Elsevier

Psychiatry Research

Volume 269, November 2018, Pages 501-507
Psychiatry Research

Sleep disturbances, functioning, and quality of life in euthymic patients with bipolar disorder

https://doi.org/10.1016/j.psychres.2018.08.104Get rights and content

Highlights

  • Euthymic bipolar patients frequently present sleep disturbances that seem to contribute to the impairment of their functioning and QoL.

  • In addition, the use of benzodiazepinesnegatively affects the QoL of these patients while the use of caffeine positively affects their occupational functioning.

  • Clinicians should be aware of these issues in their daily clinical practice. Thus, even in euthymic bipolar patients, a detailed sleep history should be made, and the use of benzodiazepines should be reduced to the minimum.

Abstract

There is scarce knowledge about the impact of sleep disturbances on functioning and quality of life (QoL). This study aims to investigate the links between sleep satisfaction and duration, and functioning and QoL in euthymic BD patients. We made a secondary analysis of a cross-sectional, naturalistic, multicenter study. Inclusion criteria: DSM-IV BD diagnosis; age > 17 years; written informed consent. Sample: 119 Spanish euthymic BD outpatients. Hierarchical multiple regressions were performed controlling for confounding factors. We found that almost half of the patients reported at least one sleep complaint, nighttime awakenings (60.5%) and difficulty falling asleep (31.9%) were the most frequent. Long sleep duration was associated with worse global functioning, and also with worse occupational functioning along with caffeine consumption. Sleep satisfaction was negatively associated with worse QoL in the mental health subscale and the summary mental. In both cases, the use of benzodiazepines negatively affects these QoL domains. In conclusion, euthymic bipolar patients frequently present sleep disturbances that seem to contribute to the impairment of their functioning and QoL. Also, the use of benzodiazepines negatively affects the QoL of these patients. Thus, a detailed sleep evaluation should be performed, and the use of benzodiazepines should be reduced to the minimum.

Introduction

Bipolar disorder (BD) is a severe, recurrent disorder with a high prevalence of comorbidities (Leboyer et al., 2012) and mortality (Kupfer, 2005), and with a significant impact on daily functioning and quality of life (QoL), even when in clinical remission (Deckersbach et al., 2016, Rosa et al., 2012, Sierra et al., 2005). Moreover, Carta and Angst (2016) discuss the hypothesis of identifying BD as an issue of clinical and public health interest, including sub-threshold cases.

Several lines of evidence highlight sleep disruptions as a key feature of the disorder. First, sleep disturbances have been identified as an early indicator of emerging BD (Duffy et al., 2007, Ritter et al., 2015), and once the diagnosis is made, they are described as the most common prodrome of mania and the sixth most common symptom occurring before the onset of a depressive episode (Harvey et al., 2005b). Second, experimentally induced sleep deprivation is linked to the onset of manic episodes and improvement of depressed mood in unipolar depression (Colombo et al., 1999; Wu and Bunney, 1990). Third, there are multiples lines of evidence suggesting that sleep disturbances contribute to relapse in BD (Bauer et al., 2006, Gruber et al., 2009, Harvey et al., 2009). Fourth, sleep disturbances have been identified as the most prominent correlates of mood episodes and inadequate recovery (Harvey, 2008). Finally, it has been estimated that between 15 and 100% of BD patients experience sleep disturbances during the euthymic phase (Iyer and Palaniappan, 2017, Millar et al., 2004, Sylvia et al., 2012).

Although it is well documented that sleep is disturbed, there is less knowledge about how it is disturbed (Harvey, 2008). The pathological sleep pattern of persons with BD depends mostly on the type of episode. Depressive episodes are typically characterized by increased nighttime awakenings and more severe insomnia or hypersomnia, while manic episodes are usually characterized by more severe insomnia or what is often described as a decreased ‘need for sleep,’ with increased energy levels (Harvey et al., 2005). Furthermore, during euthymia, it has been estimated that between 15 and 100% of individuals experience sleep disturbances (Millar et al., 2004, Sylvia et al., 2012), and one third have circadian rhythm sleep-wake disorders (Takaesu et al., 2018).

There are conflicting results in studies on sleep disturbances and their impact on functioning in euthymic individuals with BD. While some studies have shown an association between sleep disturbances and functional impairment (Keskin et al., 2018, Boland et al., 2015, Rosa et al., 2013), a recent study by Samalin et al. (2017) found that they are only indirectly associated via residual depressive symptoms and perceived cognitive performance. Other studies have described a negative impact of sleep disturbances on functioning (Cretu et al., 2016, St-Amand et al., 2013), but their results should be interpreted with caution due to methodological problems, mainly the lack of psychometric instruments for assessment both sleep problems and functioning (sleep items from HDRS, and GAF and the daytime functioning item of PSQ)”.

QoL has consistently been shown to be decreased in BD patients (Sierra et al., 2005). Furthermore, two studies, one in symptomatic patients (Gruber et al., 2009) and one in euthymic patients (Giglio et al., 2009), have demonstrated that sleep disturbances are another factor that contributes to the low quality of life in BD patients.

Given the scarce and conflicting literature, this paper aims to investigate the impact of two sleep parameters (satisfaction and duration) on daily functioning and QoL in a sample of adults with BD during the euthymic phase. In contrast to previous studies, we employed psychometrically valid and reliable instruments for assessing these domains. We hypothesized that dissatisfied sleepers would have a lower functioning and would report worse health-related QoL. We also hypothesized that given the literature on the general population and acute phases of BD, long and short sleepers would exhibit worse daily functioning and poorer QoL.

Section snippets

Subjects

This paper is a secondary analysis of a huge study for developing a staging model for BD supported by the Spanish Ministry of Health, Social Services and Equality (Ref. PI11/02493).

Subjects were recruited at four sites in Spain [Oviedo (1 center), Barcelona (2 centers), and Valencia (1 center)]. Inclusion criteria were (1) BD diagnoses confirmed with the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I)(First et al., 2002); (2) older than 17 years of age; (3) receiving

Sample characteristics

Of the 119 patients with BD during the euthymic phase, 67.7% were female, and the mean age was 46.3 ± 12.2 years. Most patients (90, 76.9%) had a diagnosis of bipolar I, while 25 (21.4%) had a diagnosis of bipolar II, and 4 (3.6%) were diagnosed as BD not otherwise specified. The mean age of onset was 27.3 ± 8.9 years, and the mean duration of illness was 11.5 ± 9.0 years. Patients with a diagnosis of BD had experienced a mean of 2.2 ± 1 hospitalizations. Detailed demographic and clinical data

Discussion

This study aimed to investigate the association of two sleep parameters (satisfaction and total sleep time) on daily functioning and QoL perceptions in adults with bipolar disorder during the euthymic phase. Even though the patients were euthymic, almost half of them reported at least one sleep complaint, but only a minority met the ICD-10 criteria for insomnia disorder. Again, nearly half the patients reported sleep dissatisfaction and/or were classified as impaired (short or long) sleepers.

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