Behavioral Treatment of Insomnia in Bipolar Disorder

Abstract

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

Insomnia as a Transdiagnostic Process in Psychiatric Disorders

“…Some concern has been expressed for using CBT-I within bipolar disorder given the importance of stimulus control and sleep restriction in CBT-I and the potential risk of developing hypomania or mania symptoms as a result of treatment-related mild sleep deprivation [62]. However, CBT-I has been evaluated within bipolar disorder and results from this study indicate that neither stimulus control nor sleep restriction resulted in hypomania or mania symptom [20]. Moreover, the intervention reduced insomnia symptoms and increased sleep efficiency when compared to a sleep psychoeducation condition.…”

“…Treatments are being developed to target transdiagnostic processes across a range of psychiatric disorders including depression [10], anxiety disorders [11–13], bipolar disorder [14], schizophrenia [15], and also sleep problems [16]. One such treatment is cognitive behavioral therapy for insomnia (CBT-I), which has been shown to not only successfully treat insomnia [17,18], but to also effectively treat other comorbid disorders including depression [19], bipolar disorder [20,21], PTSD [22,23], and schizophrenia [24]. CBT-I is a multicomponent treatment that targets sleep interfering behaviors and cognitions.…”

Basic sleep and circadian science as building blocks for behavioral interventions: A translational approach for mood disorders.

“…Importantly, insomnia persists between episodes in 55% of patients (Harvey et al, 2005). In a recent case series, Kaplan and Harvey (2013) reported that CBT-I has a positive impact on sleep in patients with inter-episode BD and comorbid insomnia. Regularizing bedtimes and rise times was often sufficient to bring about improvements in sleep.…”

Insomnia Comorbid to Severe Psychiatric Illness

“…If symptoms of depression or mania emerge, changes in total sleep time that may be contributing to these symptoms should be evaluated, and consideration should be given to modifying or temporarily suspending sleep restriction or stimulus control if necessary. Notwithstanding such concerns, we recently reported preliminary findings suggesting the safety of regularizing bed and wake times using stimulus control and sleep restriction strategies with BD patients (57). …”