Transdiagnostic Approach May Benefit Patients With Sleep, Mood Disorders

Focusing on commonalities across mental illnesses can hasten the application of advances made in one disorder to others, Allison G. Harvey, Ph.D., said at the 2021 virtual annual meeting of the Associated Professional Sleep Societies.

Comorbidity among mental illnesses is the norm, not the exception, said Harvey, a professor of psychology and director of the Golden Bear Sleep and Mood Research Clinic at the University of California, Berkeley.

Sleep and circadian disturbances commonly accompany mental illnesses, which affect 27% of the U.S. population each year, said Harvey. She received the Sleep Research Society’s 2021 Distinguished Scientist Award at the meeting for her career contributions to sleep and circadian science.

People with bipolar disorder, for example, typically alternate between mania and depression. Sleep disturbance is the most common prodrome of mania and the sixth most common prodrome of depression. Sleep loss is highly correlated with daily manic symptoms and negative affect, Harvey said.

Sleep and circadian disturbances contribute to interepisode dysfunction and foster difficulty regulating mood, she said, adding, “This vicious bidirectional cycle may confer a vulnerability to relapse.”

Harvey’s group found variability in sleep and wake times of about three hours over the week in their secondary analysis of data from 2,024 individuals diagnosed with bipolar disorder enrolled in a federally funded treatment study. These patients experienced a shift comparable to flying coast to coast across the United States and back again every week, Harvey said.

People with bipolar disorder often had not only insomnia but also hypersomnia, short sleep, irregular bed and wake times, nightmares, nocturnal panic attacks, posttraumatic stress disorder, and/or long sleep inertia (long-lasting fogginess after awakening). The same problems affect people with anxiety, schizophrenia, and other mental illnesses, Harvey said, but often get little attention.

Research on specific mental disorders has advanced the understanding of their etiology and persistence, as well as the ability to treat them, Harvey said. Hundreds of treatments for mental illnesses now exist, she said.

This abundance puts a burden on clinicians in routine practice settings, such as community mental health centers, she said, as it requires them to learn multiple disorder-focused protocols with common theoretical underpinnings. There would be a substantial cost advantage to training psychiatrists and other health professionals in one treatment tactic they could adapt to treat patients with multiple sleep and circadian disorders and diverse mental illnesses. Harvey and colleagues call this transdiagnostic approach for sleep and circadian disorders TranS-C.

Harvey’s group received a grant from the National Institute of Mental Health for a pilot study using cognitive-behavioral therapy for insomnia (CBT-I) adapted for patients with both bipolar disorder and sleep or circadian disorders, including insomnia, hypersomnia, and delayed sleep phase disorder. The participants, all adults, continued to receive treatment as usual, that is, mood stabilizing medications prescribed by a psychiatrist.

The researchers randomized patients to receive eight sessions of either the CBT-I modification (n=30) or psychoeducation (n=28). Patients in the CBT-I group learned, for example, why they should be exposed to light at certain times of day and avoid it at others, why and how to regularize daily schedules, how to get going in the morning, and how to reduce sleep-related worries. Those in the psychoeducation group received information on sleep, stress, mood, diet, yoga, meditation, and other health topics, but they were not asked to change their behavior or given instruction in any techniques.

While sleep improved in both groups, it improved more in patients receiving CBT-I. At six-month follow-up, patients who had received CBT-I showed greater improvement in mood than those in the control group. They had lower relapse rates and spent fewer days in manic or hypomanic episodes.

This and further studies suggest psychiatrists can apply TranS-C principles successfully in outpatient settings, including community mental health centers, to help patients with different mental illnesses, Harvey told Psychiatric News. ■

“Implementing a Transdiagnostic Sleep and Circadian Intervention in a Community Mental Health Setting: A Qualitative Process Evaluation With Community Stakeholders” is posted here.