Sleep and Sleep-Wake Manipulations in Bipolar Depression

Abstract

In the last 30 years, it has been convincingly demonstrated that sleep in major depression is characterized by disturbances of sleep continuity, a reduction of slow wave sleep, a disinhibition of REM sleep including a shortening of REM latency (i.e. the time between sleep onset and the occurrence of the first REM period) and an increase in REM density. Furthermore, manipulations of the sleep-wake cycle like total or partial sleep deprivation or phase advance of the sleep period have been proven to be effective therapeutic strategies for patients with unipolar depression. The database concerning sleep and sleep-wake manipulations in bipolar disorder in comparison is not yet as extensive. Studies investigating sleep in bipolar depression suggest that during the depressed phase sleep shows the same stigmata as in unipolar depression. During the hypomanic or manic phase, sleep is even more curtailed, though subjectively not experienced as disturbing by the patients. REM sleep disinhibition is present as well. An important issue is the question, whether sleep-wake manipulations can also be applied in patients with bipolar depression. Work by others and our own studies indicate that sleep deprivation and a phase advance of the sleep period can be used to treat bipolar patients during the depressed phase. The risk of a switch into hypomania or mania does not seem to be more pronounced than the risk with typical pharmacological antidepressant treatment. For patients with mania, sleep deprivation is not an adequate treatment – in contrast, treatment strategies aiming at stabilizing a regular sleep-wake schedule are indicated.

Assessment of Wakefulness and Brain Arousal Regulation in Psychiatric Research

“…According to some studies, this switch risk might be higher for antidepressants, which are particularly sedating [102][103][104][105] . In contrast, stabilization of the sleep-wake rhythm is an established part in behavioural therapies for bipolar disorder [106][107][108] , and extended bed rest is used as an add-on in the treatment of acute mania [109][110][111] . Furthermore, case reports show acute antimanic effects of psychostimulants [reviewed in 112 ].…”

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Bipolar Disorders, Part I: Treatment of Bipolar Depression

“…As a chronobiological intervention strategy, sleep deprivation combined with sleep phase advance protocol is as efficacious in bipolar depression as in unipolar depression (Riemann et al 2002) (Level C). When not combined with a mood stabiliser, the risk of switch is around 10 %) (Colombo et a1 1999).…”

Seasonal influences on first-episode admission in affective and non-affective psychosis

“…In patients with bipolar disorder, changes in levels of melatonin are proposed to cause disturbances in the circadian rhythm because it is the primary regulator of the intrinsic circadian pacemakers (13)(14)(15)(16)(17)(18)(19). The disturbance in the association between external and internal timekeeping has been postulated to lead to multiple circadian disturbances (20), in particular, a disruption in the sleep-wake cycle, which is a precipitant of manic episodes (21)(22)(23)(24). The growing understanding of circadian aspects of BPAD has led to the development of treatments that focus on the normalization of circadian rhythms (25,26); however, there has been less focus on the seasonal nature of the illness and the relevance of this to current treatment approaches.…”