Activation System scale. Positive Urgency - a measure assessing the tendency to act impulsively when experiencing strong positive emotion - yielded the largest group differences: F(1,170) = 78.69, P < 0.001, partial η(2)  = 0.316. Positive Urgency was also associated with poorer psychosocial functioning in the bipolar group: ΔR(2)  = 0.24, b = -0.45, P < 0.001.

CONCLUSION

Individuals with bipolar I disorder appear to be at particular risk of behaving impulsively when experiencing strong positive emotions. Findings provide an important first step toward developing a more refined understanding of impulsivity in bipolar disorder with the potential to inform targeted interventions.

Repetitive thought impairs sleep quality: an experience sampling study

Although previous research has suggested that presleep negative cognitive activities are associated with poor sleep quality, there is little evidence regarding the association between negative thoughts and sleep in real-life settings. The present study used experience sampling and long-term sleep monitoring with actigraphy to investigate the relationships among negative repetitive thought, mood, and sleep problems. During a 1-week sampling period, 43 undergraduate students recorded their thought content and mood eight times a day at semirandom intervals. In addition to these subjective reports, participants wore actigraphs on their wrists in order to measure sleep parameters. Analyses using multilevel modeling showed that repetitive thought in the evening was significantly associated with longer sleep-onset latency, decreased sleep efficiency, and reduced total sleep time. Furthermore, impaired sleep quality was significantly associated with reduced positive affect the next morning, and decreased positive affect was indirectly associated with increased repetitive thought in the evening. These findings suggest the existence of a self-reinforcing cycle involving repetitive thought, mood, and impaired sleep quality, highlighting the importance of cognitive and emotional factors in enhancement and maintenance of good-quality sleep.

Linking stable and dynamic features of positive affect to sleep

BACKGROUND

Poor sleep contributes to adult morbidity and mortality.

PURPOSE

The study examined the extent to which trait positive affect (PA) and PA reactivity, defined as the magnitude of change in daily PA in response to daily events, were linked to sleep outcomes.

METHODS

Analyses are based on data from 100 respondents selected from the National Survey of Midlife in the United States.

RESULTS

Multilevel analyses indicated that higher levels of trait PA were associated with greater morning rest and better overall sleep quality. In contrast, PA reactivity was associated with diminished sleep efficiency. Finally, interactions between PA reactivity and trait PA emerged on all three sleep measures, such that higher event-related change in daily positive affect was associated with impaired sleep, especially among individuals high in trait PA.

CONCLUSIONS

Results suggest that high trait PA, when coupled with high PA reactivity, may contribute to poor sleep.

Glial-specific gene alterations associated with manic behaviors

Background

Glial dysfunction has been purported to be important to the pathophysiology of bipolar illness. However, manic behavior has not been previously demonstrated to result as a consequence of glial pathology. The aim of the current study was to assess the behaviors of the glial-specific sodium pump alpha2 subunit (ATP1A2) knockout (KO) heterozygote mice to determine if a glial-specific abnormality can produce manic-like behavior.

Methods

Activity and behavior of hemideficient sodium pump alpha2 KO mice and wild-type (WT) littermates (C57BL6/Black Swiss background) were examined at baseline, following forced swimming stress and restraint stress and after 3 days of sleep deprivation.

Results and discussion

At baseline, the 24-h total distance traveled and center time were significantly greater in KO mice, but there were no behavioral differences with sweet water preference or with inactivity time during forced swim or tail suspension tests. After restraint stress or forced swimming stress, there were no differences in activity. Three days of sleep deprivation utilizing the inverted flowerpot method induced a significant increase in the distance traveled by the KO versus WT mice in the 30-min observation period (p=0.016). Lithium pretreatment has no effect on WT animals versus their baseline but significantly reduces hyperactivity induced by sleep deprivation in KO. Knockout of the glial-specific alpha2 isoform is associated with some manic behaviors compared to WT littermates, suggesting that glial dysfunction could be associated with mania.

Mood and metabolic consequences of sleep deprivation as a potential endophenotype' in bipolar disorder

It has been commonly recognized that circadian rhythm and sleep/wake cycle are causally involved in bipolar disorder. There has been a paucity of systematic research considering the relations between sleep and mood states in bipolar disorder. The current study examines the possible influences of sleep deprivation on mood states and endocrine functions among first-degree relatives of patients with bipolar disorder and healthy controls. Blood samples were taken at two time points in the consecutive mornings at predeprivation and postdeprivation periods. Participants simultaneously completed the Profiles of Mood States at two time points after giving blood samples. Plasma T3 and TSH levels increased after total sleep deprivation in both groups. Sleep deprivation induced TSH levels were reversely associated with depression-dejection among healthy controls. A paradoxical effect was detected for only the first-degree relatives of the patients that changes in plasma cortisol levels negatively linked to depression-dejection and anger-hostility scores after total sleep deprivation. Plasma DHEA levels became correlated with vigor-activity scores after sleep deprivation among first-degree relatives of bipolar patients. On the contrary, significant associations of depression-dejection, anger-hostility, and confusion-bewilderment with the baseline plasma DHEA levels became statistically trivial in the postdeprivation period. Findings suggested that first-degree relatives of patients with bipolar disorder had completely distinct characteristics with respect to sleep deprivation induced responses in terms of associations between endocrine functions and mood states as compared to individuals whose relatives had no psychiatric problems. Considering the relationships between endocrine functions and mood states among relatives of the patients, it appears like sleep deprivation changes the receptor sensitivity which probably plays a pivotal role on mood outcomes among the first-degree relatives of patients with bipolar disorder.

Behavioral treatment of insomnia in bipolar disorder

Sleep disturbance is common in bipolar disorder. Stimulus control and sleep restriction are powerful, clinically useful behavioral interventions for insomnia, typically delivered as part of cognitive-behavioral therapy for insomnia (CBT-I). Both involve short-term sleep deprivation. The potential for manic or hypomanic symptoms to emerge after sleep deprivation in bipolar disorder raises questions about the appropriateness of these methods for treating insomnia. In a series of patients with bipolar disorder who underwent behavioral treatment for insomnia, the authors found that regularizing bedtimes and rise times was often sufficient to bring about improvements in sleep. Two patients in a total group of 15 patients reported mild increases in hypomanic symptoms the week following instruction on stimulus control. Total sleep time did not change for these individuals. Two of five patients who underwent sleep restriction reported mild hypomania that was unrelated to weekly sleep duration. Sleep restriction and stimulus control appear to be safe and efficacious procedures for treating insomnia in patients with bipolar disorder. Practitioners should encourage regularity in bedtimes and rise times as a first step in treatment, and carefully monitor changes in mood and daytime sleepiness throughout the intervention.

Emotion in Aging and Bipolar Disorder: Similarities, Differences, and Lessons for Further Research

In this article, we consider similarities and differences in emotion research on older adults and individuals with bipolar disorder (BD). Recent research and theory within both areas has focused on the importance of positive emotion, but the case of older adults is generally considered a case of "adaptive" positivity whereas BD is usually considered maladaptive positivity. We explore the paradox of the same phenomenon being labeled as adaptive in one group and yet maladaptive in another, with attention to commonalities and distinctions between these two groups. We identify only limited areas of overlap, and suggest a refinement of models of positive emotionality in the two populations.

Emotion dysregulation and sleep difficulties in generalized anxiety disorder

Diagnostic criteria for generalized anxiety disorder (GAD) include sleep problems, which often persist even after successful treatment of the disorder. The purpose of this study was to examine emotion dysregulation as a potential contributor to sleep problems in GAD patients. Participants comprised two groups: 59 individuals diagnosed with GAD and 66 healthy controls. They were assessed for the presence of mood and anxiety disorders and then completed self-report questionnaires assessing problems with sleep and emotion regulation. Participants in the GAD group scored significantly higher on a number of sleep outcomes than did the control group. Importantly, difficulties with emotion regulation statistically mediated the relationship between GAD and a wide range of outcomes of sleep dysfunction independently of the effects of depression and secondary anxiety diagnoses. Emotion regulation difficulties that characterize GAD mediate the relationship between symptoms of this disorder and a wide range of sleep problems. Implications for treatment and future research directions are discussed.

Evaluating sleep in bipolar disorder: comparison between actigraphy, polysomnography, and sleep diary

OBJECTIVES

Bipolar disorder is an illness characterized by sleep and circadian disturbance, and monitoring sleep in this population may signal an impending mood change. Actigraphy is an important clinical and research tool for examining sleep, but has not yet been systematically compared to polysomnography or sleep diary in bipolar disorder. The present study compares actigraphy, polysomnography, and sleep diary estimates of five standard sleep parameters in individuals with bipolar disorder and matched controls across two nights of assessment.

METHODS

Twenty-seven individuals who met diagnostic criteria for bipolar disorder type I or II and were currently between mood episodes, along with 27 matched controls with no history of psychopathology or sleep disturbance, underwent two nights of research laboratory monitoring. Sleep was estimated via polysomnography, actigraphy, and sleep diary.

RESULTS

Over the 108 nights available for comparison, sleep parameter estimates from actigraphy and polysomnography were highly correlated and did not differ between the two groups or across the two nights for sleep onset latency, wake after sleep onset, number of awakenings, total sleep time, or sleep efficiency percentage. The medium wake threshold algorithm in the actigraphy software was the most concordant with polysomnography and diaries across the five sleep parameters. Concordance between actigraphy, polysomnography, and sleep diary was largely independent of insomnia presence and medication use.

CONCLUSIONS

Actigraphy is a valid tool for estimating sleep length and fragmentation in bipolar disorder.

Social support and social strain in inter-episode bipolar disorder

OBJECTIVES

This study focused on social support and social strain and their cross-sectional associations with instabilities in sleep and social rhythms in inter-episode bipolar disorder (BD).

METHODS

Thirty-five adults diagnosed with inter-episode BD type I and 38 healthy controls completed measures of perceived social support and social strain. Group differences in support and strain were examined. Within the BD group, instabilities in sleep and social rhythms were assessed with 28 days of daily diary and actigraphy. Correlation and regression analyses were used to examine cross-sectional and prospective associations between social support, social strain, instabilities in sleep and social rhythms, and mood symptoms.

RESULTS

The BD group reported lower social support and higher social strain than the control group. Additionally, social strain was positively correlated with manic and depressive symptoms in the BD group. Furthermore, there was a cross-sectional association between social support and more stable sleep on actigraphy in the BD group, although social support did not predict future sleep instability.

CONCLUSIONS

These results indicate that inter-episode BD is associated with deficient social support and elevated social strain compared to controls, and that this may be due to persistent inter-episode mood symptoms. Social strain may be particularly important given its association with manic and depressive symptoms. The results also raise the possibility that sleep instability is related to poor social support in BD.

Restless pillow, ruffled mind: sleep and affect coupling in interepisode bipolar disorder

Disturbances in sleep and affect are prominent features of bipolar disorder, even during interepisode periods. Few longitudinal studies have prospectively examined the relationship between naturally occurring sleep and affect, and no studies to date have done so during interepisode periods of bipolar disorder and using the entire set of "gold standard" sleep parameters. Participants diagnosed with bipolar I disorder who were interepisode (n = 32) and healthy controls (n = 36) completed diagnostic and symptom severity interviews, and a daily sleep and affect diary, as well as an actigraphy sleep assessment, for eight weeks (M = 54 days, ± 8 days). Mutual information analysis was used to assess the degree of statistical dependence, or coupling, between time series data of sleep and affect. As measured by actigraphy, longer sleep onset latency was coupled with higher negative affect more strongly in the bipolar group than in the control group. As measured by sleep diary, longer wakefulness after sleep onset and lower sleep efficiency were coupled with higher negative affect significantly more strongly in the bipolar group than in the control group. By contrast, there were no significant differences between groups in the degree of coupling between any measures of sleep and positive affect. Findings support the coupling of sleep disturbance and negative affect during interepisode bipolar disorder. Ongoing monitoring of sleep-affect coupling may provide an important target for intervention in bipolar disorder.

The CLOCK gene and mood disorders: a case-control study and meta-analysis

The clock gene (CLOCK) is considered to be a good candidate gene for the pathophysiology of mood disorders, including bipolar disorder (BP) and major depressive disorder (MDD). rs1801260 (T3111C) has been detected at position 3111 in the CLOCK mRNA 3' untranslated region, and was reported to be associated with a substantial delay in preferred timing for activity and sleep in a human study. As for function, rs1801260 has been speculated to affect mRNA. Therefore, the authors investigated the association between the three tagging single-nucleotide polymorphisms (SNPs) (rs3736544, rs1801260, and rs3749474) in CLOCK and risk of BP (n=867) and MDD (n=139) compared to controls (n=889) in the Japanese population. In addition, we also performed an updated meta-analysis of nine published, genetic association studies investigating the relationship between rs1801260 and mood disorder risk, comprising 3321 mood disorders cases and 3574 controls. We did not detect any associations between tagging SNPs in CLOCK and BP or MDD in the allele, genotype, or haplotype analysis (global p(BP)=.605 and global p(MDD)=.211). Moreover, rs1801260 was also not associated with BP, MDD, or any mood disorders in the meta-analysis. In conclusion, these data suggest that CLOCK does not play a major role in the pathophysiology of mood disorders.

Risk constellations prior to the development of bipolar disorders: rationale of a new risk assessment tool

BACKGROUND

The precise characterisation of a high risk status for the development of a psychiatric disorder and the question of how well this predicts disease manifestation is of major importance as negative consequences of late diagnosis and treatment have been well demonstrated. In the absence of well defined and disease specific biological markers for bipolar disorder, the recognition of premature stages must rely on combinations of risk factors that have been associated with later disease manifestation.

METHODS

A review of the literature and our experience from the Early Recognition Centre led us to identify symptom constellations.

RESULTS

Individual categories defined and grouped included: (I) genetic risk, (II) substance use, misuse or dependence, (III) diagnosis/suspected diagnosis of attention deficit hyperactivity disorder, (IV) pronounced creativity, (V) impairment in psychosocial functioning, (VI) subthreshold affective symptoms, and (VII) early symptomatology including (a) changes in sleep and circadian rhythm, (b) changes in mood, mood swings/affective lability, (c) fearfulness/anxiety, and (d) dissociative symptoms. These risk constellations were operationalised and a new risk assessment instrument, the Early Phase Inventory for Bipolar Disorders (EPIbipolar) was developed.

LIMITATIONS

Challenges regarding the validity of the data on which the instrument is based, specificity of and correlations between risk categories, and ethical considerations were encountered.

CONCLUSIONS

Further use of EPIbipolar in research should help to refine prodromal features and narrow these down to a less cumbersome core that can be used to develop a shortened tool for use in clinical care. Prospective longitudinal research is needed to establish the predictive validity of this novel bipolar disorder risk assessment tool.

A test of the bidirectional association between sleep and mood in bipolar disorder and insomnia

The present study investigates sleep, mood, and the proposed bidirectional relationship between the two in psychiatric disorders. Participants with interepisode bipolar disorder (n = 49), insomnia (n = 34), and no psychiatric history (n = 52) completed seven consecutive days of sleep diaries and mood measures. The interepisode bipolar and insomnia participants exhibited greater sleep disturbance than the healthy control individuals. Negative mood was equally heightened in both interepisode bipolar disorder and insomnia, and there were no differences between the three groups in positive mood. Total wake time was associated with next morning negative mood in bipolar disorder, whereas evening negative mood was associated with subsequent total wake time in both bipolar disorder and insomnia. Additionally, positive mood was associated with subsequent total wake time for the insomnia group. Results support the theory that disruptions in nighttime sleep and daytime mood may be mutually maintaining and suggest the potential importance of transdiagnostic or universal processes.

Cognitive and affective control in insomnia

Insomnia is a prevalent disabling chronic disorder. The aim of this paper is fourfold: (a) to review evidence suggesting that dysfunctional forms of cognitive control, such as thought suppression, worry, rumination, and imagery control, are associated with sleep disturbance; (b) to review a new budding field of scientific investigation - the role of dysfunctional affect control in sleep disturbance, such as problems with down-regulating negative and positive affective states; (c) to review evidence that sleep disturbance can impair next-day affect control; and (d) to outline, on the basis of the reviewed evidence, how the repetitive-thought literature and the affective science literature can be combined to further understanding of, and intervention for, insomnia.

Sleep, illness course, and concurrent symptoms in inter-episode bipolar disorder

We investigated associations between sleep, illness course, and concurrent symptoms in 21 participants with bipolar disorder who were inter-episode. Sleep was assessed using a week-long diary. Illness course and symptoms were assessed via validated semi-structured interviews. Lower and more variable sleep efficiency and more variable total wake time were associated with more lifetime depressive episodes. Variability in falling asleep time was positively correlated with concurrent depressive symptoms. Sleep efficiency was positively correlated with concurrent manic symptoms. These findings suggest that inter-episode sleep disturbance is associated with illness course and that sleep may be an important intervention target in bipolar disorder.