Can sleep and activity changes really predict mania in bipolar disorder?
Bipolar disorder is characterized by recurrent episodes of mania and depression. Mania is a defining characteristic of bipolar disorder. The core symptoms of mania are unusual, persistent elation, emotional and energy euphoria, as well as further symptoms, including symptoms of increasing self-esteem and grandeur, reducing sleep needs, and more, having many thoughts and racing thoughts, prone to distractions, over-distractions, and over-engagement in goal guidance and/or potential adventures. The symptoms of mania are similar, but their severe effects are not large compared to at least seven mania and last no more than four days.
Emotional episodes don’t come from anywhere, but we don’t fully understand how we predict them to support people quickly and effectively. In between episodes, there are still climaxes and lows, mood, energy and other symptoms, including sleep. The tipping points of these changes suggest that seizures are an important area of research, as early warning signs are part of bipolar affective therapy. Instability in sleep and activity is a key trigger and early warning signal (Lobban et al., 2011), making it an important target for treatment (Harvey et al., 2015).
Wearable technology is increasingly used to track risk factors and symptoms in people with mental health difficulties. These are less invasive and can improve lifestyle behaviors, like the blog here before.
A recent paper (Ortiz et al., 2025) examines whether changes in digital monitoring of sleep and activity are early indicators of mania, the earliest indicator.
Instability in sleep and activity is a key trigger and early warning signal for bipolar disorder.
method
164 people seeking treatment for bipolar disorder I or II received a year of attention within one year. They rate their moods using self-report measures of manic and depressive symptoms weekly. This also allows to assess whether participants meet clinically significant manic attack criteria at any time in the study. The wearable device (OURA ring) automatically records sleep and activities in daily life. This includes how you sleep, how long you sleep, how long you need to fall asleep, and the energy you use.
The OURA ring (wearing device) records a year of sleep and activity.
result
- In the year of study, 50 participants experienced a manic episode at some point.
- The sleep variability with a 12-hour change is the strongest detector in manic episodes.
- Changes in activity are the earliest indicators of activity when observing specific manic symptoms (e.g., “I’m often more active than usual” or “I’m always active or always active.”)
- Changes in daily sleep variability performed well in predicting manic symptoms of reduced sleep demand. These changes can predict the onset of mania, up to three days.
- With the time range of variability, changes in sleep sensitivity and activity decrease in predicting subsequent mania (e.g., time over 12 hours is better than 12 hours than a week).
The sleep variability with a 12-hour change is the strongest detector in manic episodes.
in conclusion
Sleep and activity changes are approximately three days before the second manic episode, so early indicators of monitoring in patients with bipolar disorder can be used. The transition to emotional plots can happen soon, so fine-grained tracking of sleep, activity, and emotions is worth it.
Advantages and limitations
This study aims to address the limitations of previous studies by tracking sleep and activity using novel wearable devices. One year is a long time, so it’s nice to see this study lasting so long. It is unusual to obtain data on sleep and activity and emotional self-assessment over that duration. A mix of subjective data (participants completed their own measurements) and objective data (from wearable devices).
Over time, there are many data points and data points to identify trends and patterns. Data for variability are explored, rather than absolute variation or average scores. This provides more fine-grained information, more like things in the real world.
Measures of (low-key) manic symptoms used to monitor symptoms and identify manic episodes are widely used in research and clinical settings, meaning that other studies can be compared and have real-world applicability.
Patients with sleep disorders are eligible to participate in this study to participate from sleep mode, but sleep instability in patients with sleep disorders may be more likely. However, comorbidities are not evaluated or controlled, which are the norm for bipolar disorder, not exceptions, so this may create a more realistic situation.
The authors point out that not controlling for demographic context is a limitation. There is always bias in research, for example, a specific person may decide to attend a different person than someone who refuses to attend or does not hear about the opportunity to do so. Not controlling for demographics can make it difficult to say what the impact may have. The sample was mainly in work or research and was well educated. This is not uncommon for bipolar disorder, but the sample may be considered particularly “high-function”. Since the current sample is currently seeking treatment, as well as in work or education, there may not be people representing more social exclusion. Furthermore, wearable devices involve digital participation, and the device is also evident. If people ask why they should wear stigma, they may be delayed due to concerns about stigma.
There is always emotional self-report bias, and there is some evidence that people with bipolar disorder have found specific measures of manic symptoms that are difficult to monitor for emotion, rather than creating their own problems as reported in this blog. Although remote emotional monitoring shows hope, everyone may not be able to accept: “People with bipolar disorder track symptoms of mood swings more specifically and creatively than traditional mood monitoring tables.” For some people with bipolar disorder (Palmier-Claus et al., 2021), mood monitoring can also be helpful, so it will be more interesting to learn more about participants’ feelings about self-monitoring for a year. Could this be a fear of relapse or feeling of over-maintenance, or is it found helpful?
With the current data, I wonder why emotional variability is not considered, as emotional instability between emotional attacks can also affect daily operations. With weekly ratings, this is possible. Symptoms other than changes in sleep or activity may also be early indicators of recurrence into a secondary attack. An ecological instantaneous assessment of emotions can be built into a method to supplement fine-grained data on sleep and activity, although it will create more burdens on participants’ participation in digital technology.
Self-report of emotions is often associated with bias.
Impact on practice
Wearable devices such as OURA rings can be useful for sharing with mental health professionals and self-monitoring in daily life. Therefore, given the signs that sleep and activity are early warning signs, this may be a very useful clinical tool.
Although self-reports are only biased for emotional bias, this approach will not achieve real-world applicability, as clinician ratings are impossible. The platform used to collect this data can be related to mental health professionals.
However, this approach must be treated with caution (Depp et al., 2016). People wearing this information must be provided to help them explain early warnings and, crucially, know what to do, i.e. coping strategies. As mentioned above, the same is true for mood monitoring (Palmier-Claus et al., 2021). These approaches can be embedded in existing psychological interventions that focus on early warning signals in which clinicians will be supported and guided on how to interpret and cope with changes in mood and activity (Palmier-Claus et al., 2021).
There are also ethical issues surrounding remote monitoring and where information goes and how mental health professionals and services are used. In addition to further the work of studying its effectiveness in monitoring changes, this may be an early warning sign of emotional episodes, and it also requires access to the perspective of the person surrounding the disorder and the ability to wear equipment such as OURA rings and emotions among the disorder and promoters, and it is possible to share this with the mental health experts involved in the mental health professionals involved.
Emotional monitoring can be incorporated into clinical care and guided under the guidance of how to interpret and cope with changes in mood and activity
Link
Main paper
Ortiz, A., Halabi, R., Alda, M., Burgos, A., Deshaw, A., Gonzalez-Torres, C. Daily variability in sleep and activity predicts the onset of manic episodes in patients with bipolar disorder. Emotional Disorders Magazine,,,,, 37475-83.
Other references
Depp, C. , Tour, J. and Thompson, W. (2016). Technology-based early warning system for bipolar disorder: a conceptual framework. JMIR Mental Health,,,,, 3(3), E5798.
Harvey, AG, Kaplan, KA and Soehner, A. (2015). Interventions on sleep disorders in bipolar disorder. Sleep Medicine Clinic,,,,, 10(1), 101.
Levrat, V., Favre, S. and Richard-Lepouriel, H. (2024). Current Practice of Psychological Educational Interventions with Bipolar Disease: A Literature Review. Field of Psychiatry,,,,, 141320654.
Lobban, F., Solis-Trapala, I., Symes, W., Morriss, R. and ERP Group. (2011). The list of early warning signs is a list of recurrences in bipolar depression and mania: practicality, reliability and effectiveness. Emotional Disorders Magazine,,,,, 133(3), 413-422.
Palmier-Claus, J., Lobban, F., Mansell, W., Jones, S., Tyler, E., Lodge, C. ,…&Wright, K. (2021). Emotional Monitoring for Bipolar Disorder: Is it always helpful? Bipolar disorder, 23(4), 429-231.
