Circadian rhythms and sleep in bipolar disorder

Bipolar disorder is characterized by chronotype instability: A longitudinal investigation of circadian typology and mood

BACKGROUND

Chronotype is associated with circadian rhythmicity, a core etiological factor underlying bipolar disorder (BD). Given converging evidence linking late chronotype with poor mental health, the goal of the present study was to examine chronotype (in)stability and its relation to mood symptoms over time.

METHODS

Participants with BD I (n = 271), BD II (n = 88), and healthy controls (n = 217) were included (follow-upM=10 years, Range=5-15) from the Prechter Longitudinal Study. Chronotype category and midpoint of sleep, corrected for weekend sleep-debt (MSFsc), were measured with the Munich Chronotype Questionnaire administered every 12 months alongside clinician-rated mood and medication usage. Self-reported mood was measured bi-monthly. Mixed effects models tested whether mood was associated with (in)stability of chronotype category and MSFsc covarying for age, sex, age, and medication.

RESULTS

Compared to HC, individuals with BD self-reported having a later chronotype that significantly fluctuated over time. Individuals with BDI showed significantly less stability in MSFsc than HC. Anticonvulsant use was associated with more stability in MSFsc whereas antidepressant use was associated with less stability in MSFsc.

CONCLUSIONS

In a large longitudinal cohort, individuals with BD displayed significant instability in circadian typology. Psychopharmacology in BD may have differential impacts on circadian timing that is important to monitor.

A randomized controlled trial to compare the effects of time-restricted eating versus Mediterranean diet on symptoms and quality of life in bipolar disorder

BACKGROUND

The primary objective of this randomized controlled trial (RCT) is to establish the effectiveness of time-restricted eating (TRE) compared with the Mediterranean diet for people with bipolar disorder (BD) who have symptoms of sleep disorders or circadian rhythm sleep-wake disruption. This work builds on the growing evidence that TRE has benefits for improving circadian rhythms. TRE and Mediterranean diet guidance will be offered remotely using self-help materials and an app, with coaching support.

METHODS

This study is an international RCT to compare the effectiveness of TRE and the Mediterranean diet. Three hundred participants will be recruited primarily via social media. Main inclusion criteria are: receiving treatment for a diagnosis of BD I or II (confirmed via DIAMOND structured diagnostic interview), endorsement of sleep or circadian problems, self-reported eating window of ≥ 12 h, and no current mood episode, acute suicidality, eating disorder, psychosis, alcohol or substance use disorder, or other health conditions that would interfere with or limit the safety of following the dietary guidance. Participants will be asked to complete baseline daily food logging for two weeks and then will be randomly allocated to follow TRE or the Mediterranean diet for 8 weeks, during which time, they will continue to complete daily food logging. Intervention content will be delivered via an app. Symptom severity interviews will be conducted at baseline; mid-intervention (4 weeks after the intervention begins); end of intervention; and at 6, 9, and 15 months post-baseline by phone or videoconference. Self-rated symptom severity and quality of life data will be gathered at those timepoints, as well as at 16 weeks post baseline. To provide a more refined index of whether TRE successfully decreases emotional lability and improves sleep, participants will be asked to complete a sleep diary (core CSD) each morning and complete six mood assessments per day for eight days at baseline and again at mid-intervention.

DISCUSSION

The planned research will provide novel and important information on whether TRE is more beneficial than the Mediterranean diet for reducing mood symptoms and improving quality of life in individuals with BD who also experience sleep or circadian problems.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT06188754.

Social zeitgeber and sleep loss as risk factors for suicide in American Indian adolescents

American Indians / Alaska Natives (AI/AN) bear a high burden of suicide, the reasons for which are not completely understood, and rates can vary by tribal group and location. This article aims to identify circumstances reported by a community group of American Indian adolescent participants to be associated with their depression and/or suicide. American Indian adolescents (n  =  360) were recruited from contiguous reservations and were assessed with a semi-structured diagnostic interview. Twenty percent of the adolescents reported suicidal thoughts (ideation, plans), an additional 8% reported a history of suicide attempts, and three deaths due to suicide were reported. Suicidal behaviors and major depressive disorder (MDD) co-occurred and were more common among female adolescents. The distressing events that adolescents most often reported were: death in the family, family disruption, peer relationship problems, and school problems. All of these events were significantly associated with suicidal behaviors, however those with suicidal acts were more likely to report death in the family. Those with MDD but no suicidal behaviors were more likely to report disruptions in the family. Disruptions in falling asleep were also associated with suicidal behaviors and having experienced a death in the family. Disruptions in important relationships, particularly through death or divorce, may be interpreted as a loss or disruption in "social zeitgebers" that may in turn disturb biological rhythms, such as sleep, thus potentially increase the risk for MDD and/or suicide. Prevention programs aimed at ameliorating the impact of disruptions in important relationships may potentially reduce suicidal behaviors in AI/AN adolescents.

Social and circadian rhythm dysregulation and suicide: A systematic review and meta-analysis

This systematic review of 52 studies provides a quantitative synthesis of the empirical literature on social and circadian rhythm correlates of suicidal thoughts and behaviors (STB). Small-to-medium pooled effect sizes were observed for associations between evening chronotype and STB and suicidal ideation (SI), although the pooled effect size diminished when accounting for publication bias. Three studies employed longitudinal designs and suggested eveningness was predictive of future STB, with a small-to-medium effect size. Social rhythm irregularity was also a significant correlate of STB with pooled effect sizes in the medium range. Overall circadian rhythm disruption was not associated with STB, although certain circadian rhythm metrics, including mean daytime activity, circadian rhythm sleep-wake disorder diagnosis, and actigraphy-assessed amplitude were associated with STB. Pooled effect sizes for these indices were in the medium to large range. There is a need for additional longitudinal research on actigraphy-based circadian parameters and objective markers of circadian phase (i.e., dim-light melatonin onset) to gain a clearer understanding of associations of endogenous circadian function and STB beyond that which can be captured via self-report.

Impact of biological rhythms on perception of illness and cognitive flexibility in bipolar patients in remission

Our study aims to examine the possible mediating effects of biological rhythms on the relationship between illness perception, cognitive flexibility, and functionality in bipolar patients in remission. A total of 150 patients with bipolar disorder (BD) were enrolled. The sociodemographic data form, Biological Rhythm Interview of Assessment in Neuropsychiatry (BRIAN), Brief Illness Perception Questionnaire (BIPQ), Cognitive Flexibility Scale (CFS), Young Mania Rating Scale, Montgomery and Asberg Depression Scale, Beck Anxiety Inventory, and Short Functionality Assessment Scale were applied to the patients in the study. The mean age of the patients was 42.10 ± 12.92 (SD). The participants were 48.7% (n = 73) female and 66.6% (n = 100) BD-I. There was a negative correlation between the total BRIAN score and favorable BIPQ scores and a positive correlation between the total BRIAN score and unfavorable BIPQ scores (except timeline). Additionally, multiple regression analyses revealed that the total BRIAN score could predict favorable BIPQ (except treatment control) and unfavorable BIPQ (except timeline) scores (p < 0.05). The total CFS score also could predict favorable BIPQ (treatment control) and unfavorable BIPQ scores (except timeline). The second step mediation analysis showed that biological rhythm mediated the relationship between illness perception and cognitive flexibility. Our study found that biological rhythms played a full mediating role in the relationship between the perception of illness and cognitive flexibility. In addition, worsening in biological rhythms in bipolar patients could cause negative beliefs and attitudes towards their diseases with an unfavorable clinical course. Therefore, regularity in biological rhythms should be highly recommended for bipolar patients.

Sleep, mood disorders, and the ketogenic diet: potential therapeutic targets for bipolar disorder and schizophrenia

Bipolar disorder and schizophrenia are serious psychiatric conditions that cause a significant reduction in quality of life and shortened life expectancy. Treatments including medications and psychosocial support exist, but many people with these disorders still struggle to participate in society and some are resistant to current therapies. Although the exact pathophysiology of bipolar disorder and schizophrenia remains unclear, increasing evidence supports the role of oxidative stress and redox dysregulation as underlying mechanisms. Oxidative stress is an imbalance between the production of reactive oxygen species generated by metabolic processes and antioxidant systems that can cause damage to lipids, proteins, and DNA. Sleep is a critical regulator of metabolic homeostasis and oxidative stress. Disruption of sleep and circadian rhythms contribute to the onset and progression of bipolar disorder and schizophrenia and these disorders often coexist with sleep disorders. Furthermore, sleep deprivation has been associated with increased oxidative stress and worsening mood symptoms. Dysfunctional brain metabolism can be improved by fatty acid derived ketones as the brain readily uses both ketones and glucose as fuel. Ketones have been helpful in many neurological disorders including epilepsy and Alzheimer's disease. Recent clinical trials using the ketogenic diet suggest positive improvement in symptoms for bipolar disorder and schizophrenia as well. The improvement in psychiatric symptoms from the ketogenic diet is thought to be linked, in part, to restoration of mitochondrial function. These findings encourage further randomized controlled clinical trials, as well as biochemical and mechanistic investigation into the role of metabolism and sleep in psychiatric disorders. This narrative review seeks to clarify the intricate relationship between brain metabolism, sleep, and psychiatric disorders. The review will delve into the initial promising effects of the ketogenic diet on mood stability, examining evidence from both human and animal models of bipolar disorder and schizophrenia. The article concludes with a summary of the current state of affairs and encouragement for future research focused on the role of metabolism and sleep in mood disorders.

Reward sensitivity and social rhythms during goal-striving: An ecological momentary assessment investigation of bipolar spectrum disorders

BACKGROUND

The reward/circadian rhythm model of bipolar spectrum disorders (BSDs) posits that when individuals with hypersensitive reward systems encounter reward-relevant events, they experience social and circadian rhythm disruption, leading to mood symptoms. The aim of the current study is to test an element of this theoretical model by investigating changes in social rhythms during and after an ecologically-valid reward-relevant event and evaluating whether the strength of these associations differ by trait reward sensitivity and BSD diagnostic group.

METHODS

Young adults from three groups (low BSD risk with moderate reward sensitivity [MRew], high BSD risk with high reward sensitivity [HRew], and high reward sensitivity with BSD [HRew+BSD]) completed a reward responsiveness task and 20-day ecological momentary assessment study structured around a participant-specific goal occurring on day 15. Social rhythm disruption (SRD) and social rhythm regularity (SRR) were assessed daily. Multilevel models examined whether reward sensitivity and group moderated associations between study phase (baseline [days 1-5], goal-striving [days 16-20], or outcome [days 16-20]) and social rhythms.

RESULTS

Participants experienced greater SRD after the goal-striving event during the outcome phase, compared to the baseline phase. The HRew+BSD group had significant decreases in SRR during the outcome phase, and this pattern differed significantly from the low-risk and high-risk groups. Greater task reward responsiveness also was associated with significant decreases in SRR during the outcome phase.

LIMITATIONS

This study did not test whether social rhythm irregularity was associated with subsequent mood change.

CONCLUSIONS

Participants exhibited social rhythm changes over the course of this ecologically valid goal-striving period, providing evidence for the interplay between reward-activating events and social rhythms. The HRew+BSD group showed a distinct pattern in which their social rhythms were more irregular after completing reward-relevant goal-striving that was not observed for the low-BSD risk or high-BSD risk groups. These findings provide additional support for Interpersonal and Social Rhythms Therapy.

Sleep and circadian influences on blood alcohol concentration

STUDY OBJECTIVES

Anecdotally, adults reach higher levels of subjective intoxication on days they are fatigued or sleep-deprived, but sleep is not typically discussed as a predictor of blood alcohol concentration (BAC) in clinical settings. To inform clinical work and future research, this perspective reviews data examining the impact of sleep (process S) and circadian (process C) factors on indicators of BAC in humans and animal models.

METHODS

Literature searches of medical and psychological databases were conducted to identify articles that manipulated sleep/circadian factors and reported effects on indicators of alcohol pharmacology (e.g. BAC, alcohol metabolism).

RESULTS

Of the 86 full-text articles reviewed, 21 met inclusion criteria. Studies included manipulations of time of day, circadian phase (evidence for process C), and time in bed (evidence for process S). Evidence for time-of-day effects on alcohol pharmacology was most compelling. Studies also provided evidence for circadian phase effects, but failed to find support for time-in-bed effects. Although results were not uniform across studies, most evidence from human and animal models indicates that peak BACs occur toward the beginning of the biological day, with some studies indicating slower alcohol elimination rates at this time.

CONCLUSIONS

Circadian factors likely influence alcohol pharmacokinetics, perhaps due to altered elimination of alcohol from the body. This means that individuals may reach higher BACs if they drink during the morning (when, for most people, circadian alerting is low) versus other times of the day. Alcohol prevention and intervention efforts should highlight sleep/circadian health as a potential contributor to alcohol-related harm.

The engagement of autophagy in maniac disease

AIMS

Mania is a prevalent psychiatric disorder with undefined pathological mechanism. Here, we reviewed current knowledge indicating the potential involvement of autophagy dysregulation in mania and further discussed whether targeting autophagy could be a promising strategy for mania therapy.

DISCUSSIONS

Accumulating evidence indicated the involvement of autophagy in the pathology of mania. One of the most well-accepted mechanisms underlying mania, circadian dysregulation, showed mutual interaction with autophagy dysfunction. In addition, several first-line drugs for mania therapy were found to regulate neuronal autophagy. Besides, deficiencies in mitochondrial quality control, neurotransmission, and ion channel, which showed causal links to mania, were intimately associated with autophagy dysfunction.

CONCLUSIONS

Although more efforts should be made to either identify the key pathology of mania, the current evidence supported that autophagy dysregulation may act as a possible mechanism involved in the onset of mania-like symptoms. It is therefore a potential strategy to treat manic disorder by correting autophagy.

Neurobehavioral Reward and Sleep-Circadian Profiles Predict Present and Next-Year Mania/Hypomania Symptoms

BACKGROUND

Heightened reward sensitivity/impulsivity, related neural activity, and sleep-circadian disruption are important risk factors for bipolar spectrum disorders, the defining feature of which is mania/hypomania. Our goal was to identify neurobehavioral profiles based on reward and sleep-circadian features and examine their specificity to mania/hypomania versus depression vulnerability.

METHODS

At baseline, a transdiagnostic sample of 324 adults (18-25 years) completed trait measures of reward sensitivity (Behavioral Activation Scale), impulsivity (UPPS-P-Negative Urgency), and a functional magnetic resonance imaging card-guessing reward task (left ventrolateral prefrontal activity to reward expectancy, a neural correlate of reward motivation and impulsivity, was extracted). At baseline, 6-month follow-up, and 12-month follow-up, the Mood Spectrum Self-Report Measure - Lifetime Version assessed lifetime predisposition to subthreshold-syndromal mania/hypomania, depression, and sleep-circadian disturbances (insomnia, sleepiness, reduced sleep need, rhythm disruption). Mixture models derived profiles from baseline reward, impulsivity, and sleep-circadian variables.

RESULTS

Three profiles were identified: 1) healthy (no reward or sleep-circadian disruption; n = 162); 2) moderate-risk (moderate reward and sleep-circadian disruption; n = 109); and 3) high-risk (high impulsivity and sleep-circadian disruption; n = 53). At baseline, the high-risk group had significantly higher mania/hypomania scores than the other groups but did not differ from the moderate-risk group in depression scores. Over the follow-up period, the high-risk and moderate-risk groups exhibited elevated mania/hypomania scores, whereas depression scores increased at a faster rate in the healthy group than in the other groups.

CONCLUSIONS

Cross-sectional and next-year predisposition to mania/hypomania is associated with a combination of heightened reward sensitivity and impulsivity, related reward circuitry activity, and sleep-circadian disturbances. These measures can be used to detect mania/hypomania risk and provide targets to guide and monitor interventions.

Daily rhythm in cortical chloride homeostasis underpins functional changes in visual cortex excitability

Cortical activity patterns are strongly modulated by fast synaptic inhibition mediated through ionotropic, chloride-conducting receptors. Consequently, chloride homeostasis is ideally placed to regulate activity. We therefore investigated the stability of baseline [Cl-]i in adult mouse neocortex, using in vivo two-photon imaging. We found a two-fold increase in baseline [Cl-]i in layer 2/3 pyramidal neurons, from day to night, with marked effects upon both physiological cortical processing and seizure susceptibility. Importantly, the night-time activity can be converted to the day-time pattern by local inhibition of NKCC1, while inhibition of KCC2 converts day-time [Cl-]i towards night-time levels. Changes in the surface expression and phosphorylation of the cation-chloride cotransporters, NKCC1 and KCC2, matched these pharmacological effects. When we extended the dark period by 4 h, mice remained active, but [Cl-]i was modulated as for animals in normal light cycles. Our data thus demonstrate a daily [Cl-]i modulation with complex effects on cortical excitability.

Identifying the bridge between depression and mania: A machine learning and network approach to bipolar disorder

OBJECTIVES

Although the cyclic nature of bipolarity is almost by definition a network system, no research to date has attempted to scrutinize the relationship of the two bipolar poles using network psychometrics. We used state-of-the-art network and machine learning methodologies to identify symptoms, as well as relations thereof, that bridge depression and mania.

METHODS

Observational study that used mental health data (12 symptoms for depression and 12 for mania) from a large, representative Canadian sample (the Canadian Community Health Survey of 2002). Complete data (N = 36,557; 54.6% female) were analysed using network psychometrics, in conjunction with a random forest algorithm, to examine the bidirectional interplay of depressive and manic symptoms.

RESULTS

Centrality analyses pointed to symptoms relating to emotionality and hyperactivity as being the most central aspects of depression and mania, respectively. The two syndromes were spatially segregated in the bipolar model and four symptoms appeared crucial in bridging them: sleep disturbances (insomnia and hypersomnia), anhedonia, suicidal ideation, and impulsivity. Our machine learning algorithm validated the clinical utility of central and bridge symptoms (in the prediction of lifetime episodes of mania and depression), and suggested that centrality, but not bridge, metrics map almost perfectly onto a data-driven measure of diagnostic utility.

CONCLUSIONS

Our results replicate key findings from past network studies on bipolar disorder, but also extend them by highlighting symptoms that bridge the two bipolar poles, while also demonstrating their clinical utility. If replicated, these endophenotypes could prove fruitful targets for prevention/intervention strategies for bipolar disorders.

Circadian, Reward, and Emotion Systems in Teens prospective longitudinal study: protocol overview of an integrative reward-circadian rhythm model of first onset of bipolar spectrum disorder in adolescence

BACKGROUND

Bipolar spectrum disorders (BSDs) are associated with a heightened sensitivity to rewards and elevated reward-related brain function in cortico-striatal circuitry. A separate literature documents social and circadian rhythm disruption in BSDs. Recently, integrated reward-circadian models of BSDs have been proposed. These models draw on work indicating that the two systems influence each other and interact to affect mood functioning. When dysregulated, reward and circadian system signaling may combine to form a positive feedback loop, whereby dysregulation in one system exacerbates dysregulation in the other. Project CREST (Circadian, Reward, and Emotion Systems in Teens) provides a first systematic test of reward-circadian dysregulation as a synergistic and dynamic vulnerability for first onset of BSD and increases in bipolar symptoms during adolescence.

METHODS

This NIMH-funded R01 study is a 3-year prospective, longitudinal investigation of approximately 320 community adolescents from the broader Philadelphia area, United States of America. Eligible participants must be 13-16 years old, fluent in English, and without a prior BSD or hypomanic episode. They are being selected along the entire dimension of self-reported reward responsiveness, with oversampling at the high tail of the dimension in order to increase the likelihood of BSD onsets. At Times 1-6, every 6 months, participants will complete assessments of reward-relevant and social rhythm disruption life events and self-report and diagnostic assessments of bipolar symptoms and episodes. Yearly, at Times 1, 3, and 5, participants also will complete self-report measures of circadian chronotype (morningness-eveningness) and social rhythm regularity, a salivary dim light melatonin onset (DLMO) procedure to assess circadian phase, self-report, behavioral, and neural (fMRI) assessments of monetary and social reward responsiveness, and a 7-day ecological momentary assessment (EMA) period. During each EMA period, participants will complete continuous measures of sleep/wake and activity (actigraphy), a daily sleep diary, and three within-day (morning, afternoon, evening) measures of life events coded for reward-relevance and social rhythm disruption, monetary and social reward responsiveness, positive and negative affect, and hypo/manic and depressive symptoms. The fMRI scan will occur on the day before and the DLMO procedure will occur on the first evening of the 7-day EMA period.

DISCUSSION

This study is an innovative integration of research on multi-organ systems involved in reward and circadian signaling in understanding first onset of BSD in adolescence. It has the potential to facilitate novel pharmacological, neural, and behavioral interventions to treat, and ideally prevent, bipolar conditions.

Regulation of dendritic spines in the amygdala following sleep deprivation

The amygdala is a hub of emotional circuits involved in the regulation of cognitive and emotional behaviors and its critically involved in emotional reactivity, stress regulation, and fear memory. Growing evidence suggests that the amygdala plays a key role in the consolidation of emotional memories during sleep. Neuroimaging studies demonstrated that the amygdala is selectively and highly activated during rapid eye movement sleep (REM) and sleep deprivation induces emotional instability and dysregulation of the emotional learning process. Regulation of dendritic spines during sleep represents a morphological correlate of memory consolidation. Several studies indicate that dendritic spines are remodeled during sleep, with evidence for broad synaptic downscaling and selective synaptic upscaling in several cortical areas and the hippocampus. Currently, there is a lack of information regarding the regulation of dendritic spines in the amygdala during sleep. In the present work, we investigated the effect of 5 h of sleep deprivation on dendritic spines in the mouse amygdala. Our data demonstrate that sleep deprivation results in differential dendritic spine changes depending on both the amygdala subregions and the morphological subtypes of dendritic spines. We observed decreased density of mushroom spines in the basolateral amygdala of sleep deprived mice, together with increased neck length and decreased surface area and volume. In contrast, we observed greater densities of stubby spines in sleep deprived mice in the central amygdala, indicating that downscaling selectively occurs in this spine type. Greater neck diameters for thin spines in the lateral and basolateral nuclei of sleep deprived mice, and decreases in surface area and volume for mushroom spines in the basolateral amygdala compared to increases in the cental amygdala provide further support for spine type-selective synaptic downscaling in these areas during sleep. Our findings suggest that sleep promotes synaptic upscaling of mushroom spines in the basolateral amygdala, and downscaling of selective spine types in the lateral and central amygdala. In addition, we observed decreased density of phosphorylated cofilin immunoreactive and growth hormone immunoreactive cells in the amygdala of sleep deprived mice, providing further support for upscaling of dendritic spines during sleep. Overall, our findings point to region-and spine type-specific changes in dendritic spines during sleep in the amygdala, which may contribute to consolidation of emotional memories during sleep.

Post-partum depression: From clinical understanding to preclinical assessments

Post-partum depression (PPD) with varying clinical manifestations affecting new parents remains underdiagnosed and poorly treated. This minireview revisits the pharmacotherapy, and relevant etiological basis, capable of advancing preclinical research frameworks. Maternal tasks accompanied by numerous behavioral readouts demand modeling different paradigms that reflect the complex and heterogenous nature of PPD. Hence, effective PPD-like characterization in animals towards the discovery of pharmacological intervention demands research that deepens our understanding of the roles of hormonal and non-hormonal components and mediators of this psychiatric disorder.

Social and environmental variables as predictors of mania: a review of longitudinal research findings

Considerable evidence suggests that psychosocial variables can shape the course of bipolar disorder. Here, though, we focus on the more specific idea that the social environment can predict the course of mania. We systematically review evidence from longitudinal studies concerning how social support, family interactions, traumatic life events, and recent life events relate to the age of onset, the frequency of episode recurrence, and the severity of manic symptoms. Although we find some evidence that the course of mania can be worsened by social environmental factors, the links are specific. Among social variables, some studies indicate that conflict and hostility are predictive, but more general social relationship qualities have not been found to predict mania. Some research indicates that childhood trauma, and recent life events involving goal attainment or sleep disruption can predict mania. Taken together, the profile of variables involving recent exposure that are most predictive include those that are activating, reward-related, or sleep-disrupting, which fits with general psychological hypotheses of behavioral activation and sleep disruption as important for mania. We discuss gaps in the literature, and we note future directions for research, including the need for more integrative, longitudinal research on a fuller range of social and biological risk variables.

The Common Effects of Sleep Deprivation on Human Long-Term Memory and Cognitive Control Processes

Sleep deprivation is known to have adverse effects on various cognitive abilities. In particular, a lack of sleep has been reported to disrupt memory consolidation and cognitive control functions. Here, focusing on long-term memory and cognitive control processes, we review the consistency and reliability of the results of previous studies of sleep deprivation effects on behavioral performance with variations in the types of stimuli and tasks. Moreover, we examine neural response changes related to these behavioral changes induced by sleep deprivation based on human fMRI studies to determine the brain regions in which neural responses increase or decrease as a consequence of sleep deprivation. Additionally, we discuss about the possibility that light as an environmentally influential factor affects our sleep cycles and related cognitive processes.

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.

Which Actigraphy Dimensions Predict Longitudinal Outcomes in Bipolar Disorders?

Bipolar disorder (BD) is characterized by recurrent mood episodes. It is increasingly suggested that disturbances in sleep–wake cycles and/or circadian rhythms could represent valuable predictors of recurrence, but few studies have addressed this question. Euthymic individuals with BD (n = 69) undertook 3 weeks of actigraphy recording and were then followed up for a median duration of 3.5 years. Principal component analyses were used to identify core dimensions of sleep quantity/variability and circadian rhythmicity. Associations between clinical variables and actigraphy dimensions and time to first recurrence were explored using survival analyses, and then using area under the curve (AUC) analyses (early vs. late recurrence). Most participants (64%) experienced a recurrence during follow-up (median survival time: 18 months). After adjusting for potential confounding factors, an actigraphy dimension comprising amplitude and variability/stability of circadian rhythms was a significant predictor of time to recurrence (p = 0.009). The AUC for correct classification of early vs. late recurrence subgroups was only 0.64 for clinical predictors, but combining these variables with objectively measured intra-day variability improved the AUC to 0.82 (p = 0.04). Actigraphy estimates of circadian rhythms, particularly variability/stability and amplitude, may represent valid predictive markers of future BD recurrences and could be putative targets for future psychosocial interventions.

Guidelines for the management of psychosis in the context of mood disorders

Psychotic episodes occur in a substantial proportion of patients suffering from major mood disorders (both unipolar and bipolar) at some point in their lives. The nature of these episodes is less well understood than the more common, non-psychotic periods of illness and hence their management is also less sophisticated. This is a concern because the risk of suicide is particularly high in this subtype of mood disorder and comorbidity is far more common. In some cases psychotic symptoms may be signs of a comorbid illness but the relationship of psychotic mood to other forms of psychosis and in particular its interactions with schizophrenia is poorly understood. Therefore, our targeted review draws upon extant research and our combined experience to provide clinical context and a framework for the management of these disorders in real-world practice - taking into consideration both biological and psychological interventions.

A Smartphone-Based Self-management Intervention for Individuals With Bipolar Disorder (LiveWell): Empirical and Theoretical Framework, Intervention Design, and Study Protocol for a Randomized Controlled Trial

Background

Bipolar disorder is a severe mental illness with high morbidity and mortality rates. Even with pharmacological treatment, frequent recurrence of episodes, long episode durations, and persistent interepisode symptoms are common and disruptive. Combining psychotherapy with pharmacotherapy improves outcomes; however, many individuals with bipolar disorder do not receive psychotherapy. Mental health technologies can increase access to self-management strategies derived from empirically supported bipolar disorder psychotherapies while also enhancing treatment by delivering real-time assessments, personalized feedback, and provider alerts. In addition, mental health technologies provide a platform for self-report, app use, and behavioral data collection to advance understanding of the longitudinal course of bipolar disorder, which can then be used to support ongoing improvement of treatment.

Objective

A description of the theoretical and empirically supported framework, design, and protocol for a randomized controlled trial (RCT) of LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder, is provided to facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar disorder. The goal of the trial is to determine the effectiveness of LiveWell for reducing relapse risk and symptom burden as well as improving quality of life (QOL) while simultaneously clarifying behavioral targets involved in staying well and better characterizing the course of bipolar disorder and treatment response.

Methods

The study is a single-blind RCT (n=205; 2:3 ratio of usual care vs usual care plus LiveWell). The primary outcome is the time to relapse. Secondary outcomes are percentage time symptomatic, symptom severity, and QOL. Longitudinal changes in target behaviors proposed to mediate the primary and secondary outcomes will also be determined, and their relationships with the outcomes will be assessed. A database of clinical status, symptom severity, real-time self-report, behavioral sensor, app use, and personalized content will be created to better predict treatment response and relapse risk.

Results

Recruitment and screening began in March 2017 and ended in April 2019. Follow-up ended in April 2020. The results of this study are expected to be published in 2022.

Conclusions

This study will examine whether LiveWell reduces relapse risk and symptom burden and improves QOL for individuals with bipolar disorder by increasing access to empirically supported self-management strategies. The role of selected target behaviors (medication adherence, sleep duration, routine, and management of signs and symptoms) in these outcomes will also be examined. Simultaneously, a database will be created to initiate the development of algorithms to personalize and improve treatment for bipolar disorder. In addition, we hope that this description of the theoretical and empirically supported framework, intervention design, and study protocol for the RCT of LiveWell will facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar and other mental health disorders.

Trial Registration

ClinicalTrials.gov NCT03088462; https://www.clinicaltrials.gov/ct2/show/NCT03088462

International Registered Report Identifier (IRRID)

DERR1-10.2196/30710

The significance of sleep quality in euthymic bipolar patients from Nigeria

Background

Bipolar disorder is highly under-researched in Africa. Existing studies show that racial/ethnic disparities exist for sleep quality. Poor sleep quality in bipolar disorder causes significant morbidity and mortality even during periods of euthymia.

Aim

This study aimed to assess sleep quality and its correlates amongst euthymic patients with bipolar I disorder from Nigeria.

Setting

The study was carried out in a teaching hospital, and state hospital, in Ibadan, Nigeria.

Method

This cross-sectional study was conducted amongst 76 euthymic bipolar patients aged between 18 and 60 years, meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for bipolar disorder. Euthymia was defined as having a score of ≤ 5 on the Young Mania Rating Scale and < 8 on the Hamilton Depression Rating Scale. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI).

Results

A total of 37 (48.7%) participants had poor quality sleep. Sleep quality was associated with marital status (p = 0.013) and suicide plan (p = 0.047). Participants with good sleep quality had higher total sleep duration, lower time to fall asleep (sleep latency), better subjective quality of sleep, were less likely to use sleep medications and had less daytime dysfunction than participants with poor sleep quality. All p-values were < 0.05. Subjective quality of sleep, ongoing use of sleep medication, daytime dysfunction were independently associated with poor sleep quality.

Conclusion

Poor sleep quality frequently persists during euthymic periods in patients with bipolar disorder. The correlates identified can be targeted for intervention during treatment.

Motor activity patterns can distinguish between interepisode bipolar disorder patients and healthy controls

BACKGROUND

Bipolar disorder (BD) is linked to circadian rhythm disruptions resulting in aberrant motor activity patterns. We aimed to explore whether motor activity alone, as assessed by longitudinal actigraphy, can be used to classify accurately BD patients and healthy controls (HCs) into their respective groups.

METHODS

Ninety-day actigraphy records from 25 interepisode BD patients (ie, Montgomery-Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS) < 15) and 25 sex- and age-matched HCs were used in order to identify latent actigraphic biomarkers capable of discriminating between BD patients and HCs. Mean values and time variations of a set of standard actigraphy features were analyzed and further validated using the random forest classifier.

RESULTS

Using all actigraphy features, this method correctly assigned 88% (sensitivity = 85%, specificity = 91%) of BD patients and HCs to their respective group. The classification success may be confounded by differences in employment between BD patients and HCs. When motor activity features resistant to the employment status were used (the strongest feature being time variation of intradaily variability, Cohen's d = 1.33), 79% of the subjects (sensitivity = 76%, specificity = 81%) were correctly classified.

CONCLUSION

A machine-learning actigraphy-based model was capable of distinguishing between interepisode BD patients and HCs solely on the basis of motor activity. The classification remained valid even when features influenced by employment status were omitted. The findings suggest that temporal variability of actigraphic parameters may provide discriminative power for differentiating between BD patients and HCs while being less affected by employment status.

Variability in Sleep Is Associated with Trait-Based and Daily Measures of Bipolar Spectrum Psychopathology

INTRODUCTION

Although sleep disturbances are well documented in bipolar spectrum disorders (BSDs), significantly less research has examined whether these disturbances are present in those at risk for developing BSDs or with subsyndromal symptoms. The present study examined associations between risk for BSDs, as measured by the Hypomanic Personality Scale (HPS), and sleep assessed using experience sampling. We assessed whether intraindividual variability in sleep was associated with affect, cognition, and behavior in daily life and potential directionality of these relationships.

METHODS

233 young adults oversampled for high scores on the HPS completed 14 days of experience sampling assessing total sleep time (TST), bed/rise time, sleep quality, affect (negative and positive affect), cognition (difficulty concentrating, racing thoughts), and behavior (impulsivity) in daily life. We used Dynamic Structural Equation Modeling (DSEM) to assess within-person links between sleep and bipolar spectrum psychopathology.

RESULTS

HPS scores were associated with less TST, later bedtime, and more variable TST and bedtime. Variability in TST was associated with negative affect, difficulty concentrating/racing thoughts, and impulsivity. Within-person decreases in sleep were associated with next day increases in negative affect, stress, difficulty concentrating, and racing thoughts.

LIMITATIONS

Measurement of sleep was limited. Future studies should examine both objective measures of sleep (e.g., actigraphy) and fragmentation in sleep.

CONCLUSIONS

Risk for BSD was associated with similar patterns of sleep disruptions as seen in BSDs. Important dynamic links between sleep and bipolar spectrum psychopathology emerged indicating that sleep is an important target for improving symptoms of BSDs in daily life.

Comparative transcriptome analysis and CRISPR/Cas9 gene editing reveal that E4BP4 mediates lithium upregulation of Per2 expression

Bipolar disorder (BPD) is a psychiatric disorder characterized by alternate episodes of mania and depression. Disruption of normal circadian clock and abnormal sleep cycles are common symptoms of BPD patients. Lithium salt is currently an effective clinical therapeutic drug for BPD. Animal and cellular studies have found that lithium salt can upregulate the expression of the clock gene Per2, but the mechanism is unknown. We aim to understand the mechanism underlying the Per2 upregulation by lithium treatment. By taking approaches of both comparative transcriptome analysis and comparative qPCR analysis between human and murine cells, Lumicycle assay, luciferase assay and RT-qPCR assay showed that lithium could significantly upregulate the expression of Per2 in both mouse and human cells, and significantly inhibit the expression of E4bp4, which encodes a transcriptional inhibitor of Per2. After knocking out the cis-element upstream on the Per2 promoter that responds to E4BP4, the upregulation effect on Per2 by lithium disappeared. When E4bp4 gene was knocked out, the upregulation effect on Per2 by lithium salt disappeared. This study has found that lithium upregulates Per2 expression by reducing the expression of transcription factor E4BP4, but the mechanism of lithium salt downregulation of E4BP4 remains to be further studied. Our study provides a new therapeutic target and approaches for treating BPD.

Stress predicts depression symptoms for women living with bipolar disorder during the menopause transition

OBJECTIVE

Although sleep disturbance is an important feature in bipolar disorder, the relationship between mood symptoms, sleep disturbances, and hot flash symptom severity during menopause for women with bipolar disorder is largely unknown.

METHODS

Women with bipolar disorder (n = 100) who were categorized as perimenopausal using the STRAW and Monash criteria took part in an international online survey. The survey contained questions on history of reproductive health; the clinical course of bipolar disorder; menopausal symptoms (Menopause Rating Scale [MRS]); depression, anxiety, and stress (Depression Anxiety and Stress Scale-21) and the Altman Mania Rating Scale.

RESULTS

MRS sleep problems and hot flash severity were positively correlated with each other and with depression, anxiety, and stress symptoms. Mania scores were not significantly correlated with sleep or hot flash severity scores. A stepwise regression analysis on depression symptoms, using MRS sleep disturbance and MRS hot flash severity scores as predictors with anxiety and stress symptoms in the model, found that stress alone predicted 40% of the variance in total depression scores.

CONCLUSION

Stress plays an important role in the experience of depression for women living with bipolar disorder during the perimenopausal phase. More research is needed to determine if stress management programs may be helpful for women living with bipolar disorder during this time of life and if these in turn, may improve depressive symptoms.

Sleep quality and neuropsychological functioning in bipolar I disorder

BACKGROUND

Individuals with bipolar I disorder (BD-I) experience both poor sleep and neuropsychological dysfunction relative to non-psychiatric populations, which limits functional recovery. Poor sleep adversely affects learning, memory, and executive functioning in healthy individuals; however, little is known about the role of poor sleep in neuropsychological functioning in BD-I. We tested whether sleep disturbance was greater in BD-I than healthy control participants (HC), and compared the effect of sleep quality on learning, memory, and executive functioning between BD-I and HC.

METHODS

Participants with BD-I (N=250) and HC (N=206) completed the Pittsburgh Sleep Quality Index, neuropsychological testing, and clinician-administered mood measures as part of a naturalistic study of bipolar disorder. We examined effects of both diagnosis and sleep quality on neuropsychological functioning.

RESULTS

Relative to HC, BD-I showed poorer sleep quality and neuropsychological functioning in verbal learning, verbal and visual memory, processing speed, psychomotor speed, inhibitory control, and selective attention (7/9 domains). Poor sleep quality was associated with poorer verbal learning, verbal fluency, processing speed, and interference control (4/9). Effects of poor sleep on neuropsychological functioning did not differ between BD-I and HC.

LIMITATIONS

The assessment of sleep quality using a self-report measure and the effects of medications/sleeping aids (given the naturalistic study design) should be considered when interpreting results.

CONCLUSIONS

Those with BD-I experiencing poor sleep may also be more vulnerable to verbal learning and executive functioning impairments. The findings of poor sleep in relation to poorer neuropsychological functioning have implications for assessment and treatment of sleep disturbance in BD-I.

For whom the circadian clock ticks? Investigation of PERIOD and CLOCK gene variants in bipolar disorder

Clock genes play significant roles in the regulation of circadian rhythms, which are thought to be involved in the pathophysiology of neurodegenerative and psychiatric diseases. We aimed to investigate the association of five gene polymorphisms (PER3 VNTR (rs57875989), PER2 rs2304672, CLOCK rs1801260, CLOCK rs10462028, CLOCK rs11932595) with PCR-based methods as potential risk factors in bipolar disorder (BD). We used a multiple testing methodology in BD patients (n = 121) and healthy control individuals (n = 121) of Turkish descent to analyze the effects of these gene variants both as risk factors for the disorder and for the evaluation of these variants in the patient group with multiple subscales. We evaluated the circadian rhythm disturbances and seasonal variations in mood and behavior in BD patients using the Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN) and Seasonal Pattern Assessment Questionnaire (SPAQ) to enlighten the possible links between these scores and the studied circadian gene variants. The results of our study revealed significant associations: PER3 VNTR (rs57875989) 5/5 repeat genotype displayed a protective effect against BD when compared with 4/4 repeat genotype. Moreover, patients with PER3 VNTR 5/5 repeat genotype displayed a higher ratio of hypomania. PER2 rs2304672 G allele frequency increased the risk for BD. There was no association in terms of genotype/allele frequency comparisons between patients and controls for CLOCK gene variants. However, significant associations were found in patients in terms of clinical and behavioral patterns such as mean age at disease onset and BRIAN total scores enabling some risk stratifications for patients. Our results indicate the significance of circadian gene variants in BD, which need to be confirmed in different studies with larger samples. Thus, the possible endophenotypes of BD can be enlightened and advanced chronotherapeutics approaches can be manipulated in the future for clinical benefit.

T cell reactivity to regulatory factor X4 in type 1 narcolepsy

Type 1 narcolepsy is strongly (98%) associated with human leukocyte antigen (HLA) class II DQA1*01:02/DQB1*06:02 (DQ0602) and highly associated with T cell receptor (TCR) alpha locus polymorphism as well as other immune regulatory loci. Increased incidence of narcolepsy was detected following the 2009 H1N1 pandemic and linked to Pandemrix vaccination, strongly supporting that narcolepsy is an autoimmune disorder. Although recent results suggest CD4+ T cell reactivity to neuropeptide hypocretin/orexin and cross-reactive flu peptide is involved, identification of other autoantigens has remained elusive. Here we study whether autoimmunity directed against Regulatory Factor X4 (RFX4), a protein co-localized with hypocretin, is involved in some cases of narcolepsy. Studying human serum, we found that autoantibodies against RFX4 were rare. Using RFX4 peptides bound to DQ0602 tetramers, antigen RFX4-86, -95, and -60 specific human CD4+ T cells were detected in 4/10 patients and 2 unaffected siblings, but not in others. Following culture with each cognate peptide, enriched autoreactive TCRαβ clones were isolated by single-cell sorting and TCR sequenced. Homologous clones bearing TRBV4-2 and recognizing RFX4-86 in patients and one twin control of patient were identified. These results suggest the involvement of RFX4 CD4+ T cell autoreactivity in some cases of narcolepsy, but also in healthy donors.

Polygenic risk scores for major psychiatric and neurodevelopmental disorders contribute to sleep disturbance in childhood: Adolescent Brain Cognitive Development (ABCD) Study

Sleep disturbance is a common symptom of psychiatric and neurodevelopmental disorders and, especially in childhood, can be a precursor to various mental disorders. However, the genetic etiology of mental illness that contributes to sleep disturbance during childhood is poorly understood. We investigated whether the polygenic features of psychiatric and neurodevelopmental disorders are associated with sleep disturbance during childhood. We conducted polygenic risk score (PRS) analyses by utilizing large-scale genome-wide association studies (GWASs) (n = 46,350-500,199) of five major psychiatric and neurodevelopmental disorders (autism spectrum disorder, schizophrenia, attention-deficit/hyperactivity disorder (ADHD), major depressive disorder (MDD), and bipolar disorder) and, additionally, anxiety disorders as base datasets. We used the data of 9- to 10-year-olds from the Adolescent Brain Cognitive Development study (n = 9683) as a target dataset. Sleep disturbance was assessed based on the Sleep Disturbance Scale for Children (SDSC) scores. The effects of PRSs for these psychiatric and neurodevelopmental disorders on the total scores and six subscale scores of the SDSC were investigated. Of the PRSs for the five psychiatric and neurodevelopmental disorders, the PRSs for ADHD and MDD positively correlated with sleep disturbance in children (ADHD: R² = 0.0033, p = 6.19 × 10^-5, MDD: R² = 0.0042, p = 5.69 × 10^-6). Regarding the six subscale scores of the SDSC, the PRSs for ADHD positively correlated with both disorders of initiating and maintaining sleep (R² = 0.0028, p = 2.31 × 10^-4) and excessive somnolence (R² = 0.0023, p = 8.44 × 10^-4). Furthermore, the PRSs for MDD primarily positively correlated with disorders of initiating and maintaining sleep (R² = 0.0048, p = 1.26 × 10^-6), followed by excessive somnolence (R² = 0.0023, p = 7.74 × 10^-4) and sleep hyperhidrosis (R² = 0.0014, p = 9.55 × 10^-3). Despite high genetic overlap between MDD and anxiety disorders, PRSs for anxiety disorders correlated with different types of sleep disturbances such as disorders of arousal or nightmares (R² = 0.0013, p = 0.011). These findings suggest that greater genetic susceptibility to specific psychiatric and neurodevelopmental disorders, as represented by ADHD, MDD, and anxiety disorders, may contribute to greater sleep problems among children.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

Neuroendocrine Stress System in Bipolar Disorder

Hormones have a crucial part in the progress and manifestation of a wide variety of different behaviors. The main influence of the neuroendocrine system on behavior is its action on the neurobiology of neuropsychiatric disorders and its relationship with the pharmacodynamics of medicines. Of all the neuroendocrine axes, the hypothalamic-pituitary-adrenal (HPA) axis has been the most extensively studied. There is evidence that disturbance in the HPA axis, the primary stress hormone system, could increase treatment resistance and relapse, worsen illness outcome, and cause cognitive deficits. Glucocorticoids mediate their actions in negative feedback binding in two different cytoplasmatic receptors described as mineralocorticoid receptors (MRs) and glucocorticoid receptors (GRs). Different psychopathologies underlying bipolar disorders are supposed to involve persistent dysfunctions in the expression and role of both MR and GR in the hippocampus. We review and analyze the evidence related to the correlation between bipolar disorders and the consequences and impact of stressful life events on the HPA axis, exploring the importance of these findings in bipolar disorders and as potential new targets for treatment.

Major depressive disorder with mixed features and treatment response to lurasidone: A symptom network model

BACKGROUND

To investigate the symptom network structure of major depressive disorder (MDD) with mixed features and implications for treatment.

METHODS

In this post-hoc analysis of a previously reported randomized trial, patients meeting DSM-IV-TR criteria for MDD presenting with two or three manic symptoms (DSM-5 mixed features specifier) were randomized to 6 weeks of double-blind treatment with lurasidone 20-60 mg/d (N = 109) or placebo (N = 100). The network structure of symptoms at baseline and their treatment moderating effects were investigated.

RESULTS

Network analyses showed that both ``elevated mood'' (YMRS item 1) and ``increased motor activity-energy'' (YMRS item 2) were associated with ``sleep disturbance'' ("bridge" symptom) and the depressive symptom cluster. Presence of both "elevated mood" and "increased motor activity-energy" at baseline predicted significantly less improvement in MADRS and CGI-S score at week 6 with lurasidone (vs. placebo) compared to patients without these manic symptoms at baseline. The network model also showed "rapid/pressured speech" (YMRS item 6) at baseline predicted improvement in both manic and depressive symptoms with lurasidone vs. placebo treatment.

LIMITATIONS

This was a post-hoc analysis where findings need to be confirmed by prospective controlled studies.

CONCLUSIONS

This post-hoc analysis describes the symptom network structure of MDD with mixed features in a patient sample at study baseline. Specific manic symptoms were found to be linked to sleep disturbance (characterized as a "bridge" symptom), which in turn linked the manic and depressive symptom clusters. The presence (vs. absence) of the specific manic symptoms we identified moderated the antidepressant and antimanic effects of lurasidone in the treatment of MDD with mixed (subthreshold hypomanic) features.

Analyzing the effects of memory biases and mood disorders on social performance

Realistic models of decision-making and social interactions, considering the nature of memory and biases, continue to be an area of immense interest. Emotion and mood are a couple of key factors that play a major role in decisions, nature of social interactions, size of the social network, and the level of engagement. Most of the prior work in this direction focused on a single trait, behavior, or bias. However, this work builds an integrated model that considers multiple traits such as loneliness, the drive to interact, the memory, and mood biases in an agent. The agent system comprises of rational, manic, depressed, and bipolar agents. The system is modeled with an interconnected network, and the size of the personal network of each agent is based on its nature. We consider a game of iterated interactions where an agent cooperates based on its past experiences with the other agent. Through simulation, the effects of various biases and comparative performances of agent types is analyzed. Taking the performance of rational agents as the baseline, manic agents do much better, and depressed agents do much worse. The payoffs also exhibit an almost-linear relationship with the extent of mania. It is also observed that agents with stronger memory perform better than those with weaker memory. For rational agents, there is no significant difference between agents with a positive bias and those with a negative bias. Positive bias is linked with higher payoffs in manic and bipolar agents. In depressed agents, negative bias is linked with higher payoffs. In manic agents, an intermediate value of mood dependence offers the highest payoff. But the opposite is seen in depressed agents. In bipolar agents, agents with weak mood dependence perform the best.

Daily self-reported and automatically generated smartphone-based sleep measurements in patients with newly diagnosed bipolar disorder, unaffected first-degree relatives and healthy control individuals

OBJECTIVES

(1) To investigate daily smartphone-based self-reported and automatically generated sleep measurements, respectively, against validated rating scales; (2) to investigate if daily smartphone-based self-reported sleep measurements reflected automatically generated sleep measurements and (3) to investigate the differences in smartphone-based sleep measurements between patients with bipolar disorder (BD), unaffected first-degree relatives (UR) and healthy control individuals (HC).

METHODS

We included 203 patients with BD, 54 UR and 109 HC in this study. To investigate whether smartphone-based sleep calculated from self-reported bedtime, wake-up time and screen on/off time reflected validated rating scales, we used the Pittsburgh Sleep Quality Index (PSQI) and sleep items on the Hamilton Depression Rating Scale 17-item (HAMD-17) and the Young Mania Rating Scale (YMRS).

FINDINGS

(1) Self-reported smartphone-based sleep was associated with the PSQI and sleep items of the HAMD and the YMRS. (2) Automatically generated smartphone-based sleep measurements were associated with daily self-reports of hours slept between 12:00 midnight and 06:00. (3) According to smartphone-based sleep, patients with BD slept less between 12:00 midnight and 06:00, with more interruption and daily variability compared with HC. However, differences in automatically generated smartphone-based sleep were not statistically significant.

CONCLUSION

Smartphone-based data may represent measurements of sleep patterns that discriminate between patients with BD and HC and potentially between UR and HC.

CLINICAL IMPLICATION

Detecting sleep disturbances and daily variability in sleep duration using smartphones may be helpful for both patients and clinicians for monitoring illness activity.

TRIAL REGISTRATION NUMBER

clinicaltrials.gov (NCT02888262).

Classification of Actigraphy Records from Bipolar Disorder Patients Using Slope Entropy: A Feasibility Study

Bipolar Disorder (BD) is an illness with high prevalence and a huge social and economic impact. It is recurrent, with a long-term evolution in most cases. Early treatment and continuous monitoring have proven to be very effective in mitigating the causes and consequences of BD. However, no tools are currently available for a massive and semi-automatic BD patient monitoring and control. Taking advantage of recent technological developments in the field of wearables, this paper studies the feasibility of a BD episodes classification analysis while using entropy measures, an approach successfully applied in a myriad of other physiological frameworks. This is a very difficult task, since actigraphy records are highly non-stationary and corrupted with artifacts (no activity). The method devised uses a preprocessing stage to extract epochs of activity, and then applies a quantification measure, Slope Entropy, recently proposed, which outperforms the most common entropy measures used in biomedical time series. The results confirm the feasibility of the approach proposed, since the three states that are involved in BD, depression, mania, and remission, can be significantly distinguished.

The associations between illness perceptions and social rhythm stability on mood symptoms among patients with bipolar disorder

BACKGROUND

The association between illness perceptions and the effectiveness of patients' illness-management strategies has been supported across a range of medical and psychiatric disorders. Few studies have examined these variables or their association in bipolar disorder (BD). This study examined the main and interactive associations between illness perceptions and one important illness management strategy - social rhythms stability on mood symptom severity in adults with BD.

METHODS

A cross-sectional study with 131 patients with BD in Taiwan was conducted using clinician- and patient-rated mood symptoms, self-reported illness perceptions, and a measure of daily and nightly social rhythms.

RESULTS

Illness perceptions were associated with mood symptom severity, but social rhythms were not. Unfavorable illness perceptions (e.g., beliefs of experiencing more BD symptoms, having stronger emotional responses to the illness) were associated with more severe mood symptoms. Favorable illness perceptions (e.g., beliefs of being able to understand and control the illness) were associated with less severe mood symptoms, with personal control as the strongest correlate of mood symptom severity. Finally, social rhythm stability moderated the relationship between unfavorable illness perceptions and clinician-rated manic symptoms.

LIMITATIONS

The cross-sectional design limits our ability to make causal conclusions. Also, the effects pertain to patients in remission and may not generalize to more severely ill or hospitalized bipolar patients.

CONCLUSIONS

This study indicates that in patients with BD, illness perceptions are associated with symptom severity. Interventions to enhance favorable IPs and reduce unfavorable IPs may improve mood outcomes, particularly when patients have adopted regular social rhythms.

Association between coffee, tobacco, and alcohol daily consumption and sleep/wake cycle: an actigraphy study in euthymic patients with bipolar disorders

Individuals with bipolar disorder (BD) have higher than average rates of coffee, tobacco and alcohol use. These substances may have deleterious effects on sleep quality and quantity, which may destabilize sleep/wake cycles and negatively impact the clinical course and prognosis of BD. The use of these substances may also be perceived as a self-medication attempt, for example, to induce sleep or to increase vigilance during the day. The objective of the current study was to investigate associations between the self-reported daily use of coffee, tobacco, and alcohol, and objective measures of sleep and activity patterns in adult individuals with BD. A sample of 147 euthymic individuals with BD were assessed for daily coffee, tobacco and alcohol consumption and 21 days of actigraphy monitoring. Actigraphic measures of sleep quantity and daytime activity were compared between groups classified as coffee+/coffee-, tobacco+/tobacco- and alcohol+/alcohol-, defined according to their current daily use. Then, we examined potential correlations between sleep/wake cycle parameters and the amount of daily consumption of each substance. Multivariable analyses identified associations between the use of coffee, tobacco, and alcohol and several sleep and activity parameters, such as between coffee, alcohol, and the relative amplitude of activity (respectively, p = .003 and p = .005), between alcohol and M10 onset (onset time of the 10 most active hours during the 24-h cycle) (p = .003), and between coffee and sleep duration (p = .047). This study supports the hypothesis that there is a relationship, whose direction would be bidirectional, between the daily use of these substances and the sleep/wake cycle in euthymic individuals with BD. These preliminary results require replications in other retrospective and prospective samples. They may have a clinical impact on psycho-education strategies to be proposed to individuals with BD.

Sleep duration and timing in obsessive-compulsive disorder (OCD): evidence for circadian phase delay

OBJECTIVES

To investigate potential delays in endogenous melatonin in individuals with obsessive-compulsive disorder (OCD).

METHODS

First, data are presented for 15 individuals with OCD and matched healthy controls. Next, nine additional participants with OCD who did not have matched controls were added, resulting in a sample of 24 individuals with OCD. All participants were assessed for sleep and circadian rhythm disturbance. Dim light melatonin onset (DLMO) was derived from salivary melatonin and was used in conjunction with sleep diaries, interview measures, and questionnaires. A subset of the OCD group (n = 16) also used actigraphy.

RESULTS

In sum, 42% percent (10/24) of the patients with OCD met the criteria for delayed sleep-wake phase disorder (DSWPD) in comparison to 0% in the control sample. DLMO was significantly later in individuals with OCD compared to controls. DLMO and bedtime were not significantly associated with the severity of obsessive-compulsive symptoms or negative affect.

CONCLUSIONS

Replication of the findings presented herein, particularly the DLMO results, is warranted. Further, there are now three studies showing that nearly ½ of individuals with OCD meet criteria for a DSWPD. Future studies can explore the mechanisms underlying these connections and the implications of this comorbidity. These findings may increase our understanding of OCD and inform future interventions.

Current understandings of the trajectory and emerging correlates of cognitive impairment in bipolar disorder: An overview of evidence

OBJECTIVES

Cognitive dysfunction affects a significant proportion of people with bipolar disorder (BD), but the cause, trajectory and correlates of such dysfunction remains unclear. Increased understanding of these factors is required to progress treatment development for this symptom dimension.

METHODS

This paper provides a critical overview of the literature concerning the trajectories and emerging correlates of cognitive functioning in BD. It is a narrative review in which we provide a qualitative synthesis of current evidence concerning clinical, molecular, neural and lifestyle correlates of cognitive impairment in BD across the lifespan (in premorbid, prodromal, early onset, post-onset, elderly cohorts).

RESULTS

There is emerging evidence of empirical links between cognitive impairment and an increased inflammatory state, brain structural abnormalities and reduced neuroprotection in BD. However, evidence regarding the progressive nature of cognitive impairment is mixed, since consensus between different cross-sectional data is lacking and does not align to the outcomes of the limited longitudinal studies available. Increased recognition of cognitive heterogeneity in BD may help to explain some inconsistencies in the extant literature.

CONCLUSIONS

Large, longitudinally focussed studies of cognition and its covariation alongside biological and lifestyle factors are required to better define cognitive trajectories in BD, and eventually pave the way for the application of a precision medicine approach for individual patients in clinical practice.

The chronotherapeutic treatment of bipolar disorders: A systematic review and practice recommendations from the ISBD task force on chronotherapy and chronobiology

AIMS

To systematically review the literature on the efficacy and tolerability of the major chronotherapeutic treatments of bipolar disorders (BD)-bright light therapy (LT), dark therapy (DT), treatments utilizing sleep deprivation (SD), melatonergic agonists (MA), interpersonal social rhythm therapy (IPSRT), and cognitive behavioral therapy adapted for BD (CBTI-BP)-and propose treatment recommendations based on a synthesis of the evidence.

METHODS

PRISMA-based systematic review of the literature.

RESULTS

The acute antidepressant (AD) efficacy of LT was supported by several open-label studies, three randomized controlled trials (RCTs), and one pseudorandomized controlled trial. SD showed rapid, acute AD response rates of 43.9%, 59.3%, and 59.4% in eight case series, 11 uncontrolled, studies, and one RCT, respectively. Adjunctive DT obtained significant, rapid anti-manic results in one RCT and one controlled study. The seven studies on MA yielded very limited data on acute antidepressant activity, conflicting evidence of both antimanic and maintenance efficacy, and support from two case series of improved sleep in both acute and euthymic states. IPSRT monotherapy for bipolar II depression had acute response rates of 41%, 67%, and 67.4% in two open studies and one RCT, respectively; as adjunctive therapy for bipolar depression in one RCT, and efficacy in reducing relapse in two RCTs. Among euthymic BD subjects with insomnia, a single RCT found CBTI-BP effective in delaying manic relapse and improving sleep. Chronotherapies were generally safe and well-tolerated.

CONCLUSIONS

The outcome literature on the adjunctive use of chronotherapeutic treatments for BP is variable, with evidence bases that differ in size, study quality, level of evidence, and non-standardized treatment protocols. Evidence-informed practice recommendations are offered.

Chronotypes and its association with psychological morbidity and childhood parasomnias

BACKGROUND

The relationship between chronotypes and sleeping problems is not clear. The objective of the study was to identify the relative occurrence of chronotypes among college students and to explore adult psychological morbidity and childhood sleeping problems across chronotypes.

MATERIALS AND METHODS

One hundred and fifty undergraduate medical students were assigned into different chronotypes by Morningness-Eveningness Questionnaire and they were further assessed using Self-Reporting Questionnaire, Parasomnia Questionnaire (adapted from the Adult Sleep Disorders Questionnaire), and Pittsburgh Sleep Quality Index.

RESULTS

Intermediate chronotype was the most common, seen in 87 (58%) students, followed by evening type in 34 (22.7%). Evening types have more difficulties in making a decision, becoming exhausted more easily and feeling worthless than other chronotypes. Evening-oriented students showed a significantly higher frequency of initial insomnia and poorer overall sleep quality than the other groups. The current bedwetting was more in evening types; there was no difference in any other current and childhood parasomnias.

CONCLUSIONS

Evening chronotypes had greater difficulty in decision-making, and they were more vulnerable to feel worthless. No significant association was found between childhood parasomnias and chronotypes except persistent bedwetting during adulthood in evening types.

Current understanding of bipolar disorder: Toward integration of biological basis and treatment strategies

Biological studies of bipolar disorder initially focused on the mechanism of action for antidepressants and antipsychotic drugs, and the roles of monoamines (e.g., serotonin, dopamine) have been extensively studied. Thereafter, based on the mechanism of action of lithium, intracellular signal transduction systems, including inositol metabolism and intracellular calcium signaling, have drawn attention. Involvement of intracellular calcium signaling has been supported by genetics and cellular studies. Elucidation of the neural circuits affected by calcium signaling abnormalities is critical, and our previous study suggested a role of the paraventricular thalamic nucleus. The genetic vulnerability of mitochondria causes calcium dysregulation and results in the hyperexcitability of serotonergic neurons, which are suggested to be susceptible to oxidative stress. Efficacy of anticonvulsants, animal studies of candidate genes, and studies using induced pluripotent stem cell-derived neurons have suggested a relation between bipolar disorder and the hyperexcitability of neurons. Recent genetic findings suggest the roles of polyunsaturated acids. At the systems level, social rhythm therapy targets circadian rhythm abnormalities, and cognitive behavioral therapy may target emotion/cognition (E/C) imbalance. In the future, pharmacological and psychosocial treatments may be combined and optimized based on the biological basis of each patient, which will realize individualized treatment.

Interactome Analyses implicated CAMK2A in the genetic predisposition and pharmacological mechanism of Bipolar Disorder

Bipolar disorder (BPD) is a severe mental illness characterized by fluctuations in mood states, behaviors and energy levels. Growing evidence suggests that genes associated with specific illnesses tend to interact together and encode a tight protein-protein interaction (PPI) network, providing valuable information for understanding their pathogenesis. To gain insights into the genetic and physiological foundation of BPD, we conduct the physical PPI analysis of 184 BPD risk genes distilled from genome-wide association studies and exome sequencing studies. We have identified several hub genes (CAMK2A, HSP90AA1 and PLCG1) among those risk genes, and observed significant enrichment of the BPD risk genes in certain pathways such as calcium signaling, oxytocin signaling and circadian entrainment. Furthermore, while none of the 184 genetic risk genes are "well established" BPD drug targets, our PPI analysis showed that αCaMKII (encoded by CAMK2A) had direct physical PPIs with targets (HRH1, SCN5A and CACNA1E) of clinically used anti-manic BPD drugs, such as carbamazepine. We thus speculated that αCaMKII might be involved in the cellular pharmacological actions of those drugs. Using cultured rat primary cortical neurons, we found that carbamazepine treatment induced phosphorylation of αCaMKII in dose-dependent manners. Intriguingly, previous study showed that CAMK2A heterozygous knockout (CAMK2A^+/-) mice exhibited infradian oscillation of locomotor activities that can be rescued by carbamazepine. Our data, in combination with previous studies, provide convergent evidence for the involvement of CAMK2A in the risk of BPD.

Sleep Disturbance in Bipolar Disorder: Neuroglia and Circadian Rhythms

The worldwide prevalence of sleep disorders is approximately 50%, with an even higher occurrence in a psychiatric population. Bipolar disorder (BD) is a severe mental illness characterized by shifts in mood and activity. The BD syndrome also involves heterogeneous symptomatology, including cognitive dysfunctions and impairments of the autonomic nervous system. Sleep abnormalities are frequently associated with BD and are often a good predictor of a mood swing. Preservation of stable sleep-wake cycles is therefore a key to the maintenance of stability in BD, indicating the crucial role of circadian rhythms in this syndrome. The symptom most widespread in BD is insomnia, followed by excessive daytime sleepiness, nightmares, difficulty falling asleep or maintaining sleep, poor sleep quality, sleep talking, sleep walking, and obstructive sleep apnea. Alterations in the structure or duration of sleep are reported in all phases of BD. Understanding the role of neuroglia in BD and in various aspects of sleep is in nascent state. Contributions of the different types of glial cells to BD and sleep abnormalities are discussed in this paper.