The role of sleep in bipolar disorder

Sleep disturbances are highly prevalent among bipolar patients and exert a detrimental impact on course of illness, self-reported quality of life, functioning, symptom burden, and overall treatment outcomes.9–11 Sleep disturbances are often highly comorbid with other psychiatric conditions and maladaptive health behaviors such as substance-use disorders,12 anxiety disorders,13 increased weight and obesity, and lack of physical activity.12 Such sleep disturbances occur across all stages of the illness such as directly preceding a mood episode and during an acute mood episode (eg, a depressive, manic, or mixed episode). Further, sleep disturbances are not unique to symptomatic bipolar patients; studies have noted the presence of sleep problems in euthymic (or remitted) bipolar patients,9,14 highlighting the importance of sleep as a treatment target throughout all stages of the bipolar illness.

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The high rates of sleep disturbance in individuals with bipolar disorder, its pervading presence across the subtypes and stages of this condition, and its deleterious impact on its course raise an important question: Why does sleep seem to be at the root of bipolar disorder? If we could answer this question, it may lead to answers in how to treat this complex and chronic condition more effectively. To that end, this manuscript investigates the mechanisms and pathways contributing to sleep disturbances in bipolar patients. Broadly, individuals with bipolar disorder may possess a certain genetic predisposition for sleep problems; this predisposition may subsequently contribute to an abnormal shift or dysregulation within the bipolar individual’s circadian rhythm systems.9,20,21 This manuscript will examine the factors influencing sleep disturbances in bipolar disorder, biomarkers of sleep disturbances across various bipolar episodes, and the role of sleep disturbances in bipolar episode relapse.


[...] Given the impact of sleep disturbances on bipolar disorder, future research would benefit from examining novel psychosocial, pharmacological, and technological strategies to improve sleep. Zachariae et al86 conducted a meta-analysis of Internet-delivered cognitive behavioral therapy for insomnia (eCBT-I) with findings indicating that eCBT-I was effective in improving self-reported sleep quality, sleep onset latency, sleep efficiency, and total sleep time among individuals with insomnia or self-reported sleep problems.86 An eCBT-I approach warrants further attention in a bipolar sample. Harvey et al11 developed a cognitive behavioral therapy for insomnia specific to bipolar disorder and compared this intervention to a psychoeducational control group. They found that cognitive behavioral therapy for insomnia specific to bipolar disorder lowered overall rate of mood episode relapse, rate of hypomania/mania relapse, days in a bipolar episode, and lowered insomnia severity compared to the control group.11