Research reportThe effect of poor sleep quality on mood outcome differs between men and women: A longitudinal study of bipolar disorder
Introduction
Bipolar disorder (BD) is a recurrent, disabling illness. Though BD is an episodic illness, individuals with BD suffer from depressive symptoms up to 32% of the time, and manic symptoms about 9% of the time (Judd et al., 2002). Subsyndromal and mixed symptoms are prevalent, and contribute to restricting the effort of individuals with BD to achieve life goals in areas such as education, occupation, and personal relationships (Judd et al., 2005).
Poor sleep quality is a state marker and symptom of depressive and manic episodes (Goodwin and Jamison, 2007). Lack of sleep can incite mania, and sleep deprivation has been shown since the 1970s to treat depressions (Wu and Bunney, 1990, Jackson et al., 2003), especially in bipolar disorder (Barbini et al., 1998, Colombo et al., 1999). Insomnia and poor sleep quality has been linked to worse symptom severity and poor outcome in bipolar disorder (Wu and Bunney, 1990, Colombo et al., 1999, Bauer et al., 2006, Perlman et al., 2006, Gruber et al., 2009, Gruber et al., 2011). Also, sleep-disordered breathing, primary insomnia and sleep phase disorders are often comorbid with bipolar disorder, begging the question of these pathologies being related to the underlying mood pathology (Kripke et al., 1978, Wehr, 1992, Harvey, 2008, Soehner et al., 2013, Naqvi et al., 2014).
Rates and phenotypes of mood disorders differ between men and women. Women of reproductive age were more prone to depression in the Stanley Foundation bipolar disorder cohort (Altshuler et al., 2010), but not in the STEP-BD study (Baldassano et al., 2005). In addition, the comorbidity of BD with illnesses that present with gender differences (including anxiety disorders (Baldassano et al., 2005, Baldassano, 2006, Altshuler et al., 2010, Saunders et al., 2012), migraine (Fasmer, 2001, Low et al., 2007, Baptista et al., 2012, Saunders et al., 2014), and eating disorders (Baldassano et al., 2005; Baldassano, 2006; Jen et al., 2013)) has been shown to cause more depression and worse course of illness in BD. Women in the general population report more insomnia than men during the reproductive years at a ratio of 1.4:1.0, (Ohayon, 2002, Zhang and Wing, 2006, Phillips et al.,, Fernandez-Mendoza et al., 2012, Singareddy et al., 2012, Vgontzas et al., 2012), and persistence of insomnia has been associated with depressive disorders, as well as sleep misperception (Fernandez-Mendoza et al., 2011, Fernandez-Mendoza et al., 2012).
Sleep and gender are both important factors in influencing course of illness in bipolar disorder (Baldassano, 2006, Gruber et al., 2009, Eidelman et al., 2010, Gruber et al., 2011, Saunders et al., 2012, Saunders et al., 2014). Women in the general population have more insomnia than men and women are also more prone to mood disorders and different courses of illness in BD. We investigated the relationship between perceived sleep quality and mood outcome in a cohort of patients with BD that were deeply-phenotyped and followed prospectively for two years. We hypothesized women would be more sensitive to the effect of poor sleep quality on mood outcome, and that sleep would differentially affect mood outcome in men and women with bipolar disorder.
Section snippets
Participants
The Prechter Longitudinal Study of Bipolar Disorder at the University of Michigan (UM) is an IRB approved observational study of outcomes in bipolar disorder (IRBMED HUM000606). Participants in the Prechter Longitudinal Study were evaluated initially for a baseline and study intake assessment described below and followed long-term with self-reported questionnaires and yearly visits. Patients with BD (bipolar disorder type I, bipolar disorder type II, schizoaffective disorder, bipolar type or
Demographic description of the sample (Table 1)
We followed 216 individuals with BD for 2 years. The majority of the patients were female (152/216, 70%), the average age was 40 years old with a BMI of 29. Age and BMI did not differ between males and females. The majority of both men and women had BPI disorder and were Caucasian. The rates of marriage differed between men and women. About one-quarter of the women had undergone menopause. During the two-year follow-up period, women had greater severity and frequency of depression, and severity
Discussion
We found that poor sleep quality at baseline prospectively predicted poor mood outcome in bipolar disorder above and beyond baseline depression in women, but not in men. Women had increased depression severity and frequency, increased mania severity and variability, and increased frequency of mixed episodes if, at the intake baseline, sleep was of poor quality. Why would we see an effect of sex in the relationship of quality of sleep to outcome in bipolar disorder? Sleep abnormalities have been
Conclusion
Sleep quality differentially affected mood outcome in bipolar disorder by sex. Baseline sleep quality predicted worse mood outcome in women. These data suggest that particular attention to sleep quality in BD women during clinical treatment would be beneficial. Subjective and biological factors may be involved, and further studies of the hormonal influence on the sleep-wake cycle may elucidate the relationship between sex differences in sleep and mood in BD.
Author access to data
The Heinz C. Prechter Bipolar Research Fund supported the collection of the data for the Prechter Longitudinal Study of Bipolar Disorder and the Prechter Bipolar Genetic Repository. The data reside at the University of Michigan, and can be requested through inquiries addressed to Dr. Melvin G. McInnis, MD, Department of Psychiatry, University of Michigan School of Medicine, Ann Arbor, MI, 48109.
Conflict of interest
Disclaimer: E. Saunders –Projects in Knowledge CME (consultant); M. McInnis – Merck Pharmaceuticals (Honoraria for Speaker׳s bureau); M Kamali has received research grant support from Janssen Pharmaceutical and Assurex Health.
Sources of funding
We would like to thank Mrs. Heinz C. Prechter and the Prechter Bipolar Research Fund for generously supporting this research. In addition, EFHS was supported by the National Center for Research Resources, GrantKL2 RR033180, and is now at the National Center for Advancing Translational Sciences, Grant KL2 TR000126. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Role of funders
The sponsors of this research did not have direct influence over the collection, analysis or interpretation of data.
Prior presentation of data
These data have not been presented elsewhere.
Acknowledgments
We would like to thank the participants of the Prechter Bipolar Research Studies for dedicating time and effort to the study of bipolar disorder, and the dedicated research team of the Prechter Bipolar Group for support for this work.
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