Sleep and Bipolar Disorder

Sleep disturbance is a cardinal feature of bipolar disorder. During acute mania, patients exhibit markedly reduced sleep time and report a reduced need for sleep. The reduced need for sleep can be further defined as the “ability to maintain energy without sufficient sleep” (Plante and Winkelman, 2008). Even when euthymic, sleep disturbance is common (Harvey 2008). In a recent study, 55% of euthymic bipolar patients had chronic insomnia (Harvey et al 2005). Both insomnia and hypersomnia have been reported in patients with bipolar depression (Harvey 2008). Children with bipolar disorder (who often display ultradian rapid cycling rather than distinct mood episodes) exhibit reduced sleep efficiency and frequent nocturnal awakenings (Mehl et al 2006).

Both homeostatic and circadian sleep abnormalities are thought to play a role in bipolar disorder (Plante and Winkelman 2008).

Polysomnographic studies of unmedicated manic panics have found shortened total sleep time, shortened REM latency, and increased time awake in bed (Plante and Winkelman 2008).

**Harvey AG. Sleep and circadian rhythms in bipolar disorder: seeking synchrony, harmony, and regulation. Am J Psychiatry 2008;165(7):820-9.**


Harvey AG, Schmidt DA, Scarna A, Semler CN, Goodwin GM. Sleep-related functioning in euthymic patients with bipolar disorder, patients with insomnia, and subjects without sleep problems. Am J Psychiatry 2005;162(1):50-7.

Mehl RC, O’Brien LM, Jones JH, Dreisbach JK. Correlates of sleep and pediatric bipolar disorder. Sleep 2006;29(2):193-7.

**Plante DT, Winkelman JW. Sleep disturbance in bipolar disorder: therapeutic implications. Am J Psychiatry 2008;165(7):830-43.**

The above is excerpted from an article I wrote on Sleep Disorders and Mental Illness for Medlink Neurology.

Behavioral Sleep Medicine- Who Should Practice It?

I would like to thank Dr. Perlis for his thougtful response to my Saturday March 1 post. Since not everyone reads the comments, I think that Dr. Perlis's reply deserves its own post and am reprinting it below:

===========> Michael Perlis Reply RE: Michael Rack, MD Post #1169The Threat FROM Psychologists===========>
It is interesting that Dr. Rack phrased the subject to his email this way. I think many people who specialize in Behavioral Sleep Medicine would see this differently, i.e., be concerned about recent initiatives by the AASM as a THREAT TO the continued participation of Psychologists in Sleep Medicine.
MR: Has anyone read the editorial in this month's issue of JCSM by Michael Perlis, Phd? In this editorial about behavioral sleep medicine/CBT-insomnia, Dr. Perlis advocates for the requirement that all accredited sleep disorders centers be required to "have a provider on staff (full time or part time) who is BSM "boarded" or board eligible. ===========>

This was indeed one of many recommendations. There are two issues here. First, it is a fact that most accredited Sleep Disorders Centers (SDCs) do not have people who specialize in the assessment and tx of insomnia. Second, it is a fact that the people who are "boarded" in BSM specialize in the assessment and tx of insomnia and are the only Sleep Medicine clinicians with any certification to conduct CBT-I. So it follows that fully accredited SDCs
Given that the need to provide treatment for all sleep DXs Incl. insomnia
Given the desire to provide the highest standard of care possible
should have BSM "boarded" or board eligible on staff.

MR: I am a DABSM and also certified in sleep medicine by the ABIM. I have also passed the AASM behavioral sleep medicine certification exam, and so I periodically receive emails from Dr. Perlis regarding the issue of who can provide behavioral sleep medicine services (I am also a member of the behavioral sleep medicine committee, but I will not reveal those confidential discussions). There is a growing movement among psychologists who are upset because they are not eligible for the new physician sleep boards to require accredited sleep centers to have BSM-certified individuals (primarily psychologists) on staff.===========>
While there is a contingent of PhD clinicians that are indeed upset about not being eligible for the ABMS exam, this is not the main issue for BSM clinicians. In fact, this issue is old news. The BSM exam was designed and established by the original AASM Presidential Committee for BSM (of which I was a member) precisely to fill the void left by the closure of the ABMS to PhD clinicians. Note: Unlike the new Sleep Medicine Exam… The BSM exam is (and should continue to be) open to PhDs and MDsThe current debate is whether to extend the credentialing process to MA level clinicians (NPs, PAs, etc.). The commentary written by Dr. Smith and I airs out the issues related to this movement and how this might be achieved in a manner that guarantees the highest standards of care be maintained. Finally, please note that one of the recommendations made in our JCSM Commentary is that both BSM and ABMS certified individuals should supervise MA level clinicians.
MR: I encourage all sleep physicians to write the AASM Board of Directors and support the position that physician board certification in sleep medicine qualifies the physician to practice all aspects of sleep medicine, including behavioral sleep medicine. ===========>
There is no question that the certification in sleep medicine does indeed proffer the right for all such certified individuals to practice BSM. The real questions are
1. Do most MDs certified in sleep medicine feel themselves qualified to practice and/or supervise CBT-I and other BSM interventions ?
2. Do most MDs want to practice in this arena ? I think the answer to both questions would be an emphatic “No!”. Perhaps the best analogy, as I understand this, is that MD degree and license is sufficient to for any MD to conduct any form of medicine. So any MD, for example, can conduct assessments and treatment for sleep disorders. The question here, again, is should they ? Are they really qualified? Will they provide the best possible treatment? Like Dr. Rack – I also encourage you to engage these issues and, whatever your opinion, share them with the BSM section leaders and the AASM BOD.
MR: In addition, consider attending the Insomnia Section meeting at Sleep 2008. The Insomnia Section has become a center for psychologists who support Dr. Perlis's position.===========> Please do attend. Although if your expecting this to be a Perlis Supporter Che-Guevara-type meeting… you’ll likely be very disappointed. Sincerely Michael Perlis

Circadian Rhythms

USAToday has a nice article today about circadian rhythms, with the final part of the article focusing on the possible role of circadian rhythm disturbance in bipolar disorder:

In people, circadian rhythm disorders can trigger serious problems, notably depression. Seasonally affective disorder is a winter depression tied to a lack of the sunlight cues that trigger the SCN into proper rhythm.
Also, there are indications that bipolar disorder also involves circadian problems, McClung says. This disorder causes unusual shifts in mood and energy, with episodes varying between extremes and afflicting some 5.7 million people nationwide, according to the National Institute of Mental Health. "People might sleep all the time or not sleep at all," says McClung. Body temperatures and hormone levels similarly race, all pointing to a body clock with its springs missing.
At the Cold Harbor conference, McClung presented a mouse engineered to lack a specific clock gene which "looks as close to a bipolar person in a manic state as we can determine in a mouse," she says. The manic mice are hyperactive, sleep little, disregard signs of predators and voraciously consume cocaine.
For medical research, the most intriguing thing about the manic mice is that lithium, which human bipolar patients take to treat their illness, cuts their symptoms. "We don't know why lithium works, and we hope the mouse gives us an opportunity to explore its mechanism," McClung says.
Opening up the mechanism by which clock genes work, or don't work, is the task before scientists today, McClung adds. "Everyone on this planet has a 24-hour internal clock, and it is deeply ingrained in our biology," she says. "If we lived on a different planet, we'd have a different rhythm — that's how fundamental they are."