Sleep disturbances, functioning, and quality of life in euthymic patients with bipolar disorder
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.
References (45)
- et al.
A comparative psychometric study of the Spanish versions with 6, 17, and 21 items of the Hamilton Depression Rating Scale
Med. Clin.
(2003) - et al.
Associations between sleep disturbance, cognitive functioning and work disability in Bipolar Disorder
Psychiatry Res.
(2015) - et al.
Screening for bipolar disorders: a public health issue
J. Affect. Disord.
(2016) - et al.
Spanish version of a scale for the assessment of mania: validity and reliability of the Young Mania Rating Scale
Med. Clin.
(2002) - et al.
Rate of switch from depression into mania after therapeutic sleep deprivation in bipolar depression
Psychiatry Res.
(1999) - et al.
Sleep, residual mood symptoms, and time to relapse in recovered patients with bipolar disorder
J. Affect. Disord.
(2016) - et al.
Functional impact of biological rhythm disturbance in bipolar disorder
J. Psychiatry Res.
(2010) - et al.
Sleep functioning in relation to mood, function, and quality of life at entry to the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)
J. Affect. Disord.
(2009) - et al.
Sleep matters: sleep functioning and course of illness in bipolar disorder
J. Affect. Disord.
(2011) - et al.
Biological dysrhythm in remitted bipolar I disorder
Asian J. Psychiatr.
(2017)
Assessment of sleep quality in bipolar euthymic patients
Compr. Psychiatry
Can bipolar disorder be viewed as a multi-system inflammatory disease?
J. Affect. Disord.
The sleep of remitted bipolar outpatients: a controlled naturalistic study using actigraphy
J. Affect. Disord.
Prevalence of insomnia and sleep characteristics in the general population of Spain
Sleep Med.
Disturbed sleep as risk factor for the subsequent onset of bipolar disorder: Data from a 10-year prospective-longitudinal study among adolescents and young adults
J. Psychiatr. Res.
Residual depressive symptoms, sleep disturbance and perceived cognitive impairment as determinants of functioning in patients with bipolar disorder
J. Affect. Disord.
Sleep disturbances in bipolar disorder during remission
J. Affect. Disord.
Homeostatic sleep regulation in habitual short sleepers and long sleepers
Am. J. Physiol.
DSM-IIIR. Diagnostic and Statistical Manual Disorders
Temporal relation between sleep and mood in patients with bipolar disorder
Bipolar Disord.
Propiedades psciométricas del cuestionario de Oviedo de sueño
Psicothema
Sleep disturbances in euthymic bipolar patients
Ann. Clin. Psychiatry
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2022, Journal of Psychiatric ResearchCitation Excerpt :For example, a study from Lee et al. (2015) found that poorer sleep hygiene was related to a lower QOL independent of sleep quality, anxiety, and depressive symptoms in a sample of individuals with epilepsy. Additionally, research has found a strong relationship between sleep hygiene and sleep quality (Irish et al., 2015; Mastin et al., 2006) with sleep quality being related to QOL in samples dealing with physical and mental illnesses (Castro-Marrero et al., 2018; De la Fuente-Tomás et al., 2018; Travaglini et al., 2019). These findings suggest that interventions targeting sleep hygiene practices may improve QOL, sleep, and schizophrenia-spectrum symptomology.
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2021, Personality and Individual DifferencesCitation Excerpt :In addition, life satisfaction is popularly utilized as a great indicator to show individuals' general well-being (Diener et al., 1985), and it has been found to have correlations with perceived stress, psychological distress and self-efficacy in many previous researches (e.g. Coffman & Gilligan, 2002; Lee et al., 2016). However, the underlying mechanism in which life satisfaction internalize sleep disturbance has not answered clearly (Kim & Ko, 2018; Wang & Boros, 2020), especially for university students (Lund et al., 2010), although the important role of sleep for well-being and quality of life has been documented for another groups, such as elderly people (Kim & Ko, 2018; Zhi et al., 2016), athletes (Litwic-Kaminska & Kotyśk, 2017), Parkinson's disease caregivers (Perez et al., 2020), and euthymic patients (De la Fuente-Tomás et al., 2018). Thus, more studies examining the linkage between sleep problems and life satisfaction in university students is needed.
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2020, Current Opinion in PsychologyCitation Excerpt :The presence of sleep problems is associated with other markers of poor course in BD, including rapid cycling [26], anxiety and substance use comorbidities [27,28], poor physical health outcomes (including cardiovascular disease, increased weight and diabetes; [29,30]), and a history of suicide attempts [27,31,32]. Sleep problems also impact consumers’ subjective quality of life: sleep has been identified as a core quality of life domain in BD [33], and sleep problems have been found to correlate with poorer quality of life during both symptomatic [12] and euthymic periods [34]. Given that quality of life is rated by consumers as one of the most important treatment outcome in BD [35,36], clinicians should routinely assess for sleep problems (see below).