Insomnia Increases Emotional Dysregulation, Impulsivity, and Suicidality in Bipolar Disorder

can't sleep, sitting on bed
can’t sleep, sitting on bed
Sleep has important functions for the regulation of mood and emotion, and treatment of sleep disturbances in bipolar disorder may improve patient outcomes.

Insomnia increases the risk for emotional dysregulation, impulsivity, and suicidality in patients with bipolar II disorder and depression with mixed features, according to the results of a study published in Comprehensive Psychiatry.

Insomnia is prevalent among those with bipolar disorder and is listed as a diagnostic criterion for mood disorders. Insomnia occurs during a depressive episode in 80% to 100% of individuals with bipolar disorder, whereas 30% to 35% experience insomnia during a manic episode, and 45% to 55% experience insomnia during the interepisodic period. It is believed that insomnia may contribute to exaggerated neural and behavioral reactions to experiences.

Laura Palagini, MD, PhD, of the Psychiatric Clinic, Department of Clinical and Experimental Medicine, University of Pisa, Italy, and colleagues recruited 77 participants diagnosed with bipolar disorder type II during a major depressive episode with mixed features. They used the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, the Insomnia Severity Index, the Difficulties in Emotion Regulation Scale, and the Scale for Suicide Ideation and to evaluate patients’ manic and depressive symptoms.

The investigators found that those with symptoms of insomnia had higher Difficulties in Emotion Regulation scale and subscale scores, including impulsivity, and also had higher scores on the Scale for Suicide Ideation scale than those without insomnia. The presence of insomnia increased the risk for more severe depressive symptoms, emotional dysregulation, and suicidality.

According to the authors, the results confirm that insomnia symptoms are an important feature of bipolar disorder and that symptoms of insomnia are associated with difficulties in acceptance of emotion, engaging in goal-directed behaviors, impulse control, and accessing effective regulatory strategies. The authors suggest that emotional dysregulation may regulate the relationship between symptoms of insomnia and the depressive symptoms and suicidality of bipolar disorder. Furthermore, they assert that sleep has important functions for the regulation of mood and emotion, and that treatment of sleep disturbances in bipolar disorder may improve patient outcomes.

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The authors noted several study limitations, including the lack of physiologic measures of insomnia and the cross-sectional design of the study.

The authors maintain that individuals with bipolar disorder should be evaluated for the presence of insomnia early in the course of the disease so that effective therapy can be initiated.


Palagini L, Cipollone G, Masci I, et al. Insomnia symptoms predict emotional dysregulation, impulsivity and suicidality in depressive bipolar II patients with mixed features. Compr Psychiatry. 2019;89:46-51.