Sleep [or, lack of it] in Bipolar Illness

Sleep Disturbance in Bipolar Disorder Across the Lifespan.

Harvey AG, Talbot LS, Gershon A. [see the full reference at the end of the section on Summary and Implications.]

Abstract: The aim of this article is to highlight the importance of the sleep–wake cycle in children, adolescents, and adults with bipolar disorder. After reviewing the evidence that has accrued to date on the nature and severity of the sleep disturbance experienced, we document the importance of sleep for quality of life, risk for relapse, affective functioning, cognitive functioning, health (sleep disturbance is implicated in obesity, poor diet, and inadequate exercise), impulsivity, and risk taking. We argue that sleep may be critically important in the complex multifactorial cause of interepisode dysfunction, adverse health outcomes, and relapse. An agenda for future research is presented that includes improving the quality of sleep measures and controlling for the impact of bipolar medications.

Introduction: Sleep disturbance is a core symptom of bipolar disorder“.

Summary and Implications: Sleep disturbance is pervasive across the phases of bipolar disorder and across affected youth and adults. Given the adverse impact of sleep disturbance on quality of life, emotional and cognitive functioning, and health, we suggest that further studies are needed correcting for the methodological problems raised. Even more importantly, future work is needed to develop a mechanistic understanding of the role of sleep in bipolar disorder. In particular, several novel hypotheses have been posited as to the importance of sleep in aspects of functioning that are currently underrecognized and untested, such as cognitive deficits, health, and impulsivity/risk taking. Importantly, sleep deprivation may be one modifiable contributor to a range of the adverse outcomes associated with bipolar disorder. Harvey AG, Talbot LS, Gershon A. Sleep Disturbance in Bipolar Disorder Across the Lifespan. Clin Psychol (New York). 2009 Jun;16(2):256-277. doi: 10.1111/j.1468-2850.2009.01164.x. PMID: 22493520; PMCID: PMC3321357.

How is the sleep disturbance of bipolar illness dealt with by psychiatrists and perhaps also by primary care doctors? Well, you would think that for such severe sleep disturbances and for such dire consequences, that they would suggest a sleep test to check for sleep apnea, a well known cause of emotional instability, cognitive impairment and is also linked to cardiorespiratory illness in the long run.

And it seems, that you would be wrong. Again, the false divide between mental illness and physical illness is the culprit; sleep tests are often do not even come to mind when treating and investigating serious mental illness such as manic depressive insanity; Why? Because mental illness is thought of as a “mental or psychological problem” and so why would you order a breathing test for a psychological or psychiatric problem?

Have a look at the solutions suggested in Bipolar Disorder and Sleep Problems  Written by Annie Stuart Medically Reviewed by Brunilda Nazario, MD on August 05, 2022 on WebMD to see what I mean.

Sleep tests are not mentioned. Sleep Apnea is not mentioned. [even though patients are usually not aware that they have sleep apnea and need the test to discover it; [because they are asleep or having difficulty with sleep and breathing during sleep is handled by the autonomic nervous system in an integrative manner with the brain stem and the blood and the heart and the … get the idea…breathing during sleep can be just as complex and involuntary as baseline breathing awake at rest.

Same with the excellent research paper I cited earlier by Gershon A. et al. They do not talk about sleep apnea and sleep tests are not mentioned, not even as a pilot research study to see if intermittent hypoxia may be a problem in bipolar illness..

This, despite the fact that we all know that severe, continuous sleep deprivation can actually cause death [think of the poor patients suffering with severe manic attacks and being unable to sleep] . In the days before medication was available, severely manic patients did not sleep for months and sometimes did * drop dead from cardiovascular collapse. * Emile Kraepelin Manic Depressive Insanity 1926 [I have to go back and look up the page and chapter in which Kraepelin discusses this….]

and today, with available treatments, manic attacks are still shown to cause increased mortality.

While evidence suggests that depression is associated with medical morbidity and mortality, the potential role of mania has received less attention. This analysis evaluated the association between manic spectrum episodes and risk of all-cause mortality over a 26-year follow-up in a population-based study.……...These findings from a large population-based study suggest that a lifetime history of manic spectrum episodes is associated with an increased risk of all-cause mortality over a 26-year follow up in middle-aged cohorts (those aged 30-64 years at enrollment), and that this increased risk persists even after adjusting for lifetime depressive symptoms. These findings are consistent with previous findings from a record linkage study of mortality among bipolar patients discharged from hospitals in England between 1999-2006 (Hoang et al., 2011). After adjusting for age and sex, standardized all-cause mortality ratios in that study ranged from 3.4-8.0 within one year after discharge in those aged <45 years (Hoang et al., 2011). The reported risk of mortality in that study was substantially higher than the age and sex adjusted 1.39 increased odds among those aged 30-44 in our study, perhaps due to that study’s clinical sample. Taken together, these findings may suggest that while patients with bipolar disorder severe enough to require inpatient treatment are at greatest risk, individuals with the more common manic spectrum episodes in the community are also at increased risk of mortality. ” Ramsey CM, Spira AP, Mojtabai R, Eaton WW, Roth K, Lee HB. Lifetime manic spectrum episodes and all-cause mortality: 26-year follow-up of the NIMH Epidemiologic Catchment Area Study. J Affect Disord. 2013 Oct;151(1):337-42. doi: 10.1016/j.jad.2013.06.019. Epub 2013 Jul 5. PMID: 23835104; PMCID: PMC4073104.

Researcher have tested the effects of total sleep deprivation in rats and found that in comparison to the healthy control group rats, that all the sleep deprived rats died.

Ten rats were subjected to total sleep deprivation (TSD) by the disk apparatus. All TSD rats died or were sacrificed when death seemed imminent within 11-32 days. No anatomical cause of death was identified. All TSD rats showed a debilitated appearance, lesions on their tails and paws, and weight loss in spite of increased food intake.” Everson CA, Bergmann BM, Rechtschaffen A. Sleep deprivation in the rat: III. Total sleep deprivation. Sleep. 1989 Feb;12(1):13-21. doi: 10.1093/sleep/12.1.13. PMID: 2928622.

We forget that severe continuous sleep deprivation can be deadly, and as such, can surely cause chronic delirium. It definitely will cause neurological signs and symptoms.

Bishir M, Bhat A, Essa MM, Ekpo O, Ihunwo AO, Veeraraghavan VP, Mohan SK, Mahalakshmi AM, Ray B, Tuladhar S, Chang S, Chidambaram SB, Sakharkar MK, Guillemin GJ, Qoronfleh MW, Ojcius DM. Sleep Deprivation and Neurological Disorders. Biomed Res Int. 2020 Nov 23;2020:5764017. doi: 10.1155/2020/5764017. PMID: 33381558; PMCID: PMC7755475.

The results of Paula’s recent sleep study. show that Paula has moderate sleep apnea during sleep and that she is not aware of it. This is when Paula is well and feels her sleep to be undisturbed. I can only imagine what problems a sleep study will discover when she has a lot of interrupted sleep and is unwell with bipolar depression.

So to recap what we know so far [that neither Paula or her doctors were aware of , Paula has abnormal breathing during the daytime when she is awake and has abnormal breathing at night when she sleeps.

Well, it seems likely that Paula’s patterns of disturbed, breathing [day and night], is related to her bipolar depressive attacks and her bipolar illness in general.

Breathing, sleep and the function of the mind in sanity is certainly linked and poor breathing, poor sleep and insanity seem to go together.

Certainly, we think that it is time for this hypothesis to be tested in unmedicated bipolar depressive and manic patients.


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