Stable sleep patterns and regular routines may improve outcomes in bipolar disorder

Bipolar disorder, commonly known as manic-depressive disorder, is highly influenced by the circadian system - the body's internal clock - and a specific kind of psychotherapy may help decrease irregularities in the circadian system that can trigger key symptoms of bipolar disorder, according to a study presented at the American College of Neuropsychopharmacology (ACNP) annual meeting.

The results are important because they show for the first time that psychotherapy which focuses on practical lifestyle changes can ease the symptoms of bipolar disorder. Every year nearly six million American adults suffer from bipolar disorder, a brain disorder which causes severe shifts in mood, energy, and ability to function, according to the National Institute of Mental Health.

Maintaining a consistent sleep schedule and wake time can help balance the circadian system, which in turn can help people avoid nighttime sleeplessness or daytime exhaustion, which can increase the risk of new episodes of mania or depression. “Having already found that disruption in daily routines can make individuals with bipolar disorder vulnerable to new episodes of illness, we have now learned that working with patients to achieve and maintain regular social rhythms – including regular sleep patterns and adequate physical activity – will help to protect them against episodes of mania or depression,” says Ellen Frank, Ph.D., clinical psychologist and professor of psychiatry and psychology at the University of Pittsburgh School of Medicine.

People with bipolar disorder tend to have extremely sensitive circadian systems, which makes it much more difficult for them to recover from disruptions in sleep and routine. In contrast, people without bipolar disorder generally recover fairly quickly if their systems are thrown off by a change in routine or loss of sleep and might even be temporarily energized by these alterations.

Frank studied 175 adult patients with bipolar disorder and compared the effects of two approaches when combined with a common medical treatment for bipolar disorder, usually lithium carbonate: the first was interpersonal and social rhythm therapy, in which patients use a self-monitoring instrument to record and monitor the regularity of their daily routines—for example, their sleep patterns, meal times and physical activity. The second approach involved an intensive clinical management paradigm focusing just on patients' mood symptoms and management of medication side effects.

The study found that patients who participated in interpersonal and social rhythm therapy in the earlier phases of the trial were able to go longer without a new episode of mania or depression than those who received clinical management.

Frank notes that many study participants had other medical and psychiatric conditions that also had important effects on their treatment outcomes. She adds that her study was conducted in an academic environment using highly trained therapists, so results from other settings might be different.

In a related study presented at the meeting, researchers studying circadian rhythms in mice found that the genes that regulate these rhythms also control the activity of neurons in the brain that utilize dopamine, a neurotransmitter implicated in motivation and emotion. Mice that are lacking some of the key circadian genes closely resemble bipolar patients in the manic state.

Lead researcher Colleen McClung, Ph.D., assistant professor of psychiatry at the University of Texas Southwest Medical Center, says these mice are the most well characterized animal models of human mania that have been described. Symptoms of mania include increased energy, activity, and restlessness; excessively good, euphoric mood; and poor judgment.

While there has long been an association between circadian rhythms and bipolar disorder, no studies have examined whether these rhythmic disruptions contribute to the symptoms associated with bipolar disorder. McClung says the findings of this study bring researchers one small step closer to discovering why bipolar disorder occurs at all, even though the study was done in mice, not humans, and that many more studies will be needed to discover a cure.