No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Sleep in patients with remitted bipolar disorders: A meta-analysis of actigraphy studies
Abstract
Objective:
Sleep dysregulation is highly prevalent in bipolar disorders (BDs), with previous actigraphic studies demonstrating sleep abnormalities during depressive, manic, and interepisode periods. We undertook a meta-analysis of published actigraphy studies to identify whether any abnormalities in the reported sleep profiles of remitted BD cases differ from controls.
Method:
A systematic review identified independent studies that were eligible for inclusion in a random effects meta-analysis. Effect sizes for actigraphy parameters were expressed as standardized mean differences (SMD) with 95% confidence intervals (95% CI).
Results:
Nine of 248 identified studies met eligibility criteria. Compared with controls (N=210), remitted BD cases (N=202) showed significant differences in SMD for sleep latency (0.51 [0.28-0.73]), sleep duration (0.57 [0.30-0.84]), wake after sleep onset (WASO) (0.28 [0.06-0.50]) and sleep efficiency (-0.38 [-0.70-0.07]). Moderate heterogeneity was identified for sleep duration (I2=44%) and sleep efficiency (I2=44%). Post hoc meta-regression analyses demonstrated that larger SMD for sleep duration were identified for studies with a greater age difference between BD cases and controls (β=0.22; P=0.03) and non-significantly lower levels of residual depressive symptoms in BD cases (β=-0.13; P=0.07).
Conclusion:
This meta-analysis of sleep in remitted bipolar disorder highlights disturbances in several sleep parameters. Future actigraphy studies should pay attention to age matching and levels of residual depressive symptoms.
Supplementary resources (3)
... Wearables collecting actigraphy, the non-invasive method of monitoring human rest/activity [18], can capture altered sleep rhythms in remitted BD [19], and also depressive symptoms [20]. Also, actigraphy data from wearables has shown accurate to predict mood disorders' diagnosis and symptom change [21]. ...
... First, the E4 has shown accurate in measuring heart rate (HR), HRV [40], and EDA compared with laboratory conditions [41], as well as for sleep staging [42]. As previously referred, those physiological parameters have been shown altered in mood disorders and mood episodes [19][20][21][22][23][25][26][27][28]. Second, the E4 has been validated in scientific research for detecting emotional arousal, stress [43,44], and mental effort [45], using the aforementioned physiological signals. ...
... statistical, time-domain, frequency-domain features) [94], assessing EDA reactivity by extracting information of the tonic and phasic components of skin conductance using novel automated methods [18,94,95], and performing stress-elicitation to assess potential alterations (hyporeactivity) in the phasic component of EDA during mood episodes [26]. Finally, considering the sleep and circadian rhythm disturbances in mood disorders both in euthymia [19,96] and acute phases [97][98][99], we are exploring automated methods to separate sleep from wake times [86,100,101]. Our goal is to evaluate sleep disturbances and differences in physiological signals during sleep and wake periods during mood episodes [76]. ...
Background:
Depressive and manic episodes within bipolar disorder (BD) and major depressive disorder (MDD) involve altered mood, sleep, and activity alongside physiological alterations that wearables can capture.
Objective:
We explored whether physiological wearable data could predict: (aim 1) the severity of an acute affective episode at the intra-individual level, (aim 2) the polarity of an acute affective episode and euthymia among different individuals. Secondarily, we explored which physiological data were related to the prior predictions, generalization across patients, and associations between affective symptoms and physiological data.
Methods:
We conducted a prospective exploratory observational study including patients with BD and MDD on acute affective episodes (manic, depressed, and mixed) whose physiological data were recorded with a research-grade wearable (Empatica E4) across three consecutive timepoints (acute, response, and remission of episode). Euthymic patients and healthy controls (HC) were recorded during a single session (∼48 hours). Manic and depressive symptoms were assessed with standardized psychometric scales. Physiological wearable data included the following channels: acceleration (ACC), temperature (TEMP), blood volume pulse (BVP), heart rate (HR), and electrodermal activity (EDA). For data pre-processing, invalid physiological data were removed using a rule-based filter, channels were time-aligned at 1 second time units and then segmented window lengths of 32 seconds, since those parameters showed the best performances. We developed deep learning predictive models, assessed channels' individual contribution using permutation feature importance analysis, and computed physiological data to psychometric scales' items normalized mutual information (NMI). We present a novel fully automated method for analysis of physiological data from a research-grade wearable device, including a rule-based filter for invalid data and a viable supervised learning pipeline for time-series analyses.
Results:
35 sessions (1,512 hours) from 12 patients (manic, depressed, mixed, and euthymic) and 7 HC (age 39.7±12.6; 31.6% female) were analyzed. (aim 1) The severity of mood episodes was predicted with moderate (62%-85%) accuracies. (aim 2) The polarity of episodes was predicted with moderate (70%) accuracy. The most relevant features for the former tasks were ACC, EDA, and HR. Kendall W showed fair agreement (0.383) in feature importance across classification tasks. Generalization of the former models were of overall low accuracy, with better results for the intra-individual models. "Increased motor activity" was associated with ACC (NMI>0.55), "aggressive behavior" with EDA (NMI=1.0), "insomnia" with ACC (NMI∼0.6), "motor inhibition" with ACC (NMI∼0.75), and "psychic anxiety" with EDA (NMI=0.52).
Conclusions:
Physiological data from wearables show potential to identify mood episodes and specific symptoms of mania and depression quantitatively, both in BD and MDD. Motor activity and stress-related physiological data (EDA and HR) stand out as potential digital biomarkers for predicting mania and depression respectively. These findings represent a promising pathway towards personalized psychiatry, in which physiological wearable data could allow early identification and intervention of mood episodes.
... Sleep disturbances are associated with an increased risk of cardiometabolic disorders, including hypertension, myocardial infarction, stroke and morbid obesity (Bacaro et al., 2020;Larsson and Markus, 2019;Nuyujukian et al., 2019;Viot-Blanc and Levy, 2006). Significant sleep complaints are experienced by up to 80% of remitted patients with psychotic and bipolar disorders (Geoffroy and Gottlieb, 2020;Geoffroy et al., 2015;Kaskie et al., 2017;Laskemoen et al., 2019;Meyer et al., 2020). In parallel, these disorders are associated with several objective disturbances of sleepwake cycle as shown by polysomnography and actigraphy investigations (Baglioni et al., 2016;Castelnovo et al., 2018;Chan et al., 2017;Geoffroy et al., 2015;Zangani et al., 2020). ...
... Significant sleep complaints are experienced by up to 80% of remitted patients with psychotic and bipolar disorders (Geoffroy and Gottlieb, 2020;Geoffroy et al., 2015;Kaskie et al., 2017;Laskemoen et al., 2019;Meyer et al., 2020). In parallel, these disorders are associated with several objective disturbances of sleepwake cycle as shown by polysomnography and actigraphy investigations (Baglioni et al., 2016;Castelnovo et al., 2018;Chan et al., 2017;Geoffroy et al., 2015;Zangani et al., 2020). Severity of sleep disturbances correlates with worse cognitive performances and poorer functional outcomes (Kaskie et al., 2019;Morton and Murray, 2020) and has been demonstrated as a possible risk factor for onset and relapse of psychotic and mood disorders Melo et al., 2016;Pancheri et al., 2019;Soehner et al., 2019). ...
... These findings corroborate those of previous reviews involving either UHR or FE (Clarke et al., 2020;Davies et al., 2017). This supports the hypothesis that sleep disturbances appear during early stages and persist in established psychotic disorders (Geoffroy et al., 2015;Geoffroy and Gottlieb, 2020;Kaskie et al., 2017;Laskemoen et al., 2019;Meyer et al., 2020), while no conclusions about sleep status in FE-BD can be made. In contrast, we noted that specific sleep continuity, duration and initiation parameters did not differ between controls and individual early stage subgroups (e.g. ...
Objective
To provide a qualitative view and quantitative measure of sleep disturbances across and between early stages – clinical ultra high-risk and first episode – of psychotic and bipolar disorders.
Methods
Electronic databases (PubMed, Cochrane, Embase, PsychINFO) were searched up to March 2021 for studies comparing sleep measures between individuals with an early stage and controls. Standard mean deviations (Cohen’s d effect sizes) were calculated for all comparisons and pooled with random-effects models. Chi-square tests were used for direct between-subgroups (ultra high-risk vs first episode) comparisons of standard mean deviations. The effects of age, sex ratio, symptoms and treatment were examined in meta-regression analyses.
Results
A database search identified 13 studies that contrasted sleep measures between individuals with an early stage ( N = 537) and controls ( N = 360). We observed poorer subjective sleep quality (standard mean deviation = 1.32; 95% confidence interval, [1.01, 1.62]), shorter total sleep time (standard mean deviation =−0.44; 95% confidence interval, [−0.67, −0.21]), lower sleep efficiency (standard mean deviation = −0.72; 95% confidence interval, [−1.08, −0.36]), longer sleep onset latency (standard mean deviation = 0.75; 95% confidence interval, [0.45, 1.06]) and longer duration of wake after sleep onset (standard mean deviation = 0.49; 95% confidence interval, [0.21, 0.77]) were observed in early stages compared to controls. No significant differences were observed for any of the reported electroencephalographic parameters of sleep architecture. No significant between-subgroups differences were observed. Meta-regressions revealed a significant effect of the age and the antipsychotic status on subjective measures of sleep.
Conclusion
The early stage population presents with significant impairments of subjective sleep quality continuity, duration and initiation. Systematic assessments of sleep in early intervention settings may allow early identification and treatment of sleep disturbances in this population.
... While there is a remarkable lack of consensus with regard to BD patients within a depressive episode [2]. Meanwhile, a longer sleep latency, shorter sleep duration, longer wake time after sleep onset, poor sleep efficiency, and greater night-to-night variability of sleep pattern were found to be characteristics of a remitted BD sample [3,4]. ...
... Our study showed that euthymic BD patients had higher PSQI than healthy controls. This is compatible with other studies showing that residual sleep problems is common in euthymic BD patients [3,4,17]. ...
Objective:
Bipolar disorder (BD) is characterized by the poor sleep quality. Whether the striatal dopamine transporter (DAT) availability is related to sleep quality among patients with BD is unclear.
Methods:
Fifty-three euthymic patients with BD (24 BD-I and 29 BD-II) and sixty-eight healthy controls were enrolled. The Chinese Version of the Pittsburgh Sleep Quality Index (PSQI) was used, and the availability of DAT was assessed by single-photon emission computed tomography (SPECT) using [99mTc] TRODAT-1.
Results:
The sleep disturbance component of the PSQI was significantly associated with the level of DAT availability among patients with BD.
Conclusion:
The striatal dopaminergic activity that contributes to resilience to adversity was associated with sleep pattern among patients with BD.
... These disturbances are observed during the different phases of the disease and are major symptoms of mood episodes and belong to the diagnostic criteria for depression, hypomania and mania (6). In addition, these anomalies are also found during euthymic phases (7 be more likely to present a more evening chronotype and a more languid and rigid circadian type than healthy subjects as well as a decrease in the efficiency of their sleep, an increase in sleep duration, an increased sleep latency and a prolongation of the duration of awakenings after the onset of sleep (7,8). These disturbances in sleep and wake/sleep rhythms are associated, among other things, with more frequent relapses, an alteration in quality of life and cognitive disorders (9). ...
... These disturbances are observed during the different phases of the disease and are major symptoms of mood episodes and belong to the diagnostic criteria for depression, hypomania and mania (6). In addition, these anomalies are also found during euthymic phases (7 be more likely to present a more evening chronotype and a more languid and rigid circadian type than healthy subjects as well as a decrease in the efficiency of their sleep, an increase in sleep duration, an increased sleep latency and a prolongation of the duration of awakenings after the onset of sleep (7,8). These disturbances in sleep and wake/sleep rhythms are associated, among other things, with more frequent relapses, an alteration in quality of life and cognitive disorders (9). ...
Background
Bipolar disorders (BD) is a common, chronic and disabling psychiatric condition. In addition to being characterized by significant clinical heterogeneity, notable disturbances of sleep and cognitive function are frequently observed in all phases of the disease. Currently, there is no readily available biomarker in current clinical practice to help diagnose or predict the disease course. Thus, identification of biomarkers in BD is today a major challenge. In this context, the study of electrophysiological biomarkers based on electroretinogram (ERG) measurements in BD seems highly promising. The BiMAR study aims to compare electrophysiological data measured with ERG between a group of euthymic patients with BD and a group of healthy control subjects. Secondarily, we will also describe the existing potential relationship between clinical, sleep and neuropsychological phenotypes of patients and electrophysiological data.
Methods
The BiMAR study is a comparative and monocentric study carried out at the Expert Center for BD in Nancy, France. In total, 70 euthymic adult patients with BD and 70 healthy control subjects will be recruited. Electrophysiological recordings with ERG and electroencephalogram (EEG) will be performed with a virtual reality headset after a standardized clinical evaluation to all participants. Then, an actigraphic monitoring of 21 consecutive days will be carried out. At the end of this period a neuropsychological evaluation will be performed during a second visit. The primary outcome will be electrophysiological measurements with ERG flash and pattern. Secondary outcomes will be EEG data, sleep settings, clinical and neuropsychological assessments. For patients only, a complementary ancillary study, carried out at the University Hospital of Nancy, will be proposed to assess the retinal structure and microvascularization using Optical Coherence Tomography. Recruitment started in January 2022 and will continue until the end of July 2023.
Discussion
The BiMAR study will contribute to identifying candidate ERG electrophysiological markers for helping the diagnosis of BD and identify subgroups of patients with different clinical profiles. Eventually, this would allow earlier diagnosis and personalized therapeutic interventions.
Clinical trial registration
The study is registered at Clinicaltrials.gov , NCT05161546, on 17 December 2021 ( https://clinicaltrials.gov/ct2/show/NCT05161546 ).
... For example, the sample primarily comprised individuals with BD-II (64%) and most of them (59%) reported persistent residual mood symptoms at baseline. Furthermore, the 7-day duration of actigraphy recording was probably suboptimal since guidelines and meta-analyses suggest 14-21 days is preferable, especially when assessing variability in rhythms [24,25]. Finally, mood relapses were not recorded according to recognized diagnostic criteria. ...
... About two-thirds were female (n = 59.4%) and about four-fifths met the criteria for BD type I (n = 78.3%). The sample median age was 42 years (IQR: 34-55), whilst the median age at onset of BD was 23 years (IQR: [19][20][21][22][23][24][25][26][27][28][29][30]. Given the study inclusion criteria, the severity of mood symptoms was very low with a median MADRS score of 2 (IQR: 0-3.5) and a median YMRS score of 1 (IQR: 0-2). ...
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.
... Sleep and circadian rhythm disturbances (SCRD) are common state characteristics of acute episodes of bipolar disorders (BD) (Harvey et al., 2009). Further, systematic reviews and meta-analyses of cross-sectional case-control studies demonstrate that self, observer or objectively assessed SCRD occur frequently in euthymia or inter-episode intervals (Geoffroy et al., 2015;De Crescenzo et al., 2017;Melo et al., 2017;Scott et al., , 2020a. However, most publications focus on comparisons with healthy controls (HC) only and clinical studies of patients aged 40-50 with a long-standing diagnosis of BD (of 10-20 years) . ...
... Regarding sleep quality/quantity, estimates of ES were inconclusive for mean values of SOL, WASO and SE (although ES for SOL showed a similar pattern to those for TST), but we found evidence for longer TST (albeit with the opposite finding in analyses of BAR groups alone). Our findings contrast with meta-analyses of studies of older adults with long-established BD cases that often receive polypharmacy which demonstrate moderate to large ES for TST, SOL, WASO, and SE (Geoffroy et al., 2015;Meyer et al., 2020). Currently, we cannot determine whether the differences in findings are best understood from the perspective of heterogeneity in research methodologies, age-related sleep patterns, or illness-and lifestyle-related factors. ...
Sleep and circadian rhythms disturbances (SCRD) in young people at high risk or with early onset of bipolar disorders (BD) are poorly understood. We systematically searched for studies of self, observer or objective estimates of SCRD in asymptomatic or symptomatic offspring of parents with BD (OSBD), individuals with presentations meeting recognized BD-at-risk criteria (BAR) and youth with recent onset of full-threshold BD (FT-BD). Of 76 studies eligible for systematic review, 35 (46%) were included in random effects meta-analyses. Pooled analyses of self-ratings related to circadian rhythms demonstrated greater preference for eveningness and more dysregulation of social rhythms in BAR and FT-BD groups; analyses of actigraphy provided some support for these findings. Meta-analysis of prospective studies showed that pre-existing SCRD were associated with a 40% increased risk of onset of BD, but heterogeneity in assessments was a significant concern. Overall, we identified longer total sleep time (Hedges g: 0.34; 95% confidence intervals:.1,.57), especially in OSBD and FT-BD and meta-regression analysis indicated the effect sizes was moderated by the proportion of any sample manifesting psychopathology or receiving psychotropic medications. This evolving field of research would benefit from greater attention to circadian rhythm as well as sleep quality measures.
... These abnormalities in chronobiological rhythms appear during all phases of the illness, during acute phase or during remission, and include changes in mood, appetite, energy, and abnormalities in sleep-wake rhythms [72]. The highlighted abnormalities of the sleep-wake rhythm, are mainly a vesperal chronotype, a more languid and rigid circadian typology, a longer sleep duration, a longer sleep latency, a poorer sleep efficiency, a more frequent awakening after the first sleep, a poorer inter-daily stability, a variability in the bedtime, the time of awakening, or in the sleep duration and efficiency [73,74]. Hormonally, the chronobiological abnormalities found are mainly a phase delay and decreased melatonin secretion, a melatoninergic hypersensitivity to light, elevated cortisol levels at night, and an early nadir on the temperature curves [75][76][77][78][79]. Finally, genotype-mood disorder phenotype correlations have been made with core clock genes and melatonin synthesis pathway genes, including a variant of the ASMT gene promoter associated with poorer quality sleep, a TIMELESS variant associated with languid rhythms (i.e., sleep inertia) as well as a more vesperal profile and a RORA variant with less flexible profile of life rhythms [80][81][82]. ...
... Furthermore, serotonin has a strong and bidirectional relationship with the biological clock [128]. Indeed, serotonin modulates the SCN response to light [129], and light induces indirect signaling, from the SCN to the raphe median nucleus [73]. Another possible hypothesis of the antidepressant effect of light through the modulation of 5-HTT levels is that light may induce direct signaling (i.e., independently of the SCN) between the retina and the serotoninergic system such as a direct action on the raphe dorsal nucleus (Figures 1 and 2). ...
Light exerts powerful biological effects on mood regulation. Whereas the source of photic information affecting mood is well established at least via intrinsically photosensitive retinal ganglion cells (ipRGCs) secreting the melanopsin photopigment, the precise circuits that mediate the impact of light on depressive behaviors are not well understood. This review proposes two distinct retina–brain pathways of light effects on mood: (i) a suprachiasmatic nucleus (SCN)-dependent pathway with light effect on mood via the synchronization of biological rhythms, and (ii) a SCN-independent pathway with light effects on mood through modulation of the homeostatic process of sleep, alertness and emotion regulation: (1) light directly inhibits brain areas promoting sleep such as the ventrolateral preoptic nucleus (VLPO), and activates numerous brain areas involved in alertness such as, monoaminergic areas, thalamic regions and hypothalamic regions including orexin areas; (2) moreover, light seems to modulate mood through orexin-, serotonin- and dopamine-dependent pathways; (3) in addition, light activates brain emotional processing areas including the amygdala, the nucleus accumbens, the perihabenular nucleus, the left hippocampus and pathways such as the retina–ventral lateral geniculate nucleus and intergeniculate leaflet–lateral habenula pathway. This work synthetizes new insights into the neural basis required for light influence mood
... According to the "circadian hypothesis of mood disorders," mood symptoms would result from the misalignment of the circadian system due to the desynchronization of the master biological clock of the hypothalamus, that is, the suprachiasmatic nucleus, while constituting a hallmark and a key feature of these conditions role (Geoffroy, 2018;McClung, 2013;Vadnie and McClung, 2017;Wirz-Justice and Benedetti, 2020). It has been shown that most individuals with BD show disturbances of circadian rhythms, such as social interactions, physical activities, feeding patterns, and sleep/wake cycles before and during depressive or manic episodes, but also during euthymic phases (Geoffroy, 2018;Geoffroy et al., 2015;Gottlieb et al., 2019;Vadnie and McClung, 2017;Wirz-Justice and Benedetti, 2020). These sleep and circadian rhythm alterations have been associated with the severity of mood and insomnia symptoms, emotional dysregulation, and suicidality in BD Benard et al., 2019;Caruso et al., 2020;Etain et al., 2017;Geoffroy et al., 2015;Palagini et al., 2019a). ...
... It has been shown that most individuals with BD show disturbances of circadian rhythms, such as social interactions, physical activities, feeding patterns, and sleep/wake cycles before and during depressive or manic episodes, but also during euthymic phases (Geoffroy, 2018;Geoffroy et al., 2015;Gottlieb et al., 2019;Vadnie and McClung, 2017;Wirz-Justice and Benedetti, 2020). These sleep and circadian rhythm alterations have been associated with the severity of mood and insomnia symptoms, emotional dysregulation, and suicidality in BD Benard et al., 2019;Caruso et al., 2020;Etain et al., 2017;Geoffroy et al., 2015;Palagini et al., 2019a). It has been hypothesized that early life sleep and circadian rhythm disruption related to early life stressors might contribute to the pathways toward BD in adulthood (Aas et al., 2016;Palagini et al., 2019b). ...
The study aimed at investigating the potential impact of early stressful events on the clinical manifestations of bipolar disorder (BD). A sample of 162 adult individuals with BD was assessed using the Structural Clinical Interview for DSM-5, the Beck Depression Inventory-II, the Young Mania Rating Scale, the Early Trauma Inventory Self Report-Short Form, the Biological Rhythms Interview of Assessment in Neuropsychiatry, the Insomnia Severity Index, and the Scale for Suicide Ideation. A significant path coefficient indicated a direct effect of early life stressors on biological rhythms (coeff. = 0.26; p < 0.001) and of biological rhythms on depressive symptoms (coeff. = 0.5; p < 0.001), suicidal risk (coeff. = 0.3; p < 0.001), and insomnia (coeff. = 0.34; p < 0.001). Data suggested that the desynchronization of chronobiological rhythms might be one mediator of the association between early life stress and the severity of mood symptoms/suicidal ideation in BD. Addressing circadian rhythm alterations in subjects exposed to early stressors would help in preventing consequences of those stressors on BD.
... Sleep dysregulation is well-documented in bipolar disorder. 36 We found that the effects of lithium on sleep quality were mixed. In one included study, Geoffroy et al. found significantly lower PSQI scores in patients with BD I women, but not men, receiving lithium treatment. ...
... 43 Actigraphy, as one of the objective measurements, has increasingly been used in assessing circadian rhythm in mood disorder. 36,44 Actigraphy provides continuous objective measurement of movement over time, which could provide more details of circadian rhythm changes, improve assessment by reducing recall bias. 45 Thus, actigraphy might be a useful tool to further explore the effect of lithium on circadian rhythm. ...
Objectives:
Circadian rhythm disruption is commonly reported in patients with bipolar disorder. Lithium has been suggested to have effects on the circadian clock, the biological basis of the circadian rhythm. The objective of the current review was to review systematically the existing studies on the effect of lithium on circadian rhythm in patients with bipolar disorder.
Methods:
We systematically searched the scientific literature up to September 2020 for experimental or observational studies which measured circadian rhythm in bipolar patients taking lithium (in comparison with placebo or other active treatments) and carried out a meta-analysis. Circadian rest-activity was our primary outcome, but we also collected data about sleep quality and chronotype (Morningness-Eveningness). The protocol was registered in PROSPERO (CRD42018109790) RESULTS: Four observational studies (n = 668) and one experimental study (n = 29) were included. Results from the meta-analysis suggest a potential association between lithium and shifts toward morningness (standardised mean difference [SMD]: 0.42, 95% confidence interval [CI]: -0.05 to 0.90). One cohort study with 21 days of follow-up found that patients treated with lithium had significantly larger amplitude (0.68, 0.01 to 1.36) when compared to anticonvulsants.
Conclusion:
This review highlights the insufficient evidence to inform us about the effect of lithium on circadian rhythm. However, we found that chronotype can be a potential target for further exploration of biomarkers or biosignatures of lithium treatment in patients with bipolar disorder. Further studies with prospective and longitudinal study design, adopting actigraphy to monitor daily circadian rest-activity changes are needed.
... To extract physiological features from sensors raw measurements, we proceeded as follows. Cardiorespiratory (such as heart rate, breathing rate, heart rate variability) [18][19][20][21][22][23] , actigraphy (e.g., L5, M10, etc.) 46,47,51 and sleep-based physiological features (e.g., sleep stages such as REM/NREM/WASO) 52 were extracted respectively from PPG, 3-axis accelerometer and both sensors' data using a combination of standard algorithms from the literature [53][54][55] . These features were further grouped into physical activity (12 features), heart rate (25 features), heart rate variability (39 features), breathing rate (12 features) and sleep (13 features) and were smoothed with a mean filter to remove potential outliers. ...
Major Depressive Disorder (MDD) has heterogeneous manifestations, leading to difficulties in predicting the evolution of the disease and in patient's follow-up. We aimed to develop a machine learning algorithm that identifies a biosignature to provide a clinical score of depressive symptoms using individual physiological data. We performed a prospective, multicenter clinical trial where outpatients diagnosed with MDD were enrolled and wore a passive monitoring device constantly for 6 months. A total of 101 physiological measures related to physical activity, heart rate, heart rate variability, breathing rate, and sleep were acquired. For each patient, the algorithm was trained on daily physiological features over the first 3 months as well as corresponding standardized clinical evaluations performed at baseline and months 1, 2 and 3. The ability of the algorithm to predict the patient's clinical state was tested using the data from the remaining 3 months. The algorithm was composed of 3 interconnected steps: label detrending, feature selection, and a regression predicting the detrended labels from the selected features. Across our cohort, the algorithm predicted the daily mood status with 86% accuracy, outperforming the baseline prediction using MADRS alone. These findings suggest the existence of a predictive biosignature of depressive symptoms with at least 62 physiological features involved for each patient. Predicting clinical states through an objective biosignature could lead to a new categorization of MDD phenotypes.
... The exclusion criteria for eligible studies to be analyzed were: The studied actigraphy parameters were [27]: i) TST in minutes; ii) SE in percentage; iii) SOL in minutes; iv) WASO presented as the percentage of sleep period time (SPT) or in minutes; v) mean activity level; and non-parametric variables of the circadian rhythm such as, vi) intraday variability (IV), which quantifies the rhythm fragmentation; vii) interday stability (IS), which quantifies the degree of regularity in the activity-rest pattern; viii) the average activity during the five least active hours of the day, or nocturnal activity (L5); and ix) the average activity during the ten most active hours, or daily activity (M10). ...
Close relationships have been reported between sleep alterations and suicidal behaviors, nevertheless few studies used objective measures of sleep. Such objective markers would be interesting in clinical practice to better screen and prevent suicide. We conducted a systematic review and meta-analysis of published studies examining the relationship between sleep markers and suicidal behaviors using PubMed, Cochrane Library, and Web of Science databases. Actigraphy, polysomnography, and nocturnal EEG were considered. The qualitative analysis retained 15 original studies, including 1179 participants (939 with a psychiatric disorder), and 11 studies were included for the meta-analysis. Current suicidal behaviors were associated with a decreased total sleep time (TST) (SMD = -0.35, [95% CI: -0.66 to -0.04], p = 0.026, I2 = 39.8%). The evaluation of possible moderators shows that age, gender, and depression scores had no effects on the random effect model. No significant differences were observed regarding sleep efficiency, REM latency, or percentage of REM sleep. In conclusion, among candidate objective markers, decreased total sleep time seems associated with suicidal behaviors and could be easily used to assess suicide risk. Alterations of regular sleep duration should invite healthcare professionals to screen the cause and propose sleep interventions to prevent suicide.
... 126 These findings are clinically interesting because many patients with bipolar disorder experience sleep disturbance after mood symptom remission. 127 ...
Aims
Bipolar disorders are clinically complex, chronic and recurrent disorders. Few treatment options are effective across hypomanic, manic, depressive and mixed states, and as continuation or maintenance treatment after initial symptom remission. The aim of this review was to provide an up-to-date overview of research on the efficacy, tolerability and cognitive effects of electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), magnetic seizure therapy (MST), deep brain stimulation (DBS) and vagus nerve stimulation (VNS).
Methods
References included in this review were identified through multiple searches of the Embase, PubMed/MEDLINE and APA PsycINFO electronic databases for articles published from inception until February 2022. Published reviews, meta-analyses, randomised controlled trials and recent studies were prioritised to provide a comprehensive and up-to-date overview of research on brain stimulation in patients with bipolar disorders.
Results
The evidence-base for brain stimulation as an add-on or alternative to pharmacological and psychological treatments in patients with bipolar disorders is limited but rapidly expanding. Brain stimulation treatments represent an opportunity to treat all bipolar disorder states, including cognitive dysfunction during euthymic periods.
Conclusion
While findings to date have been encouraging, larger randomised controlled trials with long-term follow-up are needed to clarify important questions regarding treatment efficacy and tolerability, the frequency of treatment-emergent affective switches and effects on cognitive function.
... The majority of individuals with BDs presents alterations in the circadian rhythmicity in physiological and behavioral timekeeping processes including social life, activities, eating and sleep/wake patterns, prior and during the depressive or manic episodes, as well as during euthymia as well (Vadnie & McClung, 2017;Geoffroy, 2018;Maruani et al., 2018;. Irregular and delayed sleep patterns are frequent across mood episodes and inter-episode periods of BD (Geoffroy et al., 2015). Circadian rhythms dysregulation, in particular the de-synchronization of sleep and social life, has been associated with the severity of mood symptoms, insomnia symptoms, emotional dysregulation, and suicidal behaviors in BDs (Takaesu et al., 2018;Gonzalez & Tohen, 2018;Palagini et al., 2019;Benard et al., 2019;Palagini et al., 2021). ...
Objective:
The study aimed to investigate the possible impact of resilience and emotion dysregulation on the clinical manifestations of bipolar disorders (BDs) focusing on the possible role of circadian rhythm alterations.
Method:
A sample of 197 inpatients suffering from BD of type I (BDI) or II (BDII) were assessed during a major depressive episode using the Structural Clinical Interview for DSM-5 (SCID-5), the Beck Depression Inventory-II (BDI-II), the Young Mania Rating Scale (YMRS), Resilience Scale for Adults (RSA), Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN), Difficulties in Emotion Regulation Scale (DERS) and the Scale for Suicide Ideation (SSI). Participants with or without circadian rhythm disturbances as measured with Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN), were compared; regression and mediation analyses were computed.
Results:
Participants with circadian rhythms disturbances showed a greater severity of depressive symptoms, of suicidal risk, lower resilience and more disturbances in emotion regulation including impulsivity and regulatory strategies. The logistic regression revealed that circadian rhythm disturbances was related to depressive symptoms (O.R. 4.0), suicidal risk (OR 2.51), emotion dysregulation (OR 2.28) and low resilience (OR 2.72). At the mediation analyses, circadian rhythm alterations showed an indirect effect on depressive symptoms by impairing resilience (Z= 3.17, p=0.0014)/ emotional regulation (Z= 4.36, p<0.001) and on suicidal risk by affecting resilience (Z= 2.00, p=0.045) and favoring impulsivity (Z= 2.14, p=0.032).
Conclusions:
The present findings may show that circadian rhythm alterations might play a key role in BD manifestations, as being correlated with more severe clinical presentations of depressive symptoms, suicidal risk, impaired resilience and emotional regulation. Addressing circadian rhythm alterations might potentially promote resilience and emotion regulation hence improving mood symptoms and suicidal risk in BDs.
... In this context, and with the wide availability of wearable technology, digital biomarkers suitable to identify 1 illness activity and provide real-time patient monitoring offer a promising approach to precision medicine in mood disorders. In fact, wearables collecting highly detailed actigraphy, sleep and cardiovascular information have already been shown to accurately capture rest-activity rhythms, illness activity and episodes in BD [14,10,11]. However, their longitudinal potential on treatment response and outcomes remains poorly investigated [38]. ...
A bstract
Mood disorders are severe and chronic mental conditions exacting high costs from society. The lack of reliable biomarkers to aid clinicians in tailoring pharmacotherapy based on distinguishable patient-specific traits means that the current prescribing paradigm is largely one of trial and error. Previous studies showed that different biological signatures, such as patterns of heart rate variability or electro-dermal reactivity, are associated with clinically meaningful outcomes. Against this backdrop, the advances in machine learning and the spread of wearable devices capable of providing continuous and ecological monitoring of patients may unlock great opportunities in mental healthcare. We herewith present a pilot study on mania and depression where we moved beyond the simple disease state binary classification but pursued the more informative and clinically meaningful task of differentiating between levels of disease severity. While most previous similar endeavours used recording segments extracted from the same subjects for both training and testing, we explicitly carried out model development and evaluation on segments from different groups of patients, in order to have a fair assessment of the model out-of-sample generalisation. This illustrated how individuals heterogeneity and non-disease-related dimensions of variations (e.g. sex, age, physical fitness) may dominate the signal so that in low sample size regimes a model might learn and overfit subject-specific patterns rather than capturing disease-relevant traits generalisable across disorders. Lastly, we developed a viable baseline for pre-processing raw data from wristband recordings and compared three classical and two deep-learning models to identify levels of disease severity.
... Beyond that, there is preliminary evidence that melatonin profiles and PER1 and NR1D1 expression profiles of manic patients with BD differ from those of depressed BD patients and healthy controls (Nováková et al., 2015). Meta-analyses on circadian physiological and behavioural processes show differences between (remitted) patients with BD and healthy control subjects in total sleep time and time in bed, sleep latency, wake after sleep onset and motor activity (Geoffroy et al., 2015;Ng et al., 2015;Nováková et al., 2015;De Crescenzo et al., 2017;Meyer et al., 2020). ...
A variety of organisms including mammals have evolved a 24h, self-sustained timekeeping machinery known as the circadian clock (biological clock), which enables to anticipate, respond, and adapt to environmental influences such as the daily light and dark cycles. Proper functioning of the clock plays a pivotal role in the temporal regulation of a wide range of cellular, physiological, and behavioural processes. The disruption of circadian rhythms was found to be associated with the onset and progression of several pathologies including sleep and mental disorders, cancer, and neurodegeneration. Thus, the role of the circadian clock in health and disease, and its clinical applications, have gained increasing attention, but the exact mechanisms underlying temporal regulation require further work and the integration of evidence from different research fields. In this review, we address the current knowledge regarding the functioning of molecular circuits as generators of circadian rhythms and the essential role of circadian synchrony in a healthy organism. In particular, we discuss the role of circadian regulation in the context of behaviour and cognitive functioning, delineating how the loss of this tight interplay is linked to pathological development with a focus on mental disorders and neurodegeneration. We further describe emerging new aspects on the link between the circadian clock and physical exercise-induced cognitive functioning, and its current usage as circadian activator with a positive impact in delaying the progression of certain pathologies including neurodegeneration and brain-related disorders. Finally, we discuss recent epidemiological evidence pointing to an important role of the circadian clock in mental health.
... Il a été montré que les troubles du sommeil retrouvés chez les patients bipolaires pouvaient être retrouvés durant toutes les phases de la pathologie, et même entre les épisodes pathologiques [483], [484]. Les principaux troubles documentés pendant les périodes de dépression incluent les insomnies, les éveils nocturnes, les hypersomnies ainsi qu'une latence d'endormissement plus longue [480], [485]. ...
Toxoplasma gondii est un parasite intra-cellulaire infectant près d’un tiers de la population mondiale. Généralement asymptomatique, la toxoplasmose est associée à une symptomatologie grave chez les patients immunodéprimés et dans le cas d’infection congénitale. Négligée par les pouvoirs publics, la phase chronique de l’infection a longtemps été sous-estimée. Cette méconnaissance entraîne donc des questions telles que quel est le meilleur protocole thérapeutique ? quelle est la meilleure stratégie diagnostique ? Récemment une stratégie de dissémination très avancée a été suspectée, sur la base de la théorie de la manipulation comportementale de l’hôte. Chez l’Homme, une telle manipulation peut avoir des effets majeurs cérébraux, neurologiques ou psychologiques. Quoi qu’il en soit, son impact sur le sommeil, qui constitue un index particulièrement sensible des fonctions cérébrales, est pour le moment inconnu. C’est pourquoi nous avons établi un modèle murin expérimental afin d’étudier les effets de Toxoplasma gondii sur le cycle éveil-sommeil. Nous avons montré que l’infection chronique par T. gondii était associée de manière persistante avec une augmentation de l’éveil et une diminution du sommeil, ce qui cadre avec la stratégie du parasite pour faciliter sa dissémination grâce à la prédation de son hôte. Nos résultats montrent pour la première fois les conséquences directes de l’infection toxoplasmique sur le comportement, pouvant avoir un impact majeur sur l’apparition de pathologies neuropsychiatriques et neurodégénératives.
... We also observed a suggestive inverse association of short sleep duration (sleeping for 6 h or less) with BIP. This was consistent with a meta-analysis presenting a shorter sleep duration in controls compared to cases with BIP [61]. We also found some evidence for the association of long sleep duration (binary phenotype defined as sleeping for 9 h or more) and sleeping duration (continuous phenotype) with increased risk of SCZ. ...
Background:
There is increasing attention on the association of socioeconomic status and individual behaviors (SES/IB) with mental health. However, the impacts of SES/IB on mental disorders are still unclear. To provide evidence for establishing feasible strategies on disease screening and prevention, we implemented Mendelian randomization (MR) design to appraise causality between SES/IB and mental disorders.
Methods:
We conducted a two-sample MR study to assess the causal effects of SES and IB (dietary habits, habitual physical activity, smoking behaviors, drinking behaviors, sleeping behaviors, leisure sedentary behaviors, risky behaviors, and reproductive behaviors) on three mental disorders, including bipolar disorder, major depressive disorder and schizophrenia. A series of filtering steps were taken to select eligible genetic instruments robustly associated with each of the traits. Inverse variance weighted was used for primary analysis, with alternative MR methods including MR-Egger, weighted median, and weighted mode estimate. Complementary methods were further used to detect pleiotropic bias.
Results:
After Bonferroni correction and rigorous quality control, we identified that SES (educational attainment), smoking behaviors (smoking initiation, number of cigarettes per day), risky behaviors (adventurousness, number of sexual partners, automobile speeding propensity) and reproductive behavior (age at first birth) were causally associated with at least one of the mental disorders.
Conclusions:
MR study provides robust evidence that SES/IB play broad impacts on mental disorders.
... Among patients with BD, insomnia has been found to be associated with bipolar II (BD-II) depression and hypersomnia with bipolar I (BD-I) depression or euthymia [2]. In a meta-analysis paper, patients in remitted BD have shown to have longer sleep latency, shorter sleep duration, longer wake time after sleep onset, and poor sleep efficiency [3]. In another study, patients in remitted BD have also been found to have more night-to-night variability of the sleep pattern [4]. ...
Background: Sleep quality is an important predictor for prognosis of bipolar disorder (BD). Factors associated with sleep quality in BD such as childhood trauma experience merit investigation. Methods: We used the Pittsburgh Sleep Quality Index (PSQI), Childhood Trauma Questionnaire (CTQ), and Measurement of Support Functions (MSF) to access patients with BD-I (n = 31), and those with BD-II (n = 34). Results: We found that 71.4% of patients with BD-I and 90.9% of those with BD-II had poor sleep quality. Significantly higher CTQ physical abuse score and poor life quality were found among patients with BD-II (b = −0.008, Wald χ2 (1) = 5.024, p < 0.05). This effect remained robust (b = −0.012, Wald χ2 (1) = 8.150, p < 0.01) after controlling the use of drug (sedative, benzodiazepine, antipsychotic, and antidepressant). Moreover, the experience of childhood trauma was associated with poor sleep quality among patients with BD-II. A buffer effect of social support between physical abuse and daytime dysfunction, as measured by PSQI, was found in patients with BD-II, but not in those with BD-I. Conclusion: Social adversity and support were associated with sleep quality in patients with BD-II. This finding implied a stress-buffering model in patients with BD-II. But the underlying biological mechanism remains unclear.
... Sleep-wake cycle and circadian rhythm disturbances are among the commonest prodromal symptoms of BD episodes and some researchers propose that these disturbances may represent 'trait' markers of BD, may be heritable (i.e., may be found in individuals with a family history [FH] of BD whether or not they develop a mental disorder) and/or have a role in illness development (Harvey et al., 2009;Ng et al., 2015;Ritter et al., 2011;Melo et al., 2016;De Crescenzo et al., 2017;Murray et al., 2020). Others suggest these disturbances are associated with overall symptom burden (in acute illness episodes) or may be consequences of recurrent BD episodes and their treatment (Geoffroy et al., 2015;Meyer et al., 2020). Whilst research in this field has been aided by the use of reliable and valid self-assessments, more notable advances have been achieved using wrist-worn actiwatches, which offer a convenient and ecologically valid means of examining associations between sleep-wake cycle and circadian rhythm disturbances. ...
Aims
Actigraphy studies of individuals with bipolar disorders (BD) suggest that illness progression may be associated with a range of progressive disruptions in 24-hour rest-activity rhythms (RAR). However, those longitudinal studies were undertaken in older adults with extended histories or illness and treatment rather than young people with emerging BD. To our knowledge, this is the first study to use network modelling to examine the statistical associations between clinical phenotypes of BD and different subsets of RAR markers.
Methods
This study of adolescents and young adults (mean age 22 years; 69% female) uses network modelling to examine which self-rated or actigraphic markers of RAR are more strongly associated with full threshold BD (referred to as Stage 2; N = 15) compared with BD-at risk syndromes (subthreshold presentations referred to as Stage 1; N = 25).
Results
Network analysis demonstrated that some RAR are associated with both stage of BD and a family history of BD (such as longer sleep duration and higher levels of daytime impairment). Markers of circadian rhythmicity indicated that regulation of this system is weaker in Stage 2 compared with Stage 1 of BD.
Limitations
The small subgroup samples may have undermined the ability to detect some associations between phenotypes and RAR.
Conclusions
Network modelling may offer a useful strategy for visualizing and analysing patterns of association between RAR and clinical phenotypes defined by stage of illness, familial loading or symptom profile. This could prove useful in understanding the underlying pathophysiology of sleep-wake cycle and circadian rhythm disturbances in BD.
... Reduced sleep duration, latency and need for sleep have been associated not only with manic episodes in bipolar disorder but also with euthymic states. The study of sleep states in bipolar patients has a significant number of important confounders: duration of illness that typically correlates with loss-of-function and employment, persistence of subthreshold depressive symptomatology between episodes which would decrease activity and increase sleep duration and antipsychotic medication that is associated with hypersomnia [24,25]. In this respect, studies of non-affected offspring would provide a clearer picture, provided that the offspring are not themselves affected by a mood disorder. ...
Recent results from a small number of clinical studies have resulted in the suggestion that the process of blocking the transmission of shorter-wavelength light (‘blue light’ with a wave length of 450 nm to 470 nm) may have a beneficial role in the treatment of bipolar disorder. This critical review will appraise the quality of evidence so far as to these claims, assess the neurobiology that could be implicated in the underlying processes while introducing a common set of research criteria for the field.
... However, when analysing our actigraphic data we did not find any significant difference in TST between both groups, which stands in contrast to several meta-analysis of actigraphically derived data in BD (Tazawa et al. 2019; Page 7 of 11 Roloff et al. International Journal of Bipolar Disorders (2022) 10:6 Geoffroy et al. 2015;Meyer et al. 2020;Crescenzo et al. 2017). Our findings of an earlier sleep onset and a smaller SD in sleep onset in our BD group contradict previous studies of chronotype and circadian rhythm in BD, which showed a later chronotype to be associated with BD diagnosis (Ahn et al. 2008;Wood et al. 2009) Although those changes might be associated with more mood symptoms and therefore a potential worse clinical outcome (Krane-Gartiser et al. 2016;Vidafar et al. 2021), they were not as consistently shown in inter-episode states of BD, since Krane-Gartiser et al. (2016) found delayed sleep phase syndrome in only about 25% of all patients and Vidafar in not more than 50% with the remaining patients having either a normal or early chronotype. ...
Background
Sleep dysfunction is a core symptom in bipolar disorder (BD), especially during major mood episodes. This study investigated the possible link between subjective and objective sleep disturbances in inter-episode BD, changes in melatonin and cortisol levels, and circadian melatonin alignment. The study included 21 euthymic BD patients and 24 healthy controls. Participants had to wear an actigraphy device, keep a weekly sleep diary and take salivary samples: five samples on the last evening to determine the dim light melatonin onset (DLMO) and one the following morning to measure rising cortisol. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) and Regensburg Insomnia Scale (RIS), and circadian alignment by the phase angle difference (PAD).
Results
In comparison to healthy controls, BD patients had: (1) higher PSQI (5.52 ± 3.14 vs. 3.63 ± 2.18; p = 0.022) (significant after controlling for age and gender), and higher RIS scores (8.91 ± 5.43 vs. 5.83 ± 3.76; p = 0.031); (2) subjective a longer mean TST ( p = 0.024) and TIB ( p = 0.002) (both significant after controlling for age and gender), longer WASO ( p = 0.019), and worse SE ( p = 0.036) (significant after controlling for gender); (3) actigraphically validated earlier sleep onset ( p = 0.002), less variation in sleep onset time ( p = 0.005) and no longer TST ( p = 0.176); (4) no differing melatonin levels (4.06 ± 2.77 vs. 3.35 ± 2.23 p = 0.352), an 1.65 h earlier DLMO (20.17 ± 1.63 vs. 21.82 ± 1.50; p = 0. 001) (significant after controlling for gender), and a phase advance of melatonin (6.35 ± 1.40 vs. 7.48 ± 1.53; p = 0.017) (significant after controlling for gender); and (5) no differing cortisol awakening response (16.97 ± 10.22 vs 17.06 ± 5.37 p = 0.969).
Conclusions
Patients with BD, even in euthymic phase, have a significantly worse perception of their sleep. Advanced sleep phases in BD might be worth further investigation and could help to explain the therapeutic effects of mood stabilizers such as lithium and valproate.
... Also, the DSM-5 recommended than severe sleep disturbances should no longer be viewed simply as concomitants of a specific mental disorder but should be recorded separately (as a comorbid condition) and targeted for specific management (Reynolds and O'Hara, 2013). This is particularly relevant to BD, as sleep and circadian rhythm disturbances may predict first onset of BD and are core symptoms of acute episodes and of relapse (Geoffroy et al., 2015;Ng et al., 2015;Melo et al., 2016). Furthermore, evidence indicates that identifying, monitoring and/or intervening with sleep or chronobiological disruptions is feasible and beneficial in BD (Gottlieb et al., 2019;Murray et al., 2020). ...
Objectives: Clinical practice guidelines (CPGs) for the treatment of bipolar disorder (BD) provide guidance to health care professionals and patients about the management of core aspects of BD. This study evaluated the overall quality of CPGs and examined the quantity, specificity, clarity and utility of recommendations about four key contemporary themes: sleep, circadian rhythms, activity and energy, and healthy lifestyles.
Methods: English language editions of CPGs for the treatment of BD were identified by a systematic search of the literature from 2007 onwards (i.e. 15 years). Blind independent ratings were combined to give consensus scores for the quality of each CPGs (using the 14-item International Centre for Allied Health Evidence guideline checklist). Composite ratings of the quantity, specificity, clarity and utility of recommendations about the key themes were undertaken using a 0-3 scale.
Results: Twenty-five CPGs were eligible for review. Overall quality was high (median checklist score=10), but only 11 (44%) CPGs included even basic information about circadian rhythm disturbances. Combined scores for composite ratings about sleep and circadian rhythms were significantly correlated with overall quality of the CPG (sleep, r=.43; circadian rhythms, r=.42) but not with year of publication.
Limitations: No reliable scale exists for generating composite ratings of the four themes we examined.
Conclusions: Circadian rhythms and chronobiology represent neglected domains in CPGs. Incorporating this important theme into future editions of CPGs would aid health care professionals to identify, prevent, or intervene with these problems and improve outcomes for a significant proportion of individuals with BD.
... Les anomalies mises en évidence du rythme veille-sommeil, que ce soit en phase aiguë ou en rémission, sont sur le plan clinique essentiellement un chronotype vespéral, une typologie circadienne plus languide et rigide, une durée du sommeil plus longue, une latence d'endormissement plus longue, une efficacité du sommeil moins bonne, un réveil après le premier endormissement plus fréquent, une stabilité inter-quotidienne plus pauvre, une variabilité dans l'heure du coucher, l'heure du réveil ou dans la durée et l'efficacité du sommeil [72,73] . ...
Les effets de la lumière sur l'humeur sont décrits depuis l'Antiquité et dès les premières descriptions médicales. Les neurosciences ont permis, il y a une quarantaine d'années, un regain d'intérêt croissant pour la luminothérapie avec les toutes premières observations : la modification des rythmes bio-logiques pouvait avoir un effet antidépresseur et la lumière modifiait ces rythmes. Très vite, la confirmation clinique des effets antidépresseurs de la luminothérapie est apparue dans la dépression saisonnière puis dans la dépression unipolaire. Les neurosciences ont par la suite également permis de mieux préciser les effets de la lumière et les voies de phototransduction impliquées dans la régulation de l'humeur. Il existerait une action sur l'humeur via un effet de la lumière sur les rythmes circadiens, et des actions sur l'humeur indépendantes de ces voies circadiennes via des effets de la lumière sur le processus homéostatique du sommeil, la vigilance, et les centres de régulation des émotions. De nombreuses études et méta-analyses démontrent que la luminothérapie peut être proposée comme un traitement de première ligne, efficace en monothérapie dans la dépression saisonnière et non saisonnière, tant pour les troubles unipolaires que bipolaires. La tolérance de la luminothérapie est bonne avec une vigilance requise sur les contre-indications ophtalmologiques et le risque de virage maniaque chez les patients avec trouble bipolaire non traités par thymorégulateur. La luminothérapie peut aussi être utilisée en association aux antidépresseurs et aux régulateurs de l'humeur, avec une nette supériorité de ces combinaisons sur les monothérapies. La combinaison permet d'augmenter la réponse aux traitements médicamenteux et paraît une bonne stratégie de première intention, notamment dans les épisodes dépressifs sévères. Ces effets de la lumi-nothérapie dépendent de la dose de lumière déterminée par plusieurs paramètres : l'intensité lumineuse, la durée d'exposition, la distance et l'angle de la source de lumière, le spectre lumineux (couleurs) et le moment de la journée d'exposition à la lumière. © 2021 Elsevier Masson SAS. Tous droits réservés.
... Sleep disturbance is a core feature of bipolar disorder and can occur regardless of whether an affected patient is in a euthymic or symptomatic period (Geoffroy et al., 2015;Harvey, 2008;Ng et al., 2015). In bipolar disorder cases, sleep disturbance is associated with subsequent mood episodes, cognitive abnormalities, and suicidal ideation (Bradley et al., 2020;Gershon et al., 2017;Stange et al., 2016). ...
Background
Sleep disturbance is a core feature of bipolar disorder; hence, sleep must be accurately assessed in patients with bipolar disorder. Subjective sleep assessment tools such as sleep diary and questionnaires are often used clinically for assessing sleep in these patients. However, the insight into whether these tools are as accurate as objective tools, such as actigraphy, remains controversial.
Methods
This cross-sectional study included 164 outpatients with a diagnosis of bipolar disorder, including patients who had euthymic and residual symptomatic periods. Objective sleep assessment was conducted prospectively using actigraphy for 7 consecutive days, whereas subjective sleep assessment was conducted prospectively using a sleep diary.
Results
The correlations were high and moderate between sleep diary and actigraphy when assessing the total sleep time and sleep onset latency, respectively (r = 0.81 and 0.47). These correlations remained significant after correction for multiple testing (both p < 0.001) and in both euthymic and residual symptomatic states (total sleep time: r = 0.86 and 0.77; sleep onset latency: r = 0.51 and 0.40, respectively). The median (interquartile ranges) of the percentage difference (sleep diary parameters minus actigraphy parameters divided by actigraphy parameter) in the total sleep time was relatively small (6.2% [−0.2%–13.6%]).
Conclusions
Total sleep time assessment using a sleep diary could be clinically useful in the absence of actigraphy or polysomnography.
... Meta-analyses of actigraphy recordings consistently demonstrate significant differences for sleep duration, latency, efficiency, and fragmentation indices in euthymic cases with BD as compared to healthy controls (HC) (De Crescenzo et al., 2016;Geoffroy et al., 2015;Meyer et al., 2020;Ng et al., 2015;Tazawa et al., 2019). These differences are attenuated when sleep patterns in BD are compared with other severe mental disorders (Meyer et al., 2020). ...
Sleep disturbances are typical symptoms of acute episodes of bipolar disorder (BD) and differentiate euthymic BD cases from healthy controls (HC). Researchers often employ objective recordings to evaluate sleep patterns, such as actigraphy, whilst clinicians often use subjective ratings, such as the Pittsburgh Sleep Quality Index (PSQI). As evidence suggests the measures may disagree, we decided to compare subjective (PSQI) and objective (3 weeks of actigraphy) sleep profiles in BD cases and HC (n = 154). We examined whether a dimensional approach helps to illustrate different patterns of sleep disturbances and whether the concordance between subjective and objective recordings varies according to clinical status (BD versus HC). Principal component analysis (PCA) extracted two factors from the PSQI, and separate PCAs of actigraphy recordings extracted two factors for mean values of sleep parameters and one factor for intra-individual variability. Correlational and linear regression analyses of PCA-derived dimensions demonstrated that, in both BD and HC, a PSQI “Sleep duration-efficiency” factor was significantly correlated with an actigraphy “Sleep initiation-duration” factor. Furthermore, in BD cases only, the PSQI total score and a PSQI “Sleep Impairments” factor were each significantly correlated with an actigraphy “Sleep Variability” factor. Overall, we found that subjective experiences of sleep may be modulated by different components of objectively recorded sleep in BD compared with HC. Also, the use of PCA enabled us to consider the multi-dimensional nature of subjective sleep, whilst the inclusion of intra-individual sleep variability afforded a more subtle evaluation of objective sleep.
... Earlier systematic reviews and meta-analyses of actigraphy studies demonstrated differences in sleep quality and quantity between BD cases and comparator groups (predominantly healthy controls [HCs]). [8][9][10][11][12][13] More recently, research has explored circadian patterns of motor activity as estimated by phase, amplitude, intradaily stability and/or interdaily variability of activity and these actigraphy markers of CRAR were suggested to discriminate BD cases from controls. [14][15][16][17] Furthermore, circadian markers associated with fragmentation, variability, amount and/or amplitude of day-and night-time activity may discriminate good from poor lithium responders. ...
Objective
Chronobiological models postulate that abnormalities in circadian rest/activity rhythms (CRAR) are core phenomena of Bipolar Disorders (BD). 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 (HC)).
Method
We undertook systematic searches of 4 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 (CI).
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.
... Abnormalities within the sleep and circadian systems have been suggested in BD, mainly based on findings from case-control studies using actigraphy that measures sleep/wake patterns, or using questionnaires that assess sleep quality, such as the PSQI (Pittsburgh Sleep Quality Index) (Buysse et al. 1989) or phase preference (Melo et al. 2017). Several meta-analyses of actigraphy data reported significant differences in sleep latency, sleep duration, sleep efficiency, and wake after sleep onset (Geoffroy et al. 2015), as well as a decreased mean daily activity in euthymic individuals with BD as compared to healthy controls (De Crescenzo et al. 2017). The most widespread persistent sleep complaint in BD is insomnia, followed by hypersomnia, nightmares, difficulty falling asleep or maintaining sleep, and poor sleep quality (Steardo et al. 2019). ...
... Abnormalities within the sleep and circadian systems have been suggested in BD, mainly based on findings from case-control studies using actigraphy that measures sleep/wake patterns, or using questionnaires that assess sleep quality, such as the PSQI (Pittsburgh Sleep Quality Index) (Buysse et al. 1989) or phase preference (Melo et al. 2017). Several meta-analyses of actigraphy data reported significant differences in sleep latency, sleep duration, sleep efficiency, and wake after sleep onset (Geoffroy et al. 2015), as well as a decreased mean daily activity in euthymic individuals with BD as compared to healthy controls (De Crescenzo et al. 2017). The most widespread persistent sleep complaint in BD is insomnia, followed by hypersomnia, nightmares, difficulty falling asleep or maintaining sleep, and poor sleep quality (Steardo et al. 2019). ...
Bipolar disorder (BD) is a chronic and burdensome psychiatric disease, characterized by variations in mood and energy. The literature has consistently demonstrated an association between BD and childhood maltreatment (CM), and genetic variants of circadian genes have been associated with an increased vulnerability to develop BD. In this context, environmental factors such as CM may also contribute to the susceptibility to BD through alterations in the functioning of the biological clock linked to modifications of expression of circadian genes. In this study, we explored the associations between childhood maltreatment, sleep quality, and the level of expression of a comprehensive set of circadian genes in lymphoblastoid cell lines from patients with BD. The sample consisted of 52 Caucasian euthymic patients with a diagnosis of BD type 1 or type 2. The exposure to CM was assessed with the Childhood Trauma Questionnaire (CTQ), and the sleep quality was assessed using the Pittsburgh Sleep Quality Index. We measured the expression of 18 circadian genes using quantitative RT-PCR: ARNTL2, BHLHE40, BHLHE41, CLOCK, CRY1, CRY2, CSNK1D, CSNK1E, DBP, GSK3B, NPAS2, NR1D1, PER1, PER2, PER3, PPARGC1A, RORA, and RORB. Gene expression networks were analyzed with the disjoint graphs method. Compared to the other investigated transcripts, PPARGC1A was the only one whose expression level was differentially affected in patients who have experienced CM and, more specifically, physical abuse. We observed no significant effects of the other CTQ subscores (emotional and sexual abuses, physical and emotional neglects), nor of the sleep quality on the network of circadian genes expression. Although requiring replication in larger cohorts, the result obtained here is consistent with the hypothesis of an influence of CM exposure on circadian systems and highlights the importance of PPARGC1A in these processes.
Aim:
Sleep disturbance, a core feature of bipolar disorder, is closely associated with mood symptoms. We examined the association between actigraphy sleep parameters and mood episode relapses in patients with bipolar disorder.
Methods:
This prospective cohort study analyzed 193 outpatients with bipolar disorder who participated in the Association between the Pathology of Bipolar Disorder and Light Exposure in Daily Life (APPLE) cohort study. The participants' sleep was objectively evaluated via actigraphy over 7 consecutive days for the baseline assessment and then at the 2-year follow-up appointment for mood episode relapses. The actigraphy sleep parameters were presented using the mean and variability (standard deviation) of each sleep parameter for 7 days.
Results:
Of the 193 participants, 110 (57%) experienced mood episodes during follow-up. The participants with higher variability in total sleep time had a significantly shorter mean estimated time to mood episode relapses than those with lower variability (12.5 vs. 16.8 months; P < 0.001). The Cox proportional hazards model, when adjusted for potential confounders, demonstrated that variability in total sleep time was significantly associated with an increase in the mood episode relapses (per hour; hazard ratio [HR], 1.407; 95% confidence interval (CI), 1.057-1.873), mainly in the depressive episodes (per hour; HR, 1.477; 95% CI, 1.088-2.006).
Conclusions:
Our findings suggest that consistency in sleep time might be useful, as an adjunct therapy, in preventing the recurrence or relapse of mood episodes in bipolar disorder. This article is protected by copyright. All rights reserved.
Sleep plays a key role in the pathogenesis and clinical presentation of mood disorders. However, only a few studies have investigated sleep architecture during the manic episodes of Bipolar Disorder (BD) and changes in sleep parameters that follow clinical variations. Twenty-one patients (8 males, 13 females) affected by BD, manic phase, underwent polysomnographic recordings (PSG) at the beginning of the admission in our ward (T0) and after three weeks of hospital treatment (T1). All participants were clinically evaluated using Young Mania Rating Scale (YMRS), Pittsburgh Sleep Quality Index (PSQI) and Morningness-Eveningness Questionnaire (MEQ). During the admission, we observed an increase in both quantity (Total Sleep Time - TST) and quality (Sleep Efficiency - SE) of sleep. In addition, clinical improvement, evaluated with YMRS and PSQI scales, was accompanied by a significant increase in the percentage of REM sleep. According to our findings, the improvement of manic symptoms is accompanied by an increase in "REM pressure" (increase in REM% and REM density, reduction of REM latency). Overall, changes in sleep architecture appear to be markers sensitive to clinical variations during manic phases of Bipolar Disorder.
Background
: Several lines of evidence indicate that circadian rhythm disruption is associated with bipolar disorder (BPD). This strong association, along with evidence from genome wide association studies (GWAS) implicating clock and clock controlled genes with BDP and efficacy of lithium treatment, suggests that BPD circadian rhythm disruption may represent a core etiology feature. Lower morning expression of the neuropeptide somatostatin (SST) has been previously reported in the brain and cerebral spinal fluid of subjects with BPD, coinciding with increased morning severity of anxiety and depression. We aimed to test the hypothesis that levels of neuropeptides involved in circadian rhythm regulation, including somatostatin (SST), neuropeptide-Y (NPY), arginine vasopressin (AVP), vasoactive intestinal peptide (VIP) and cortisol levels, are altered in blood samples collected in the morning from patients BPD.
Method
: Thirty nine patients diagnosed as BPD according to DSM-5, and 38 healthy controls were enrolled in the study. Blood were collected at 9 AM from all subjects. Serum levels of SST, NPY, AVP, VIP and cortisol were measured.
Results
: We observed significantly lower levels of SST (p=0.001), NPY (p =0.001), VIP (p=0.001) and cortisol levels (p=0.001) in the morning in subjects with BPD compared to control subjects. Significant positive effects of Young Mania Rating Scale and lithium treatment with cortisol, SST, and VIP levels were observed.
Conclusion
: Our study suggests that lower morning levels of SST, NPY, VIP and cortisol may represent biomarkers underlying disrupted biological rhythms and behavioral and sleep disturbances observed in patients with BPD.
Bipolar disorder (BD) is characterized by disrupted circadian rhythms affecting sleep, arousal, and mood. Lithium is among the most effective mood stabilizer treatments for BD, and in addition to improving mood symptoms, stabilizes sleep and activity rhythms in treatment responsive patients. Across a variety of experimental models, lithium has effects on circadian rhythms. However, uncertainty exists as to whether these actions directly pertain to lithium’s therapeutic effects. Here, we consider evidence from mechanistic studies in animals and cells and clinical trials in BD patients that identify associations between circadian rhythms and the therapeutic effects of lithium. Most evidence indicates that lithium has effects on cellular circadian rhythms and increases morningness behaviors in BD patients, changes that may contribute to the therapeutic effects of lithium. However, much of this evidence is limited by cross-sectional analyses and/or imprecise proxy markers of clinical outcomes and circadian rhythms in BD patients, while mechanistic studies rely on inference from animals or small numbers of patient samples. Further study may clarify the essential mechanisms underlying lithium responsive BD, better characterize the longitudinal changes in circadian rhythms in BD patients and inform the development of therapeutic interventions targeting circadian rhythms.
Background:
There is uncertainty whether unipolar mania is a discrete sub-type of bipolar disorder. Disrupted rest/activity rhythms are a key feature of bipolar disorder (BD) but have not been well characterised in unipolar mania/hypomania (UM). We compared subjective and objective rest/activity patterns, demographic and mental health outcomes across BD, UM and control groups.
Methods:
UK residents aged 37-73 years were recruited into UK Biobank from 2006 to 2010. BD, UM and control groups were identified via a mental health questionnaire. Demographic, mental health and subjective sleep outcomes were self-reported. Accelerometery data were available for a subset of participants, and objective measures of sleep and activity were derived.
Results:
A greater proportion of males met UM criteria, and more females were in the BD group. Both BD and UM groups had poor mental health outcomes vs. controls. Objectively measured activity differed between all three groups: UM had highest levels of activity and BD lowest. The UM group had shorter sleep duration compared to controls. Subjective rest/activity measures showed that both mood disorder groups (compared to controls) had later chronotype preference, more disturbed sleep and increased difficulty getting up in the morning. However, the UM group were more likely to report an early chronotype compared to BD and control groups.
Conclusions:
BD and UM share features in common, but key differences support the proposition that UM may be a distinct and more clinically homogenous disorder. UM was characterised by a higher proportion of males, early chronotype, increased activity and shorter sleep duration.
This article reviews the literature on the relationship between sleep deficiency and unipolar and bipolar depression, anxiety disorders, and posttraumatic stress disorder. We consider the evidence for sleep as a contributory causal factor in the development of psychiatric disorders, as well as sleep as an influential factor related to the outcome and recurrence of psychopathology. A case for sleep deficiency being an important treatment target when sleep and psychiatric disorders are comorbid is also made. Our recommendation is that sleep deficiency is recognized as a means to positively impact the development and course of psychopathology and, as such, is routinely assessed and treated in clinical practice.
Sleep disturbances are a key feature of bipolar disorder (BD), and poor sleep has been linked to mood symptoms. Recent use of ecological momentary assessment (EMA) has allowed for nuanced exploration of the sleep-mood link; though, the scale and directionality of this relationship is still unclear. Using EMA, actigraphy, and self-reported sleep measures, this study examines the concurrent and predictive relationships between sleep and mood. Participants with BD (n = 56) wore actigraphy devices for up to 14 days and completed validated scales and daily EMA surveys about mood and sleep quality. Linear mixed models were used to examine overall and time-lagged relationships between sleep and mood variables. EMA mood ratings were correlated with validated rating scales for depression, mania, anxiety, and impulsivity. Poor self-reported sleep quality was associated with worse overall ratings of sadness and anger. Worse self-reported sleep quality was associated with greater sadness the following day. Higher daytime impulsivity was associated with worse sleep quality the following night. Exploratory analyses found relationships between worse and more variable mood (sadness, anger, and impulsivity) with worse and more variable sleep that evening (efficiency, WASO, and sleep onset time). The sample size was modest, fairly homogenous, and included mainly euthymic persons with BD. EMA-based assessments of mood and sleep are correlated with validated scale scores and provide novel insight into intra-individual variability. Further work on the complex two-way interactions between sleep and mood is needed to better understand how to improve outcomes in BD.
Introduction
The offspring of bipolar parents (BO) is a high-risk population for inheriting the bipolar disorder (BD) and other early clinical manifestations, such as sleep disturbances.
Objective
To compare the presence of psychiatric disorders and sleep disturbances of BO versus offspring of control parents (OCP).
Methods
A cross-sectional analytical study was conducted that compared BO versus OCP. The participants were assessed using valid tools to determine the presence of psychiatric symptoms or disorders. The “Sleep Evaluation Questionnaire” and “School Sleep Habits Survey” were used to determine sleep characteristics and associated factors. Sleep records (7-21 days) were also obtained by using an actigraphy watch.
Results
A sample of 42 participants (18 BO and 24 OCP) was recruited. Differences were found in the presentation of the psychiatric disorder. The BO group showed a higher frequency of major depression disorder (MDD; P = .04) and Disruptive Mood Dysregulation Disorder (DMDD; P = .04). The OCP group showed a higher frequency of Attention Deficit and Hyperactivity Disorder (ADHD; P = .65), and Separation Anxiety Disorder (SAD; P = .46). Differences were also found in sleep by using subjective measurements. Compared to the OCP group, BO had a worse perception of quality of sleep (P = .02), a higher frequency of nightmares (P = .01), a shorter total sleep time, and a higher sleep latency. Nevertheless, no differences were found between groups in the actigraphy measurements.
Conclusions
The BO group had a higher frequency of Mood Disorders, and at the same time a higher number of sleep disturbances in the subjective measurements. It is possible that there is an association between mood symptoms, sleep disturbances, and coffee intake. No differences were found in the sleep profile by using actigraphy.
The recent popularization of smart technology presents new opportunities for continual, digital-monitoring of patient status. In this project, we used a smartphone app to track the mood, sleep, and activity levels of 159 outpatients with bipolar disorder (BD). The participants were asked to report their daily wake/sleep time and emotional status in the app, while daily activity data were automatically collected via GPS. We performed repeated-measures correlation analysis to examine possible correlations between the readouts. Mood, sleep and activity levels all showed intra-variable correlations with readings on the next day, in the next week, and in the next month. Furthermore, mood and sleep at the reference time were positively correlated with activity in subsequent weeks or months, and activity was positively correlated with mood and sleep in the same time ranges. Thus, our results were in line with previous studies, showing that mood, sleep, and activity levels are interdependent in patients with BD. With the association between mood on future activity level was most significant, and the correlations between each readout and the others were dependent on time frame. Our findings suggest our smartphone app has potential to provide an informative and reliable means for real-time tracking of BD status.
There is now evidence from several sources that disruption of the circadian rhythms may be a key feature of bipolar disorder (BD). This chapter summarizes the evidence from both clinical and objective measures of sleep, motor activity, and circadian patterns in controlled studies of BD. Findings from recent genome-wide association studies also provide compelling links between BD and genetic architecture underlying several circadian measures. The concept of endophenotypes is illustrated in analyses of a large family study that show common heritability of chronotype and sleepiness/fatigue with Bipolar I Disorder (BP-I). Challenges and opportunities for future research on circadian biomarkers of BD are discussed.
Aim
The study aimed to investigate resilience and its association with early exposure to stressful events on the clinical manifestations of bipolar disorders (BDs), such as severity of mood symptoms, suicidal ideation and behaviors focusing on the possible role of insomnia symptoms.
Method
A sample of 188 adult participants with BD of type I or II were assessed during depressed phase using the Structural Clinical Interview for DSM-5 (SCID-5), the Beck Depression Inventory-II (BDI-II), the Young Mania Rating Scale (YMRS), the Early Trauma Inventory Self Report-Short Form (ETISR-SF), Resilience Scale for Adults (RSA), the Insomnia Severity Index (ISI) and the Scale for Suicide Ideation (SSI). Participants with or without clinically significant insomnia were compared and we carried out correlations, regression and mediation analyses.
Results
Participants with insomnia showed a greater severity of depressive symptoms as well as of suicidal risk, early life stressors and lower level of resilience. Insomnia symptoms mediated the association between early life stress and low resilience, between low resilience in planning future and depressive symptoms (Z= 2.17, p=0.029) and low resilience and suicidal risk (Z= 3.05, p=0.0002)
Conclusion
Insomnia may be related to the severity of BDs, to higher early life stressors and lower level of resilience. Assessing and targeting insomnia symptoms may potentially promote resilience in BDs in response to early life stressful events. These results should be interpreted in light of several limitations including the cross-sectional design affecting causal interpretations.
Even though tobacco-induced sleep disturbances (TISDs) have been reported in previous studies, the present article is the first meta-analysis quantitatively assessing the impact of tobacco on sleep parameters. We conducted a systematic review and meta-analysis of the studies comparing objective (i.e. polysomnography and actigraphy) and/or subjective sleep parameters in chronic tobacco smokers without comorbidities vs healthy controls. The studies were retrieved using PubMed, PsycINFO, and Web of Science. Differences are expressed as standardized mean deviations (SMD) and their 95% confidence intervals (95%CI). Fourteen studies were finally included into the review, among which ten were suitable for meta-analysis. Compared to healthy controls, chronic tobacco users displayed increased N1 percentage (SMD = 0.65, 95%CI: 0.22 to 1.07), N2 percentage (SMD = 1.45, 95%CI: 0.26 to 2.63), wake time after sleep onset (SMD= 6.37, 95%CI: 2.48 to 10.26), and decreased slow-wave sleep (SMD = -2.00, 95%CI: -3.30 to -0.70). Objective TISDs preferentially occurred during the first part of the night. Regarding subjective parameters, only the Pittsburgh Sleep Quality Index (PSQI) total score could be analyzed, with no significant between-groups difference (SMD = 0.53, 95%CI: -0.18 to 1.23). Smoking status should be carefully assessed in sleep medicine, while TISDs should be regularly explored in chronic tobacco users.
Objective:
Bipolar disorder (BD) and schizophrenia are chronic psychiatric disorders in which sleep disorders are commonly seen. In mental disorders, residual symptoms may persist even if symptoms are greatly reduced overall. The aim of this study was to compare the sleep quality of schizophrenia and BD patients in remission with that of healthy controls.
Methods:
Forty-three patients with schizophrenia, 46 BD patients in remission for at least 3 months, and 51 healthy controls were included the study. The Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Young Mania Rating Scale (YMRS) and Pittsburgh Sleep Quality Index (PSQI) were administered to all participants and the Positive and Negative Syndrome Scale (PANSS) was administered to patients with schizophrenia.
Results:
Poor sleep quality was more frequent in the patient groups than the control group (p=0.009). PSQI score was positively correlated with duration of disease (r=0.236; p=0.026), number of cigarettes smoked per day (r=0.430; p<0.001), body mass index (r=0.189; p=0.025), and negatively correlated with duration of remission (r=-0.224; p=0.0359).
Conclusion:
Schizophrenia and BD patients in remission had worse sleep quality than a control group. Sleep quality was worst in the patients with schizophrenia. The severity of sleep disorder symptoms was positively associated with disease duration and negatively associated with duration of remission. Schizophrenia and BD patients should be carefully evaluated for symptoms of sleep disorders even when they are in clinical remission and should be offered additional treatment for sleep disorder symptoms when necessary.
Background
. Although sleep disturbances are ubiquitous in depression, studies assessing sleep architecture lead to conflicting results, possibly because of the heterogeneity in this disorder. We aimed to focus on Seasonal Affective Disorder (SAD), which is directly associated with circadian and sleep homeostasis impairments.
Methods
. A systematic search was conducted in July 2019. Original papers reporting data about night sleep architecture using polysomnography (PSG), in SAD or remitted-SAD and controls, were included.
Results
. Seven studies were retained and included 183 individuals, including 109 patients with SAD and 74 healthy controls. The random-effects meta-analysis showed that rapid eye movement sleep (REM) was significantly increased in SAD compared to controls (REM amount: SMD=1[0.11,1.88], p=0.027; REM percentage: SMD=0.71[0.02,1.40], p=0.045). Remitted SAD patients, compared to controls, also had a significantly increased REM sleep (REM amount: SMD=1.84[0.78,2.90], p<0.001; REM percentage: SMD=1.27[0.51,2.03], p=0.001) and a significantly decreased REM latency (SMD=-0.93[-1.73,-0.13], p=0.022). No differences were observed for total sleep time, sleep efficiency, and slow-wave-sleep.
Limitations
. Most studies had small sample size, with no placebo group and with open designs.
Conclusions
. REM sleep amount and latency appear altered both during the acute and remitted phase of SAD, representing trait markers with interesting diagnosis and therapeutic implications.
Dans la littérature scientifique actuelle, des études ont mis en évidence par une approche transdiagnostique, l’implication de facteurs cliniques, biologiques et génétiques spécifiques des conduites suicidaires indépendamment d’un diagnostic de trouble psychiatrique de l’Axe I ou II du Manuel Diagnostique et Statistique des Troubles Mentaux (DSM) (1–3). De plus, l’existence d’un trouble psychiatrique n’apparaît pas être discriminante pour définir certains types de profils de patients à risque de suicide (4–6). En effet, le suicide peut toucher à la fois des personnes dites en situation de crise mais il est largement reconnu que les pathologies psychiatriques restent à haut risque de suicide, notamment les troubles de l’humeur tels que les troubles bipolaires et les dépressions unipolaires, et plus particulièrement avec caractéristiques psychotiques (7,8). De plus, des facteurs de risque spécifiques de suicide ont été retrouvés dans chacune de ces différentes populations (9,10). Ainsi, avec cette conception moderne du suicide, il semble pertinent d’étudier le risque suicidaire dans diverses populations de suicidants, souffrant ou non de troubles psychiatriques, et en utilisant une approche tant épidémiologique, dynamique avec l’actigraphie, et biologique (3,11,12). En me basant sur cette approche, mon projet de thèse s’articule en 3 axes décrits ci-après, et consiste à identifier des facteurs de risque de récidive de tentative de suicide ainsi qu’à définir des profils de patients suicidants dans des populations différentes. Pour cela, plusieurs études coordonnées permettront de réaliser une évaluation multi-échelles de la vulnérabilité suicidaire de façon transdiagnostique et de façon ciblée dans les troubles de l’humeur uni- et bi-polaires.
Many biological processes, at the molecular, cellular to behavioral levels, follow intrinsic rhythmicity with recurrent oscillations characterized by stable amplitude, period and phase. Circadian rhythms (i.e., those which follow a 24 h-period) are crucial to allow a functioning of the organism which synchronizes with the environmental light-dark cycle. Circadian timing of the organism relies on the oscillating patterns of expression of core clock genes, based on transcription and translational feedback loops (TTFLs). Many molecular actors are involved in the regulation of the expression, the stability or the localization of the clock core proteins, including miRNAs or protein kinases. In mammals, the master clock of the organism is located in the suprachiasmatic nuclei (SCN). This bilateral brain structure receives inputs from photo-sensitive cells of the retina and send outputs to multiple secondary oscillators in the brain and in peripheral structures. Thus, the SCN mediates the synchronization between internal circadian rhythms of the organism and environmental dark-light cycle. Alteration of circadian rhythmicity leads to major negative consequences on both physical and mental health.
Résumé
Plusieurs troubles psychiatriques, comme le trouble bipolaire et l’autisme, sont hautement héréditaires. De nombreuses études ont décrit l’existence d’une agrégation familiale dans ces troubles, c’est-à-dire que le risque d’être atteint est supérieur à celui de la population générale si l’un des membres de la famille est atteint. L’héritabilité de ces deux troubles est estimée entre 70 % et 90 %. Cependant, l’identification des gènes de vulnérabilité à ces troubles est difficile, ce qui est notamment dû à leur très grande hétérogénéité tant sur le plan clinique qu’étiologique. Une approche via l’analyse d’endophénotypes et de facteurs environnementaux dans les études de génétique a permis plusieurs avancées. Parmi les phénotypes particulièrement intéressants, les troubles du sommeil et des rythmes circadiens ont été associés à la pathogenèse et aux manifestations de ces deux troubles. Les troubles du sommeil et des rythmes circadiens, à travers des polymorphismes des gènes circadiens et des gènes codant pour les enzymes de la voie de synthèse de la mélatonine, semblent être des facteurs de vulnérabilités, voire des endophénotypes du trouble bipolaire. Cette approche peut avoir des implications thérapeutiques dans le trouble bipolaire, à travers l’évaluation du sommeil et des rythmes circadiens, et la proposition de prises en charge personnalisées de ces phénotypes.
Objectives: To assess the differences in sleep impairments in major depressive disorder (MDD) and individuals recently diagnosed with bipolar disorder (BD) across different mood stages. Methods: This is a cross-sectional study corresponding to the second wave of a prospective clinical cohort of a sample of outpatients. The first wave included subjects diagnosed with MDD aged 18 to 60 years. Averaging 3 years after the first phase (second wave), conversion from MDD to BD diagnosis was assessed using the Mini International Neuropsychiatric Interview. The sleep alterations were assessed using the Pittsburgh Sleep Quality Index. Results: The sample included 468 subjects. Euthymic BD differed from euthymic MDD only in the domains of sleep efficiency and sleep disturbances, showing lower sleep efficiency (PR 4.91 [95%CI 1.94-12.42]) and higher sleep disturbances (PR 3.38 [95%CI 1.32-8.67]) in subjects recently diagnosed with BD during euthymia. These differences remained significant after adjusting for the potential confounding factors. Conclusions: The findings point out the relevance of regular sleep assessments in individuals recently diagnosed with BD, since the differences in sleep quality observed could provide insights regarding prognosis, treatment, even in the absence of a mood episode.
Objectives
: To assess the differences in sleep impairments in major depressive disorder (MDD) and individuals recently diagnosed with bipolar disorder (BD) across different mood stages.
Methods
: This is a cross-sectional study corresponding to the second wave of a prospective clinical cohort of a sample of outpatients. The first wave included subjects diagnosed with MDD aged 18 to 60 years. Averaging 3 years after the first phase (second wave), conversion from MDD to BD diagnosis was assessed using the Mini International Neuropsychiatric Interview. The total sample was divided into four groups: euthymic MDD, MDD in a current episode, euthymic BD, and BD in a current mood episode. The sleep alterations were assessed using the Pittsburgh Sleep Quality Index.
Results
: The sample included 468 subjects (261 euthymic MDD, 149 MDD currently depressed, 16 euthymic BD, and 42 BDs currently in a (hypo)manic or depressive episode). Euthymic BD differed from euthymic MDD only in the domains of sleep efficiency and sleep disturbances, showing lower sleep efficiency (PR 4.91 [95%CI 1.94 – 12.42]) and higher sleep disturbances (PR 3.38 [95%CI 1.32 – 8.67]) in subjects recently diagnosed with BD during euthymia. These differences remained significant after adjusting for the potential confounding factors.
Conclusions
: The findings point out the relevance of regular sleep assessments in individuals recently diagnosed with BD, since the differences in sleep quality observed could provide insights regarding prognosis, treatment, and the extent to which these individuals display significant subsyndromal symptomatology, even in the absence of a mood episode.
Despite several high-quality reviews of insomnia and incidence of mental disorders, prospective longitudinal relationships between a wider range of sleep disturbances and first onset of a depressive, bipolar, or psychotic disorders during the peak age range for onset of these conditions has not been addressed. Database searches were undertaken to identify publications on insomnia, but also on other sleep problems such as hypersomnia, short sleep duration, self-identified and/or generic ‘sleep problems’ and circadian sleep-wake cycle dysrhythmias. We discovered 36 studies that were eligible for systematic review and from these publications, we identified 25 unique datasets that were suitable for meta-analysis (Number>45,000; age ∼17). Individuals with a history of any type of sleep disturbance (however defined) had an increased odds of developing a mood or psychotic disorder in adolescence or early adulthood (Odds ratio [OR]:1.88; 95% Confidence Intervals:1.67, 2.25) with similar odds for onset of bipolar disorders (OR:1.72) or depressive disorders (OR:1.62). The magnitude of associations differed according to type of exposure and was greatest for sleep disturbances that met established diagnostic criteria for a sleep disorder (OR: 2.53). However, studies that examined observer or self-rated symptoms, also reported a significant association between hypersomnia symptoms and the onset of a major mental disorder (OR:1.39). Overall study quality was moderate with evidence of publication bias and meta-regression identified confounders such as year of publication. We conclude that evidence indicates that subjective, observer and objective studies demonstrate a modest but significant increase in the likelihood of first onset of mood and psychotic disorders in adolescence and early adulthood in individuals with broadly defined sleep disturbances. Although findings support proposals for interventions for sleep problems in youth, we suggest a need for greater consensus on screening strategies and for more longitudinal, prospective studies of circadian sleep-wake cycle dysrhythmias in youth.
Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.
Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7].
In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).
Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA
Completing a Systematic Review Is an Iterative Process
The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
Bipolar disorder (BD) is a chronic psychiatric condition characterized by recurrences of depressive and (hypo)manic episodes. Patients in remission report a wide range of sleep and circadian disturbances that correlate with several outcomes measures such as functioning or physical health. The most appropriate way to measure these abnormalities in clinical practice requires further investigation since the external validity of self-reports, as compared to more physiological measures (such as polysomnography or actigraphy), has been questioned. Despite the fact that questionnaires are inexpensive, fast and easy to use, they need to be validated against objective measures. This study aims to validate three sleep and circadian questionnaires, namely the Pittsburgh Sleep Quality Index (PSQI), the Composite Scale of Morningness (CSM) and the Circadian Type Inventory (CTI) - against actigraphy in BD patients in remission. Twenty-six carefully assessed BD patients in remission completed the PSQI, the CTI and the CSM, and wore an actigraph (AW7, Camntech) for 21 consecutive days. Phase preference assessed by the CSM strongly correlated with actigraphic phase markers (M10 onset ρ = -0.69 and L5 onset ρ = -0.63). Sleep duration and sleep latency assessed by the PSQI and by actigraphy were also highly correlated (ρ = -0.76; ρ = 0.50). Moderate correlation coefficients were observed between questionnaires and actigraphy for markers that explored the stability of rhythms, sleep quality, sleep latency and sleep disturbances (|ρ| > 0.40) although these were not significant after correcting for multiple testing. No correlation was observed between markers for the amplitude of rhythms. While the external validity of the CTI clearly requires further investigation, this study supported the external validity of the CSM and the PSQI for phase preference, sleep duration and latency. We conclude that the CSM and the PSQI could be useful in routine practice and research when actigraphy is not easily available.
Introduction
Findings from actigraphic studies suggesting that sleep and circadian rhythms are disrupted in bipolar disorder (BD) patients have been undermined by methodological heterogeneity and the failure to adequately address potential confounders.
Method
Twenty-six euthymic BD cases and 29 healthy controls (HC), recruited from University Paris-Est and matched for age and gender, were compared on subjective (Pittsburgh Sleep Questionnaire Inventory; PQSI) and objective (mean scores and variability in actigraphy) measures of sleep as recorded by over 21 consecutive days.
Results
Multivariate generalized linear modelling (GLM) revealed significant differences between BD cases and HC for five PSQI items (total score and four subscales), four actigraphy variables (mean scores) and five actigraphy variability measures. Backward stepwise linear regression (BSLR) indicated that a combination of four variables (mean sleep duration, mean sleep latency, variability of the fragmentation index over 21 days, and mean score on PSQI daytime dysfunction sub-scale) correctly classified 89% of study participants as cases or controls (Chi-square=39.81; df=6; p=0.001).
Limitations
The sample size (although larger than most actigraphy studies) and incomplete matching of cases and controls may have influenced our findings. It was not possible to control for potential effects of psychotropic medication or differences in employment status between groups.
Conclusions
When potential confounders of sleep and circadian profiles are adequately taken into account (particularly age, gender, daytime sleepiness, mood symptoms, body mass index, and risk of sleep apnoea), a selected subset of quantitative (mean scores) and qualitative (variability) features differentiated euthymic BD cases from HC.
Bipolar disorder (BD) has a multifactorial etiology with heterogeneous clinical presentations. Around 25% of BD patients may present with a depressive seasonal pattern (SP). However, there are limited scientific data on the prevalence of SP, its clinical manifestations, and any gender influence. Four hundred and fifty-two BD I and II cases (62% female), recruited from three French university-affiliated psychiatric departments, were assessed for SP. Clinical, treatment, and sociodemographic variables were obtained from structured interviews. One hundred and two (23%) cases met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria for SP, with similar frequency according to gender. Multivariate analysis showed a significant association between SP and BD II (odds ratio [OR] = 1.99, p = 0.01), lifetime history of rapid cycling (OR = 2.05, p = 0.02), eating disorders (OR = 2.94, p = 0.003), and total number of depressive episodes (OR = 1.13, p = 0.002). Seventy-one percent of cases were correctly classified by this analysis. However, when stratifying the analyses by gender, SP was associated with BD II subtype (OR = 2.89, p = 0.017) and total number of depressive episodes (OR = 1.21, p = 0.0018) in males but with rapid cycling (OR = 3.02, p = 0.0027) and eating disorders (OR = 2.60, p = 0.016) in females. This is the first study to identify different associations between SP and clinical characteristics of BD according to gender. The authors suggest that SP represents a potentially important specifier of BD. These findings indicate that seasonality may reflect increased severity or complexity of disorder.
Background
The Global Burden of Disease Study 2010 (GBD 2010) identified mental and substance use disorders as the 5th leading contributor of burden in 2010, measured by disability adjusted life years (DALYs). This estimate was incomplete as it excluded burden resulting from the increased risk of suicide captured elsewhere in GBD 2010's mutually exclusive list of diseases and injuries. Here, we estimate suicide DALYs attributable to mental and substance use disorders.
Methods
Relative-risk estimates of suicide due to mental and substance use disorders and the global prevalence of each disorder were used to estimate population attributable fractions. These were adjusted for global differences in the proportion of suicide due to mental and substance use disorders compared to other causes then multiplied by suicide DALYs reported in GBD 2010 to estimate attributable DALYs (with 95% uncertainty).
Results
Mental and substance use disorders were responsible for 22.5 million (14.8–29.8 million) of the 36.2 million (26.5–44.3 million) DALYs allocated to suicide in 2010. Depression was responsible for the largest proportion of suicide DALYs (46.1% (28.0%–60.8%)) and anorexia nervosa the lowest (0.2% (0.02%–0.5%)). DALYs occurred throughout the lifespan, with the largest proportion found in Eastern Europe and Asia, and males aged 20–30 years. The inclusion of attributable suicide DALYs would have increased the overall burden of mental and substance use disorders (assigned to them in GBD 2010 as a direct cause) from 7.4% (6.2%–8.6%) to 8.3% (7.1%–9.6%) of global DALYs, and would have changed the global ranking from 5th to 3rd leading cause of burden.
Conclusions
Capturing the suicide burden attributable to mental and substance use disorders allows for more accurate estimates of burden. More consideration needs to be given to interventions targeted to populations with, or at risk for, mental and substance use disorders as an effective strategy for suicide prevention.
Circadian rhythm disturbances have been associated with bipolar disorder (BD) during both the mood episodes and the periods of remission. Circadian phase preferences for the evening have been reported for remitted patients, whereas the amplitude and stability of their rhythms have never been assessed using questionnaires. The primary aim of our study was the validation of a French version of the Circadian Type Inventory (CTI), whereas its secondary aim was the comparison between remitted patients with BD and healthy controls for rhythm stability and amplitude and for phase preference. For this purpose, we used the CTI and the Composite Scale of Morningness (CSM) that assesses phase preference (''morning'' or ''evening'' type). First, we report here on the validation of the French version of the 11-item Circadian Type Inventory in a sample of 140 remitted patients with BD and 156 healthy controls. Principal components analysis revealed a two-factor structure (FR: flexibility/rigidity scale corresponding to rhythm stability; LV: languid/vigorous scale corresponding to rhythm amplitude) explaining 52% of the variance in the control group and 47% in the bipolar group. Cronbach's alpha was 0.75 for FR and 0.73 for LV. The test-retest reliability was 0.74 for FR and 0.86 for LV (3 wks) and 0.62 for FR and 0.72 for LV (6 mos). LV and FR scores correlated with the Composite Scale of Morningness score (p50.00001 and p ¼ 0.0002, respectively). Second, as compared with controls, patients with BD were more languid (p50.00001) and showed an evening preference (p ¼ 0.0003), but they did not differ from the controls with regard to flexibility/rigidity. The French version of the CTI appeared to have satisfactory psy-chometrics characteristics. Bipolar patients exhibited not only abnormalities in phase preference but also in amplitude as measured by languidity. Since circadian rhythm dysfunction has been shown to predict poor functioning and mood relapses in interepisodic patients with BD, this tool would appear to be a promising, easy-to-use, measure of the amplitude and flexibility of circadian rhythms that could enrich the arsenal of assessments used in clinical settings.
There is growing recognition that bipolar disorder (BPD) has a spectrum of expression that is substantially more common than the 1% BP-I prevalence traditionally found in population surveys.
To estimate the prevalence, correlates, and treatment patterns of bipolar spectrum disorder in the US population.
Direct interviews.
Households in the continental United States.
A nationally representative sample of 9282 English-speaking adults (aged >or=18 years).
Version 3.0 of the World Health Organization's Composite International Diagnostic Interview, a fully structured lay-administered diagnostic interview, was used to assess DSM-IV lifetime and 12-month Axis I disorders. Subthreshold BPD was defined as recurrent hypomania without a major depressive episode or with fewer symptoms than required for threshold hypomania. Indicators of clinical severity included age at onset, chronicity, symptom severity, role impairment, comorbidity, and treatment.
Lifetime (and 12-month) prevalence estimates are 1.0% (0.6%) for BP-I, 1.1% (0.8%) for BP-II, and 2.4% (1.4%) for subthreshold BPD. Most respondents with threshold and subthreshold BPD had lifetime comorbidity with other Axis I disorders, particularly anxiety disorders. Clinical severity and role impairment are greater for threshold than for subthreshold BPD and for BP-II than for BP-I episodes of major depression, but subthreshold cases still have moderate to severe clinical severity and role impairment. Although most people with BPD receive lifetime professional treatment for emotional problems, use of antimanic medication is uncommon, especially in general medical settings.
This study presents the first prevalence estimates of the BPD spectrum in a probability sample of the United States. Subthreshold BPD is common, clinically significant, and underdetected in treatment settings. Inappropriate treatment of BPD is a serious problem in the US population. Explicit criteria are needed to define subthreshold BPD for future clinical and research purposes.
Staging models are used routinely in general medicine for potentially serious or chronic physical disorders such as diabetes, arthritis and cancers, describing the links between biomarkers, clinical phenotypes and disease extension, and promoting a personalised or stratified medicine approach to treatment planning. Clinical staging involves a detailed description of where an individual exists on a continuum of disorder progression from stage 0 (an at-risk or latency stage) through to stage IV (late or end-stage disease). The approach is popular owing to its clinical utility and is increasingly being applied in psychiatry. The concept offers an informed approach to research and the active promotion of indicated prevention and early intervention strategies. We suggest that for young persons with emerging bipolar disorder, such transdiagnostic staging models could provide a framework that better reflects the developmental psychopathology and matches the complex longitudinal inter-relationships between subsyndromal and syndromal mood, psychotic and other disorders.
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. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
Sleep disturbance is a common feature during mood episodes in bipolar disorder. The aim of this study was to investigate the prevalence of such symptoms among euthymic bipolar patients, and their association with risk for mood episode recurrence. A cohort of bipolar I and II subjects participating in the Systematic Treatment Enhancement Program for Bipolar Disorder who were euthymic for at least 8 weeks were included in this analysis. Survival analysis was used to examine the association between sleep disturbance on the Montgomery-Asberg Depression Rating Scale (MADRS) and recurrence risk. A total of 73/483 bipolar I and II subjects reported at least mild sleep disturbance (MADRS sleep item ≥2) for the week prior to study entry. The presence of sleep problems was associated with a history of psychosis, number of previous suicide attempts, and anticonvulsant use. Sleep disturbance at study entry was significantly associated with risk for mood episode recurrence. Sleep disturbance is not uncommon between episodes for individuals with bipolar disorder and may be associated with a more severe course of illness. This suggests that sleep disturbance is an important prodromal symptom of bipolar disorder and should be considered a target for pharmacologic or psychosocial maintenance treatment.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
Disturbances in motor activity pattern are seen in both schizophrenia and depression. However, this activity has rarely been studied objectively. The purpose of the present study has been to study the complexity of motor activity patterns in these patients by using actigraphy.
Motor activity was recorded using wrist-worn actigraphs for periods of 2 weeks in patients with schizophrenia and major depression and compare them to healthy controls. Average motor activity was recorded and three non-parametric variables, interdaily stability (IS), intradaily variability (IV), and relative amplitude (RA) were calculated on the basis of these data. The motor activity was significantly lower both in patients with schizophrenia (153 +/- 61, mean +/- SD, p < 0.001) and depression (187 +/- 84, p < 0.001), compared to controls (286 +/- 80). The schizophrenic patients had higher IS and lower IV than the controls reflecting a more structured behavioural pattern. This pattern was particularly obvious in schizophrenic patients treated with clozapine and was not found in depressed patients.
Motor activity was significantly reduced in both schizophrenic and depressed patients. However, schizophrenic patients differed from both depressed patients and controls, demonstrating motor activity patterns marked by less complexity and more structured behaviour. These findings may indicate that disturbances in motor activity reflect different pathophysiological mechanisms in schizophrenia compared to major depression.
Psychomotor retardation (PR) is among the most important features of depression. This study investigates the development of day- and night-time as well as intensity and quantity of circadian motor activity during a 4-week course of treatment among 27 patients with depression compared to 27 healthy controls. A diagnosis of major depression was made using SCID. Motor activity was continuously measured with an actigraph during the study and clinical course of depression with HAM-D-21. Motor activity was described as the quantity and intensity of movements during day- and night- time. Clinically improved patients had significantly intensified movements after 4 weeks, compared to subjects with <50% improvement on HAM-D. While the measures of day-time level of movements captured the clinical improvement of depression, clinical improvement was not reflected by the night-time measurements. This study demonstrates that the separated analysis of level and quantity of movements supports a better understanding of the nature of psychomotor retardation during depression. The subdivision in day- and night-time activity objectively measured with actigraphy captures distinct patterns of motor activity and represents prognostic factors in the treatment outcome of depression. The study also highlights the importance of studying the intensity of movements separately from the quantity of movements in relation to treatment outcome.
We present a revised version of the metareg command, which performs meta-analysis regression (meta-regression) on study-level summary data. The major revisions involve improvements to the estimation methods and the addition of an option to use a permutation test to estimate p-values, including an adjustment for multiple testing. We have also made additions to the output, added an option to produce a graph, and included support for the predict command. Stata 8.0 or above is required. Copyright 2008 by StataCorp LP.
Wrist motor activity was continuously recorded by a solid-state monitor in 12 patients with major depression throughout their stay in hospital; their clinical state was evaluated using three scales. During the day, activity troughs and immobility peaks occurred before noon and around 1500 hrs. Activity level progressively increased, while the duration of immobility decreased, with clinical improvement. The immobility measurement appeared to be a valuable index of depression and is more sensitive than the activity level, mainly for agitated depressed patients. Immobility episodes during the day could suggest the release of an ultradian sleep-wake rhythm in depression.
Wrist motor activity was continuously monitored in 10 major unipolar depressed inpatients. Clinical state and motor activity parameters were studied. The data obtained at the beginning of the hospitalization, before the antidepressant treatment, were compared to chose found just before discharge. Time of day effect and subtypes of depression (endogenous versus non-endogenous) were considered. Motor retardation is related to both fluctuations of activity level and high number of 15 minute immobility epochs. Immobility parameters at night and during day were a good indicator of the severity of the depressive state. The temporal pattern of activity level was related to the subtype of depression.
The 24-hour motor activity pattern was evaluated in 26 inpatients with major depression at treatment onset and after 4 weeks of antidepressant therapy. Clinical state, depression, and psychomotor retardation, as well as motor activity level and circadian rhythm, were simultaneously assessed. Treatment responders and nonresponders were also considered. Diurnal hypoactivity and reduced 24-hour rhythm amplitude were found at treatment onset. Activity level increased significantly on discharge. The rest-activity cycle for each depressed patient fit a cosine function of 24-hour periodicity. Data tended to show no phase shift but a large intragroup phase variability. Preliminary findings of a negative correlation between basic activity level and clinical improvement, and a trend toward responders having a lower activity level than nonresponders, suggest that activity could be used to predict therapeutic response.
Background
Actigraphy is increasingly used in sleep research and the clinical care of patients with sleep and circadian rhythm abnormalities. The following practice parameters update the previous practice parameters published in 2003 for the use of actigraphy in the study of sleep and circadian rhythms.
Methods
Based upon a systematic grading of evidence, members of the Standards of Practice Committee, including those with expertise in the use of actigraphy, developed these practice parameters as a guide to the appropriate use of actigraphy, both as a diagnostic tool in the evaluation of sleep disorders and as an outcome measure of treatment efficacy in clinical settings with appropriate patient populations.
Recommendations
Actigraphy provides an acceptably accurate estimate of sleep patterns in normal, healthy adult populations and inpatients suspected of certain sleep disorders. More specifically, actigraphy is indicated to assist in the evaluation of patients with advanced sleep phase syndrome (ASPS), delayed sleep phase syndrome (DSPS), and shift work disorder. Additionally, there is some evidence to support the use of actigraphy in the evaluation of patients suspected of jet lag disorder and non-24hr sleep/wake syndrome (including that associated with blindness). When polysomnography is not available, actigraphy is indicated to estimate total sleep time in patients with obstructive sleep apnea. In patients with insomnia and hypersomnia, there is evidence to support the use of actigraphy in the characterization of circadian rhythms and sleep patterns/disturbances. In assessing response to therapy, actigraphy has proven useful as an outcome measure in patients with circadian rhythm disorders and insomnia. In older adults (including older nursing home residents), in whom traditional sleep monitoring can be difficult, actigraphy is indicated for characterizing sleep and circadian patterns and to document treatment responses. Similarly, in normal infants and children, as well as special pediatric populations, actigraphy has proven useful for delineating sleep patterns and documenting treatment responses.
Conclusions
Recent research utilizing actigraphy in the assessment and management of sleep disorders has allowed the development of evidence-based recommendations for the use of actigraphy in the clinical setting. Additional research is warranted to further refine and broaden its clinical value.
