Brief Sleep Intervention for Bipolar Disorder
Condition: Bipolar Disorder; Sleep Problems; Suicidal Thoughts
MeSH terms: Dyssomnias; Parasomnias; Bipolar Disorder; Suicidal Ideation
Study type: Interventional

Summary: 
      Individuals with bipolar disorder (BD) experience extreme mood swings, or episodes of
      depression and (hypo)mania. These episodes are associated with poor functioning, worse course
      of illness, and high rates of suicidality. It is estimated that between 25 to 65% of
      individuals with BD attempt suicide and 4 to 19% of individuals with BD eventually die by
      suicide. Sleep disturbance has been identified as a primary prodromal as well as causal
      symptom of mood episodes and recently, has been found to be associated with higher rates of
      suicidal ideation and behavior. Given the role that sleep may have in mood stability and
      suicidality in BD, it seems imperative to further understand the association of sleep and
      suicide and how sleep interventions may be useful to reduce suicidality in BD. Thus, the
      primary aim of this study is to use an innovative home sleep monitoring device, or the Embla,
      to examine the association of sleep and suicidality in adult outpatients with BD. The Embla
      is unique in that it is a non-invasive device that can characterize sleep profiles by
      measuring the degree of sleep fragmentation and percentage of rapid eye movement (REM) sleep.
      The study duration is five to six weeks such that patients wear the Embla device for Week 1,
      participate in a brief sleep intervention for suicide during Weeks 2 and 3, and 4, and then
      wear the Embla device for one more week (Week 5). This intervention consists of three, 60-min
      sessions and utilizes cognitive-behavioral therapy strategies (e.g., psychoeducation,
      cognitive re-structuring, problem solving, behavioral activation) to improve sleep
      disturbance. The investigators expect that individuals at study entry with more sleep
      disturbance (as measured by the Embla) will report more suicidal ideation and behaviors. The
      investigators also hypothesize that from pre- to post-intervention, individuals will report
      less sleep disturbance as well as suicidal ideation and behaviors. Data from this research
      has immediate and practical implications for providers and their patients as it the first
      examination of sleep phenotypes and suicide in a high risk population as well as to explore
      the association of improvements in sleep with suicidality.
    

Detailed description: 
      Bipolar disorder is characterized by episodes of depression as well as episodes of mania
      (abnormally high mood). Individuals with bipolar disorder experience high rates of suicidal
      ideation and behavior, with risk of death due to suicide estimated to be 20 times greater
      than the general population. Moreover, some research suggests that among individuals treated
      for bipolar disorder, approximately 40% will report a past suicide attempt. Other studies
      suggest that between 25 and 65% of patients with bipolar disorder will attempt suicide and
      that between 4 and 19% of these individuals will be successful. Among the DSM-IV-TR Axis I
      disorders, suicide appears to be the highest in bipolar disorder. Individuals with bipolar
      disorder have a greater likelihood of both current and past suicidal ideation if they have an
      anxiety disorder, have an earlier age of onset, or a more severe course of illness.
      Nevertheless, there is a continued need for information on the epidemiology and risk factors
      for suicidal ideation and behavior in this population.

      Several studies have shown that sleep difficulties (i.e., insomnia, hypersomnia, poor sleep
      quality, and nightmares) are significantly associated with suicidal ideation, even after
      controlling for depression. These disturbances are well documented during episodes of
      depression and mania, but sleep disturbances have also been shown to persist during periods
      of relative mood stability. A common symptom in bipolar patients experiencing manic episodes
      is a reduced need for sleep, and several studies using polysomnography have identified
      decreased REM sleep latency in manic episodes. Utilizing self-report measures, studies of
      bipolar patients in depressive episodes have identified variable rates of hypersomnia and
      insomnia as common factors. However, research conducted using laboratory-based
      polysomnography during depressive episodes have reported disparate findings.

      This proposal involves a test of a novel measure of sleep architecture in patients with
      bipolar disorder, using a newly available home sleep monitoring device called Embla
      (www.embla.com). This device sticks to the skin on the chest with standard EKG-adhesive
      stickers and captures electrocardiogram (EKG) during sleep. The Embla device also measures
      movement, snoring, body position, and light levels. The on-board storage allows 2-3 weeks of
      nightly recording. By using an unobtrusive and potentially informative measure of sleep
      architecture, this protocol will allow longitudinal, objective information about sleep
      disturbance to be compared with corresponding mood states in patients with bipolar disorder.

      Overall, this protocol is investigating the relationship between suicidality and sleep
      disturbance as well as assessing whether a brief CBT intervention for sleep disturbance is
      associated with reduced suicidal ideation and/or behavior. Since research suggests that CBT
      is an effective adjunct treatment for reducing suicidality in this population, and that
      treatment for insomnia can improve sleep in individuals with bipolar disorder, the present
      research has important implications for the prevention and intervention of suicide in this
      vulnerable population. To the investigators knowledge, no investigations have looked at the
      effectiveness of CBT on both sleep and suicidality in bipolar disorder. Furthermore, while
      past research has relied almost exclusively on subjective reports of sleep, this study
      captures both subjective and objective measures of sleep.
    

Intervention name(s): Brief Sleep Intervention
Intervention type(s): Behavioral
Intervention description(s): Participants will meet with a therapist for three sessions to try to improve sleep problems (hypersomnia or insomnia, depending on the problems the participant has).
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Bipolar Disorder; Sleep Intervention; Suicide; Cognitive Behavioral Therapy; Sleep Quality