BACKGROUND: Recurrent course and disruption of circadian rhythms are among the core features of bipolar disorder (BD). Thus, ongoing symptom monitoring is an essential part of good clinical management. OBJECTIVE: We conducted a study to validate the English version of the ASERT (Aktibipo questionnaire), a tool for self-assessment of mood symptoms. We also analyzed the relationship of self-assessed symptoms with clinician ratings and actigraphy measures, and investigated the possibility of predicting depressive episodes using subjective and digital measures. METHODS: This was a longitudinal study of twenty individuals with BD, followed for up to 11 months. The participants completed weekly mood self-assessments (ASERT) using a smartphone app and wore wrist actigraphs. During monthly appointments, the severity of their mood symptoms was rated by clinicians, and the participants completed questionnaires addressing overall functioning (FAST), and biological rhythms (BRIAN). RESULTS: The study confirmed the validity and reliability of the ASERT as a measure of subjective mood. Additionally, we found significant associations between ASERT responses, clinical scales, and actigraphy data (ASERT_dep vs. MADRS β = 1.42, p < 0.001, ASERT_man vs. YMRS β = 0.38, p < 0.001, mixed-effect model). In our analysis, a combination of self-assessment and actigraphy data detected depression relapse with 67% sensitivity, 90% specificity, 81% balanced accuracy, and AUC of 0.80. Furthermore, we observed a strong correlation between the actigraphy-derived interdaily stability and BRIAN scores (β=-3.86, p = 0.005) overall functioning, emphasizing the significance of circadian rhythm disruptions in BD. CONCLUSION: This study highlights the potential of digital tools, such as digitally administered self-assessments and actigraphy, to enhance the management of BD by providing valuable insights into mood states and detecting relapse. Further research is needed to refine and optimize these tools for widespread clinical application, such as informing personalized treatment plans.

Center for first episodes of SMI National Institute of Mental Health Klecany Czech Republic

Department of Psychiatry and Behavioural Neurosciences McMaster University Hamilton Canada

Department of Psychiatry Dalhousie University Halifax NS Canada

Department of Psychiatry Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil

Dept of Cybernetics Czech Technical University Prague Czech Republic

Mindpax Prague Czech Republic

National Institute of Science and Technology Translational Medicine Porto Alegre RS Brazil

Neuroscience Graduate Program Faculty of Health Sciences McMaster University Hamilton ON Canada

The Institute for Mental and Physical Health and Clinical Translation School of Medicine Deakin University Geelong Australia

Zobrazit více v PubMed

Merikangas KR, Jin R, He J-P, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011;68(3):241–51. 10.1001/archgenpsychiatry.2011.12. PubMed DOI PMC

Chung J, Kim Y-C, Jeong J-H. Bipolar disorder, circadian rhythm and clock genes. Clin Psychopharmacol Neurosci. 2024;22(2):211–21. 10.9758/cpn.23.1093. PubMed DOI PMC

Ketchesin KD, Becker-Krail D, McClung CA. Mood‐related central and peripheral clocks. Eur J Neurosci. 2020;51(1):326–45. 10.1111/ejn.14253. PubMed DOI PMC

Gottlieb JF, Benedetti F, Geoffroy PA, et al. The chronotherapeutic treatment of bipolar disorders: a systematic review and practice recommendations from the ISBD task force on chronotherapy and chronobiology. Bipolar Disord. 2019;21(8):741–73. 10.1111/bdi.12847. PubMed DOI

de Aguiar KR, Cabelleira MD, Montezano BB, Jansen K, de Azevedo Cardoso T. Sleep alterations as a predictor of bipolar disorder among offspring of parents with bipolar disorder: a systematic review and meta-analysis. Trends Psychiatry Psychother. 2021;43(4):256–69. 10.47626/2237-6089-2021-0256. PubMed DOI PMC

Duarte Faria A, De Azevedo Cardoso T, Campos Mondin T, et al. Biological rhythms in bipolar and depressive disorders: A community study with drug-naïve young adults. J Affect Disord. 2015;186:145–8. 10.1016/j.jad.2015.07.004. PubMed DOI

Alloy LB, Ng TH, Titone MK, Boland EM. Circadian rhythm dysregulation in bipolar spectrum disorders. Curr Psychiatry Rep. 2017;19(4):21. 10.1007/s11920-017-0772-z. PubMed DOI PMC

Gold A, Sylvia L. The role of sleep in bipolar disorder. Nat Sci Sleep. 2016;8:207–14. 10.2147/NSS.S85754. PubMed DOI PMC

Harvey AG, Schmidt DA, Scarnà A, Semler CN, Goodwin GM. Sleep-related functioning in euthymic patients with bipolar disorder, patients with insomnia, and subjects without sleep problems. Am J Psychiatry. 2005;162(1):50–7. 10.1176/appi.ajp.162.1.50. PubMed DOI

Geoffroy PA, Scott J, Boudebesse C, et al. Sleep in patients with remitted bipolar disorders: a meta-analysis of actigraphy studies. Acta Psychiatr Scand. 2015;131(2):89–99. 10.1111/acps.12367. PubMed DOI

Esaki Y, Obayashi K, Saeki K, Fujita K, Iwata N, Kitajima T. Association between circadian activity rhythms and mood episode relapse in bipolar disorder: a 12-month prospective cohort study. Transl Psychiatry. 2021;11(1):525. 10.1038/s41398-021-01652-9. PubMed DOI PMC

Merikangas KR, Swendsen J, Hickie IB, et al. Real-time mobile monitoring of the dynamic associations among motor activity, energy, mood, and sleep in adults with bipolar disorder. JAMA Psychiatr. 2019;76(2):190–8. 10.1001/jamapsychiatry.2018.3546. PubMed DOI PMC

Goulding EH, Dopke CA, Rossom R, Jonathan G, Mohr D, Kwasny MJ. Effects of a smartphone-based self-management intervention for individuals with bipolar disorder on relapse, symptom burden, and quality of life. JAMA Psychiatr. 2023;80(2):109. 10.1001/jamapsychiatry.2022.4304. PubMed DOI PMC

Goulding EH, Dopke CA, Michaels T, et al. A smartphone-based self-management intervention for individuals with bipolar disorder (LiveWell): protocol development for an expert system to provide adaptive user feedback. JMIR Form Res. 2021;5(12):e32932. 10.2196/32932. PubMed DOI PMC

Li H, Mukherjee D, Krishnamurthy VB, et al. Use of ecological momentary assessment to detect variability in mood, sleep and stress in bipolar disorder. BMC Res Notes. 2019;12(1):791. 10.1186/s13104-019-4834-7. PubMed DOI PMC

Patapoff M, Ramsey M, Titone M, et al. Temporal relationships of ecological momentary mood and actigraphy-based sleep measures in bipolar disorder. J Psychiatr Res. 2022;150:257–63. 10.1016/j.jpsychires.2022.03.055. PubMed DOI PMC

Esaki Y, Obayashi K, Saeki K, Fujita K, Iwata N, Kitajima T. Circadian variability of objective sleep measures predicts the relapse of a mood episode in bipolar disorder: findings from the < scp > APPLE cohort. Psychiatry Clin Neurosci. 2023;77(8):442–8. 10.1111/pcn.13556. PubMed DOI

Hett D, Morales-Muñoz I, Durdurak BB, Carlish M, Marwaha S. Rates and associations of relapse over 5 years of 2649 people with bipolar disorder: a retrospective UK cohort study. Int J Bipolar Disord. 2023;11(1):23. 10.1186/s40345-023-00302-x. PubMed DOI PMC

Vázquez GH, Holtzman JN, Lolich M, Ketter TA, Baldessarini RJ. Recurrence rates in bipolar disorder: systematic comparison of long-term prospective, naturalistic studies versus randomized controlled trials. Eur Neuropsychopharmacol. 2015;25(10):1501–12. 10.1016/j.euroneuro.2015.07.013. PubMed DOI

Anýž J, Bakštein E, Dally A, et al. Validity of the Aktibipo self-rating questionnaire for the digital self-assessment of mood and relapse detection in patients with bipolar disorder: instrument validation study. JMIR Ment Health. 2021;8(8):e26348. 10.2196/26348. PubMed DOI PMC

Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134(4):382–9. 10.1192/bjp.134.4.382. PubMed DOI

Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry. 1978;133(5):429–35. 10.1192/bjp.133.5.429. PubMed DOI

Rosa AR, Sánchez-Moreno J, Martínez-Aran A, et al. Validity and reliability of the functioning assessment short test (FAST) in bipolar disorder. Clin Pract Epidemiol Ment Health. 2007;3(1):5. 10.1186/1745-0179-3-5. PubMed DOI PMC

Giglio LMF, Magalhães PV, da Andreazza S. Development and use of a biological rhythm interview. J Affect Disord. 2009;118(1–3):161–5. 10.1016/j.jad.2009.01.018. PubMed

The MathWorks Inc. (2022). MATLAB version: 9.13.0 (R2022b), Natick, Massachusetts: The MathWorks Inc. https://www.mathworks.com

Schneider J, Bakštein E, Kolenič M, et al. Motor activity patterns can distinguish between interepisode bipolar disorder patients and healthy controls. CNS Spectr. 2022;27(1):82–92. 10.1017/S1092852920001777. PubMed DOI

Salvatore P, Ghidini S, Zita G, et al. Circadian activity rhythm abnormalities in ill and recovered bipolar I disorder patients. Bipolar Disord. 2008;10(2):256–65. 10.1111/j.1399-5618.2007.00505.x. PubMed DOI

St-Amand J, Provencher MD, Bélanger L, Morin CM. Sleep disturbances in bipolar disorder during remission. J Affect Disord. 2013;146(1):112–9. 10.1016/j.jad.2012.05.057. PubMed DOI

Schneider J, Fárková E, Bakštein E. Human chronotype: comparison of questionnaires and wrist-worn actigraphy. Chronobiol Int. 2021;39(02):205–20. 10.1080/07420528.2021.1992418. PubMed DOI

Gonçalves BSBB, Adamowicz T, Louzada FM, Moreno CR, Araujo JF. A fresh look at the use of nonparametric analysis in actimetry. Sleep Med Rev. 2015;20:84–91. 10.1016/j.smrv.2014.06.002. PubMed DOI

Gonçalves BSB, Cavalcanti PRA, Tavares GR, Campos TF, Araujo JF. Nonparametric methods in actigraphy: an update. Sleep Sci. 2014;7(3):158–64. 10.1016/j.slsci.2014.09.013. PubMed DOI PMC

R Core Team. 2023 R: A language and environment for statistical computing. R foundation for statistical computing. https://www.R-project.org/

Bates D, Mächler M, Bolker BM, Walker SC. Fitting linear mixed-effects models using lme4. J Stat Softw. 2015;67(1):1–48. 10.18637/jss.v067.i01. DOI

Luke SG. Evaluating significance in linear mixed-effects models. Behav Res Methods. 2017;49(4):1494–502. 10.3758/s13428-016-0809-y. PubMed DOI

Kuznetsova A, Brockhoff PB, Christensen RHB. LmerTest package: tests in linear mixed effects models. J Stat Softw. 2017;82(13):1–26. 10.18637/jss.v082.i13. DOI

Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16(3):297–334. 10.1007/BF02310555. DOI

Tohen M, Frank E, Bowden CL, et al. The international society for bipolar disorders (ISBD) task force report on the nomenclature of course and outcome in bipolar disorders. Bipolar Disord. 2009;11(5):453–73. 10.1111/j.1399-5618.2009.00726.x. PubMed DOI

Bair E, Hastie T, Paul D, Tibshirani R. Prediction by supervised principal components. J Am Stat Assoc. 2006;101(473):119–37. 10.1198/016214505000000628. DOI

Pinho M, Sehmbi M, Cudney LE, et al. The association between biological rhythms, depression, and functioning in bipolar disorder: a large multi-center study. Acta Psychiatr Scand. 2016;133(2):102–8. 10.1111/acps.12442. PubMed DOI

Giglio LM, Magalhães PVS, Kapczinski NS, Walz JC, Kapczinski F. Functional impact of biological rhythm disturbance in bipolar disorder. J Psychiatr Res. 2010;44(4):220–3. 10.1016/j.jpsychires.2009.08.003. PubMed DOI

Cudney LE, Frey BN, Streiner DL, Minuzzi L, Sassi RB. Biological rhythms are independently associated with quality of life in bipolar disorder. Int J Bipolar Disord. 2016;4(1):9. 10.1186/s40345-016-0050-8. PubMed DOI PMC

Allega OR, Leng X, Vaccarino A, et al. Performance of the biological rhythms interview for assessment in neuropsychiatry: an item response theory and actigraphy analysis. J Affect Disord. 2018;225(July 2017):54–63. 10.1016/j.jad.2017.07.047. PubMed DOI

Slyepchenko A, Allega OR, Leng X, et al. Association of functioning and quality of life with objective and subjective measures of sleep and biological rhythms in major depressive and bipolar disorder. Aust N Z J Psychiatry. 2019;53(7):683–96. 10.1177/0004867419829228. PubMed DOI

Bauer M, Grof P, Rasgon N, Bschor T, Glenn T, Whybrow PC. Temporal relation between sleep and mood in patients with bipolar disorder. Bipolar Disord. 2006;8(2):160–7. 10.1111/j.1399-5618.2006.00294.x. PubMed DOI

Ng THTK, Chung KF, Ng THTK, Lee CT, Chan MS. Correlates and prognostic relevance of sleep irregularity in inter-episode bipolar disorder. Compr Psychiatry. 2016;69:155–62. 10.1016/j.comppsych.2016.05.016. PubMed DOI

Takaesu Y, Inoue Y, Ono K, et al., et al. Circadian rhythm sleep-wake disorders predict shorter time to relapse of mood episodes in euthymic patients with bipolar disorder: a prospective 48-week study. Sleep Med. 2017;40(2017):e324. 10.1016/j.sleep.2017.11.951. PubMed DOI

Gershon A, Do D, Satyanarayana S, et al. Abnormal sleep duration associated with hastened depressive recurrence in bipolar disorder. J Affect Disord. 2017;218(1):374–9. 10.1016/j.jad.2017.05.015. PubMed DOI PMC

Monti JM. The effect of second-generation antipsychotic drugs on sleep parameters in patients with unipolar or bipolar disorder. Sleep Med. 2016;23:89–96. 10.1016/j.sleep.2016.04.020. PubMed DOI

Hwang JY, Choi JW, Kang SG, Hwang SH, Kim SJ, Lee YJ. Comparison of the effects of quetiapine XR and lithium monotherapy on actigraphy-measured circadian parameters in patients with bipolar II depression. J Clin Psychopharmacol. 2017;37(3):351–4. 10.1097/JCP.0000000000000699. PubMed DOI

Hossain S, Mainali P, Bhimanadham NN, Imran S, Ahmad N, Patel RS. Medical and psychiatric comorbidities in bipolar disorder: insights from National inpatient Population-based study. Cureus. 2019;11(9). 10.7759/cureus.5636. PubMed PMC