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Research shows that a combination of sleep knowledge and education about sleep can have a substantial impact on a person’s sleep habits. An often underrecognized fact is that healthy sleep habits are not intuitive, and attitudes about sleep vary widely. Inconsistent sleep schedules, sacrificing sleep, poorly timed naps, and use of electronics before sleep are all common habits among individuals of all ages, including those with and without sleep disorders. These habits can lead to consequences like behavioral and emotional issues, even among individuals who do not fit the criteria for a psychiatric diagnosis.

For example, a study assessing parental practices among parents whose children were enrolled in an early child education program showed that 81% of the parents surveyed believed that their children had healthy sleep habits, yet 50% and 33% of the children had unhealthy bedtime practices and insufficient sleep that were not recognized as such by their parents.

 These habits may lead to lifelong sleep problems if parents and children are not provided with the correct information about the importance of sleep and instructed about safe and effective ways to improve sleep quality and quantity.

Older adults often have sleep practices that can be detrimental to emotional and health as well. A large study that included 2312 participants aged 65 and older showed a high prevalence of insufficient sleep that was found to be associated with a sedentary lifestyle and an overall lack of physical activity.

Sleep knowledge and attitudes include several different components. One study conducted at the Department of Psychological Science at the University of North Carolina at Charlotte defined 3 separate components of sleep attitudes:

1) A cognitive component includes a person’s beliefs about the importance and necessity of adequate sleep.

2) An emotional component involves having a positive evaluation of the necessity of sleep.

3) A behavioral component involves taking action to make time for sleep in a person’s schedule.

The study found that participants who reported positive attitudes about sleep also experienced longer sleep duration, better sleep quality, and better sleep hygiene.

 Of these 3 interrelated components, it is the behavioral that has the most definitive impact, as it is a necessary factor in actually achieving adequate sleep. However, most individuals would not take the steps to incorporate the behavioral component in the absence of the cognitive and emotional components, so they are all key factors.

Another study used objective measures tracked by a Fitbit Flex accelerometer for 7 days to assess sleep among a group of 218 college students. Interestingly, while the study also showed that sleep attitudes were directly associated with longer sleep duration and better sleep quality, the researchers found that greater sleep knowledge did not correlate with these outcomes.

 These results suggest that a fundamental comprehension about the benefits of sleep and a baseline knowledge of the effective ways to attain good sleep are not enough to impact a person’s daily sleep habits and sleep outcomes. It appears that the attitudes a person has about sleep play a far greater role than pure knowledge when it comes to influencing behavior.

Of course, a positive attitude about sleep must be paired with accurate knowledge, as even the most well-intentioned patient can potentially attempt to use methods for sleep that are not beneficial. These can include drinking alcohol before bed, which many believe promotes healthy sleep, but can reduce the quality of a person’s sleep. For individuals who do not have sleep problems, interventions to improve sleep can include a variety of strategies, including stress management, relaxation, stimulus control, sleep hygiene, and exercise.

It is not uncommon for people to underestimate the importance of sleep and its impact on health. For instance, workaholism and competitive sleep deprivation are common among highly productive individuals—even health professionals. The outcomes can lead to interpersonal relationship difficulties, and in some instances, may lead to a referral for a psychiatric or psychological evaluation.

Physicians can help promote accurate sleep knowledge and healthy sleep attitudes for patients. Cognitive and behavioral interventions have been shown to have a positive impact on sleep,

 and these interventions can have lasting effects once patients experience an improved quality of life with less daytime fatigue, improved mood, and better productivity after adopting them.

; clinical assistant professor, Case Western Reserve University School of Medicine, Division of Medical Education; and editor in chief emeritus of 

Sleep health literacy in head start families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep

2. Ortolá R, García-Esquinas E, Cabanas-Sánchez V, et al. 

Association of physical activity, sedentary behavior, and sleep with unhealthy aging: consistent results for device-measured and self-reported behaviors using isotemporal substitution models

Association of sleep attitudes with sleep hygiene, duration, and quality: a survey exploration of the moderating effect of age, gender, race, and perceived socioeconomic status

Direct and indirect associations of sleep knowledge and attitudes with objective and subjective sleep duration and quality via sleep hygiene

5. Murawski B, Wade L, Plotnikoff RC, et al. 

A systematic review and meta-analysis of cognitive and behavioral interventions to improve sleep health in adults without sleep disorders

How can knowledge—and positive attitudes—about sleep improve quality of life for patients?

Sleep Attitudes Influence Sleep More than Knowledge

Borderline personality disorder has many clinical features, including relatively unrecognized sleep disturbances. Generally, sleep problems are not considered a primary characteristic of this condition, but research is beginning to identify specific patterns of sleep disruptions that are associated with the disorder.

 is characterized by substantial emotional instability, relationship strains, behavioral problems, and difficulties with self-image. It is disruptive for the person who has the disorder, as well as for other individuals in their lives. There is no effective or recommended pharmacological treatment for this chronic disorder. The clinical management, which consists of behavioral and cognitive therapies, is challenging.

 differ from the criteria for diagnosis of bipolar disorder, there are some similarities, and it can be difficult at times to differentiate the 2 conditions.

 Bipolar disorder is a psychiatric disorder characterized by fluctuations in mood and energy levels, often with features of 

 and depression. Borderline personality disorder and bipolar disorder can both profoundly interfere with an affected patient’s quality of life, and they both often cause mood instability, hopelessness, and other overlapping symptoms. Unlike borderline personality disorder, 

 is often treated with prescription medication, along with counseling and behavioral therapy. A 

 of either of these disorders can delay proper referral to a psychiatrist or behavioral specialist and delay the timely implementation of appropriate therapy.

Several studies have shown that patients who have borderline personality disorder experience substantial variability in their sleep times from night to night when compared with the general population. These trends have been documented by clinical history and questionaries, and objectively with actigraphy and polysomnogram studies.

 is a disruptive condition that causes fluctuations in sleep rhythms, with phase delay and misaligned rest-activity pattens. Patients who have circadian rhythm sleep disturbance can experience irregular sleep patterns, with inconsistency and unpredictability from day to day. This causes a lack of adequate sleep, as well as low energy and concentration during the day. This sleep disturbance has been associated with borderline personality disorder.

Furthermore, the severity of certain symptoms of borderline personality disorder has been shown to correlate with certain actigraphy patterns that demonstrate daytime and nighttime abnormalities that are consistent with circadian sleep disturbance. In one study, patients who carried a diagnosis of borderline personality disorder and who had high levels of impulsivity and mood instability showed substantial phase delayed daytime activity patterns, low inter daily stability, weak amplitude, and greater fragmentation of rest activity states over a study duration of 28 days.

 These patterns were not noted in the study participants who had a diagnosis of 

 or in the controls. Another study showed that patients with borderline personality disorder had delayed phase of nighttime rest patterns, delayed daytime activity onset, as well as delayed temperature phase, while controls and patients who had bipolar disorder did not exhibit these features.

While there appears to be a correlation between the severity of symptoms of borderline personality disorder and circadian rhythm dysfunction, the clinical implications have not been established, nor has any specific cause-and-effect relationship. Whether the emotional and behavioral aspects of borderline personality disorder affect circadian rhythm regulation, or the circadian rhythm dysregulation affects symptoms of borderline personality disorder is not clear. The distinct differences in circadian rhythm disturbance patterns between patients with borderline personality disorder and patients with bipolar disorder that has been replicated in several studies is interesting, especially given the similarities between the 2 conditions.

Circadian rhythm disturbance is objectively quantifiable, but difficult to treat, and these observations do not clearly provide direction for the treatment of borderline personality disorder. However, awareness and treatment of sleep disturbances are important aspects of patient management. Screening tests, including interviews and actigraphy, can identify 

 that patients might not have otherwise reported if they did not know those problems were abnormal. Patients who would benefit from appropriate therapy for their sleep disorder may experience an improved quality of life if treatment is implemented. Furthermore, the diagnostic signs can potentially provide an adjunct in the diagnostic process for patients when borderline personality disorder is considered in the differential diagnosis. Because borderline personality disorder lacks objective criteria, it is possible that some patients may feel empowered, heard, and understood when they are made aware of an objective feature of their condition. This may potentially improve compliance with treatment for some patients.

Self-report screening instruments differentiate bipolar disorder and borderline personality disorder.

The emerging circadian phenotype of borderline personality disorder: mechanisms, opportunities and future directions.

3. McGowan NM, Goodwin GM, Bilderbeck AC, Saunders KEA. 

Actigraphic patterns, impulsivity and mood instability in bipolar disorder, borderline personality disorder and healthy controls.

4. McGowan NM, Goodwin GM, Bilderbeck AC, Saunders KEA. 

Circadian rest-activity patterns in bipolar disorder and borderline personality disorder.

Sleep disturbances in borderline personality disorder are relatively unrecognized. 

Sleep Patterns in Borderline Personality Disorder 

There is overwhelming evidence that sleep and circadian rhythm disturbances and disorders are prevalent in psychiatric patients and associated with worse outcomes. Nonetheless, the associations between sleep/rhythms and psychiatric disorders are not well understood, and additional research is necessary to mechanistically link sleep dysfunction to mental illness. Furthermore, despite the fact that there is evidence that treating sleep and behavioral rhythms improves psychiatric outcomes, training in sleep medicine for psychiatrists is often insufficient. As a result, sleep and rhythms are often not adequately assessed or appropriately targeted in the clinical practice of psychiatry.

The articles in this Special Report address key issues. While the association between insomnia and psychiatric disorders has long been recognized, more recent evidence demonstrated a strong relationship between insomnia and suicidal ideation and behaviors across the lifespan, as discussed by Wilfred R. Pigeon, PhD, and Todd M. Bishop, PhD. Thus, patients with insomnia, even in the absence of severe psychiatric symptomatology, should be screened for suicide, and treatment for insomnia should be considered to reduce suicidal ideation.

Circadian rhythm abnormalities are also prevalent in psychiatric patients, although they have received less attention than sleep problems. Practitioners may not always recognize circadian abnormalities in their patients and may lack the training and knowledge to provide adequate chronotherapy; for example, delayed onset due to a shifted circadian rhythm may be mistaken for sleep onset insomnia if a careful sleep history is not obtained. Helen J. Burgess, PhD, and Leslie M. Swanson, PhD, discuss the association between delayed sleep phase and mood, anxiety and substance abuse, as well as the increased risk of psychiatric illness related to irregular sleep timing. Their expert tips and guidance in screening patients for circadian rhythm abnormalities as well as stabilizing and entraining rhythms with light therapy, melatonin, and behavioral interventions is most useful.

Similarly, the article by Ellen E. Lee, MD, discusses how sleep can affect psychiatric disorders by increasing inflammation and oxidative stress. Her group has shown that patients with serious mental illnesses have increased levels of pro-inflammatory cytokines. Other studies have shown that sleep deprivation, insomnia, and obstructive sleep apnea are not only more common in patients with psychiatric disorders, but they are also associated with worse outcomes and contribute to inflammation. Conversely, treatments for insomnia and sleep apnea have been shown to have positive effects on psychiatric symptomatology. Taken together, these findings suggest mechanistic pathways by which sleep disorders, inflammation, and psychiatric illness are linked.

In summary, there is increasing evidence that disturbed sleep and circadian rhythms impact the risk for developing psychiatric disorders, and inflammatory processes are suggested as one possible mechanism of this well-established relationship. Sleep and circadian rhythm disturbances are modifiable factors, and while data on the effects of sleep disorder treatment on inflammatory processes is preliminary and limited, treating sleep and behavioral activity rhythms have consistently shown positive impact on mental health outcomes. Most importantly, treatment of sleep dysfunction may reduce suicide risk.

Future research is necessary to better understand the mechanistic pathways and to improve the availability of evidence-based treatments of sleep disorders in patients with mental health disturbances. Hopefully this Special Report will help you better understand some of these relationships and will lead to improved patient outcomes.

Dr Benca is Chair of Psychiatry & Human Behavior in the School of Medicine at University of California, Irvine. She reports that she has served as a consultant to Eisai, Genomind, Jazz, and Merck.

The associations between sleep/rhythms and psychiatric disorders are not well understood. With additional research we can better address key issues and improve patient outcomes.

Sleep Disorders: A Wake-Up Call

The steadily rising rate of suicide in the US is a vexing public health crisis. Between 2007 and 2017, suicide was the 10th leading cause of death, claiming the lives of nearly half a million people.

 It is perhaps even more striking that suicide is the fourth leading cause of death for individuals aged 35 to 54 as well as the second leading cause for those aged 10 to 34. Based on 2018 epidemiologic data, 1.4 million adults per year make a non-fatal suicide attempt and 10.4 million have serious thoughts of suicide.

 Among the many risk factors for suicidal thoughts and behaviors, one that consistently emerges as an independent risk factor is sleep disturbance (broadly defined) along with the specific sleep disorders of insomnia, nightmares, and sleep apnea.

One reason that this sleep-suicide relationship is so important is that sleep disorders represent a modifiable risk factor. As noted a decade ago, several sleep medicine interventions can potentially make a difference in the lives of individuals who may be on a trajectory to suicide.

It has yet to be firmly established if improving sleep actually reduces suicide. However, in a recent analysis of a large medical record study, it was observed that having a sleep medicine consultation was a protective factor for subsequent suicide attempts among those with a sleep disorder.

 There are also some indications that cognitive-behavioral therapy for insomnia (CBT-I) reduces suicidal thoughts.

Mechanisms by which improved sleep may reduce risk are also putative. Indirectly, we can say with some certainty that sleep disorders (eg, insomnia, sleep apnea) are strongly related to the development and course of depression and their reversal improves mood. Other hypothesized mechanisms through which poor sleep may be associated with suicidal thought and behavior include increased impulsivity, emotional dysregulation, and impaired executive functioning, each of which may be reversed with improved sleep.

What, then, are actionable items for the clinician wishing to address the sleep-suicide relationship? We present three focal areas:

• Suicide assessment and safety planning

• Sleep treatment options in the suicidal patient

Given the high prevalence of insomnia in psychiatric populations and the ability of psychiatrists to fully manage insomnia (as opposed to sleep apnea), the primary focus of treatment options is for insomnia disorder.

Often a sleep disturbance is identified in an initial psychiatric evaluation or in the normal course of a treatment episode by either a general screening question, “Do you have trouble sleeping?” or a direct patient complaint “My sleep is terrible.” We strongly recommend leveraging the use of standard depression screening tools to identify sleep complaints. For example, item 3 of the Patient Health Questionnaire-9, which probes for insomnia and hypersomnia has been found to be a good screen for clinically meaningful insomnia.

 An endorsement of 1 or higher on this 0-3 Likert-type scale item can be followed with questions to quickly assess for the possible presence of either of the two most common sleep disorders (ie, insomnia and sleep apnea).

Alternatively, the 7-item Insomnia Severity Index and the 8-item Stop-Bang Questionnaire can be used to assess sleep problems.

 Both are efficient and well-validated instruments for detecting probable insomnia and apnea, respectively.

Even among mental health providers a frequent barrier to reliable suicide risk assessment is the clinician’s comfort with asking the patient about suicide. It is, therefore, worth highlighting the importance of asking patients about all aspects of suicide risk. These inquiries range from asking whether the patient is thinking of killing themselves to inquiring whether they have made a plan or started gathering the means to attempt suicide.

For those involved in graduate medical education or residency training, the coupling of traditional didactic suicide prevention training with videotaped standardized patient interactions can optimize supervision around suicide assessment.

 Having a well-established safety protocol and clinical staff that are trained to use it will free you and your staff to conduct more thorough assessments with the confidence that a plan is in place to handle risk, should it emerge or worsen. For the same reason that we ask patients to write down their safety/crisis plan, it is best to have these safety protocols in writing so that they can be easily referred to when the situation to use them arises (see 

Safety contracts or no-harm contacts between patient and provider, which were widely used, are of limited value. Instead, the use of a more involved safety planning or crisis response planning process is recommended.

 Safety planning and crisis response planning differ slightly but share many common features (

While the presence of a sleep complaint or sleep disorder may increase the risk of suicide compared with the absence of sleep disturbance in otherwise similar patients, it does not significantly change the approach to the treatment of suicidality. One important exception is that patients with current prescriptions for sedative-hypnotics have at their disposal a potential means of suicide (ie, overdose); this needs to be evaluated as part of safety or crisis planning. Otherwise, the recommended treatments for suicide prevention can be utilized for suicidal patients with sleep disorders.

Cognitive behavioral therapy for suicide prevention (CBT-SP) is the only intervention with enough empirical evidence to warrant a strong recommendation; no other nonpharmacologic or any pharmacologic treatment for suicide prevention has enough evidence to receive more than a weak recommendation for its use.

 In contrast, there are very well-supported, strongly recommended treatments for several sleep disorders.

Generally, standard sleep interventions can be delivered to patients endorsing suicidal thoughts with few modifications, provided that an office/clinic safety protocol and a patient-specific crisis plan are in place. For instance, suspicion of apnea would lead to a referral for a diagnostic evaluation at a sleep center. For nightmares, which can present as idiopathic nightmares but are more commonly associated with PTSD, two main nightmare interventions are considered to have the strongest evidence base: the use of the Î±1-adrenergic agonist prazosin and imagery-rehearsal therapy. 

For insomnia disorder, CBT-I, is the recommended first-line treatment.

 CBT-I typically consists of 6 to 8 weekly individual or group sessions including sleep psychoeducation, stimulus control, sleep restriction, sleep hygiene, and cognitive therapy and tends to be more enduring than pharmacological interventions. It has been effectively delivered in numerous comorbid populations and can have positive effects on mood.

Numerous pharmacologic interventions for insomnia are recommended as second-line treatment when there is no response to CBT-I or it is contra-indicated. Despite clinical practice guidelines, pharmacotherapy for insomnia is far more common than CBT-I or related approaches and may be preferred by some patients. Hypnotics can be administered safely to suicidal patients with insomnia as has been done with zolpidem ER, which may reduce suicidal ideation.

 The prescribing physician must be cognizant that: many hypnotics come with FDA black-box warnings; overdose is the most common means of suicide attempt; and off-label use of medications with sedating properties (eg, trazodone, tiagabine) have a significant harm-to-benefit profile.

Psychiatrists are in an excellent position to manage deprescribing hypnotics in the not uncommon presentation of persistent severe insomnia despite multiple sedating medications taken at night. We find many patients who present with major depressive disorder, insomnia disorder, and suicidal ideation who have been prescribed a nightly antidepressant (eg, 40-mg fluoxetine) are also using a non-benzodiazepine receptor agonist (eg, 10-mg zolpidem) and 100-mg trazodone or 150-mg quetiapine fumarate while supplementing with an over-the-counter formulation at well-above the recommended dosage (eg, diphenhydramine, doxylamine, melatonin). Discontinuation plans may precede or be combined with CBT-I, however, the latter may be more advantageous.

In addition, when patients present with insomnia and a co-occurring condition (eg, depression, posttraumatic stress disorder, chronic pain) there is good evidence that CBT-I can be combined with psychological or pharmacologic therapy that targets the comorbid condition. For example, CBT-I can be combined with an antidepressant in depressed patients or with trauma-focused treatments for patients with PTSD. With appropriate safety planning, patients who also endorse suicidal thoughts can be similarly treated.

We recognize that a full course of CBT-I may not fit every psychiatrist’s clinic model and/or they have few appropriate referral options. In such cases, very viable alternatives exist. Shorter versions of CBT-I have been utilized with good effect, as have single components of CBT-I (eg, stimulus control, sleep restriction).

Sleep hygiene, which is often delivered with minimal follow-up, is insufficient for many patients. If sleep hygiene is delivered as the primary method of addressing insomnia, it may be improved by systematically incorporating specific goals (eg, reduce caffeine intake, limit napping), daily tracking, and problem-solving during follow-up sessions.

Treatment outcomes for sleep disorders are enhanced by regular assessment, follow-up, and/or titration of treatment. For example, ask patients to complete a sleep diary each morning and to meet with you on a weekly or biweekly basis in order to interpret the results and adjust the sleep schedule accordingly. Likewise, patients starting positive airway pressure (PAP) for sleep apnea will nonetheless benefit from psychiatric consultations early in the treatment process to encourage and support treatment adherence. Moreover, patients may benefit from the use of apps and web-based platforms that aid in monitoring behavior and logging sleep diary data as well as providing supplemental education (eg, CBT-I Coach: 

www.veterantraining.va.gov/insomnia/index.asp

Although a myriad of pressing clinical issues face a patient with suicidal ideation, incorporating sleep assessments and interventions into the clinical care plan has multiple advantages. First, improving sleep not only provides immediate relief of sleep related symptoms, it may also lead to improvements in co-occurring pathology such as depression. Second, sleep disorders represent a comparatively low stigma entry point into treatment, and a successful course of sleep-focused therapy can instill confidence in the patient that therapy works and is worth the investment. Finally, sleep disorders have been linked to increased suicide risk and, thus, their treatment may reduce this risk.

Dr Pigeon is Professor of Psychiatry and Public Health Sciences, University of Rochester Medical Center, Rochester, NY, and Executive Director, Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, US Department of Veterans Affairs; Dr Bishop is Assistant Professor of Psychiatry, University of Rochester Medical Center, and Health Science Specialist, Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center. Dr Pigeon reports that he is a consultant for CurAegis Technologies, Inc; Dr Bishop reports no conflicts of interest concerning the subject matter of this article.

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16. McCall WV, Benca RM, Rosenquist PB, et al. Hypnotic medications and suicide: risk, mechanisms, mitigation, and the FDA. 

17. McCall WV, Benca RM, Rosenquist PB, et al. Reducing suicidal ideation through insomnia treatment (REST-IT): a randomized clinical trial. 

18. Pigeon WR, Funderburk JS, Cross W, et al. Brief CBT for insomnia delivered in primary care to patients endorsing suicidal ideation: a proof-of-concept randomized clinical trial. 

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20. Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update: an American Academy of Sleep Medicine report. 

The steadily rising rate of suicide in the US is a vexing public health crisis. Among the many risk factors for suicidal thoughts and behaviors is sleep disturbance.

The Strong Relationship Between Sleep and Suicide

Impact on Sleep and Psychiatric Disorders

Circadian rhythms have a profound effect on our mental and physical health. This is not surprising due to our evolution under a 24-hour light/dark cycle. Almost every cell in the body contains a molecular circadian clock, which is influenced by the master circadian clock in the suprachiasmatic nucleus in the anterior hypothalamus. At least half of all genes in the genome oscillate with a circadian rhythm.

There is growing recognition that circadian health, which is defined as robust ~24-hour rhythms that are stably and appropriately timed with respect to both the external light-dark cycle and social rhythms (eg, sleep times), is a key pillar of health. This ensures that human behaviors and biological processes are optimized by occurring at biologically appropriate times. Indeed, mental health and circadian health are tightly entwined, and circadian interventions can improve mood and well-being, even in healthy people.

The human suprachiasmatic nucleus starts oscillating in utero, in synchrony with time cues from the mother. With birth, newborns lose this time cue and have irregular sleep patterns, which begin to consolidate around 3 to 5 months. The emergence of a stable sleep-wake pattern is likely to reflect the development of the infant’s endogenous circadian system. Increased daily exposure to light is associated with a faster transition to a stable sleep-wake pattern, and a stronger, more well-defined circadian pattern in infant activity levels. This suggests the possibility that increasing daytime exposure to moderate light intensities and maximizing light-dark differences in the 24-hour day may promote circadian entrainment in infants.

 Needless to say, a consolidated sleep pattern in infants is associated with less sleep disruption and improved mood in caregivers.

With the onset of puberty, circadian rhythms shift later in time (phase delay). This is at least in part physiologically driven by sex hormones, as it is also observed in other mammals.

 Behaviors such as staying up later and the associated increased exposure to evening light also shifts the timing of the clock later.

The increased use of blue-light–emitting electronic devices close to the face in the evening will phase delay the clock, as the circadian clock is maximally sensitive to blue light.

 Phase delays in circadian timing (a later circadian clock and more “eveningness”) are associated with increased incidence of depression, anxiety, and substance use, and may well be a transdiagnostic risk factor.

When circadian phase delays lead to chronic complaints of difficulties in falling asleep and waking up at desired, often socially mandated earlier clock times, the patient may have delayed sleep-wake phase disorder (DSWPD). DSWPD affects approximately 7% to 16% of adolescents and young adults.

 Indeed, these later sleep onsets in combination with early school or work start times result in chronic sleep deprivation. Adolescents and young adults are arguably the most sleep-deprived segment of society. The major sleep and circadian disruption that occurs in adolescence and young adulthood likely contributes to the emergence of many psychiatric illnesses during this developmental stage.

Circadian rhythms drift back earlier with aging. Eveningness tends to peak in the late teens or earlier twenties, and thereafter there is a progressive drift towards earlier circadian rhythms-or more “morningness”-with aging.

 In general, females tend to have slightly earlier timed circadian rhythms than males. Most healthy adults (~70%), have an endogenous circadian period that is greater than 24 hours.

 This suggest that the majority of adults need to shift earlier (phase advance) to stay in synchrony with the external light-dark cycle. Despite increased time spent indoors, endogenous circadian timing in humans is still influenced by the external light/dark cycle. Later sunsets lead to later sleep onsets and, in the face of socially mandated fixed wake times, also to shorter sleep durations.

Historically, only adults engaged in shift work were considered to suffer from chronic circadian disruption. Rotating shift work or irregular shifts lead to a constantly changing light/dark cycle to which the circadian clock continually tries to adjust. Even stable permanent shifts, whether morning, evening, or night shifts, can be difficult, particularly as most shift workers prefer to sleep at socially normative night-time hours on days off. Thus, shift work is associated with sleep disruption and worse mental (particularly depressive symptoms) and physical health.

 If possible, shift work should be avoided, particularly in patients with or at risk for mental health conditions.

More recently, irregular sleep timing has been recognized as a subtle, but chronic form of circadian disruption. Irregular sleep timing in general is associated with poorer mental and physical health, which is likely to be due in part to the circadian shifting in response to the associated irregular light/dark cycle.

 A subtype of irregular sleep timing is known as “social jet lag,” which refers to shifts in sleep times from work or school days to free days.

 Typically, socially mandated work or school schedules push sleep to earlier clock times, while sleep drifts back to later more circadian appropriate clock times on free days.

Shifts of two hours or more in the midpoint of sleep between work days and free days is associated with depression, greater substance use, and worse physical health, and is estimated to occur in approximately 30% of the general population.

 Irregular sleep timing and social jet lag appear to be risk factors for psychiatric disorders, but longitudinal studies are needed.

In the elderly, several factors can contribute to circadian disruption. Circadian rhythms continue to drift earlier in time. If this morningness leads to complaints of falling asleep too early in the evening and waking too early in the morning, the patient may have advanced sleep-wake phase disorder (ASWPD).

 Aging is also associated with reduced light exposure, as less time is spent outdoors and indoor lighting can be very dim.

The lenses in the eyes yellow with aging; this reduces exposure to the most potent, blue wavelengths of light.

 In the extreme case of dementia, these factors, in addition to a potentially disintegrating suprachiasmatic nucleus, can result in irregular sleep-wake rhythm disorder (ISWRD).

 This consists of a less robust circadian rhythm with multiple episodes of sleep during the day and multiple periods of wake during the night.

Circadian timing is currently difficult to objectively measure outside of specialized sleep and circadian research laboratories. There are several approaches in development to address this problem. A home saliva collection kit to assess dim light melatonin onset, the current gold standard marker of circadian timing in humans, is in development.

Blood-based transcriptomic biomarkers and algorithms to analyze data from wearables are starting to be validated against the dim light melatonin onset kit. Meanwhile, the Morningness-Eveningness Questionnaire (MEQ) asks people to consider their “feeling best” rhythms and indicate preferred clock times for sleep and engagement in various hypothetical situations (eg, physical exercise, exams, work).

 The questionnaire also assesses morning alertness, morning appetite, evening tiredness, and alarm clock dependency. Lower MEQ scores indicate more eveningness, and higher scores indicate greater morningness. Although morningness or eveningness correlates with dim light melatonin onset (r = -0.70) there can be up to a 4-hour range in dim light melatonin onset for a given MEQ score.

The Munich ChronoType Questionnaire (MCTQ) focuses on sleep timing and the regularity of one’s work schedule, number of workdays per week, and sleep timing and alarm clock use on workdays and free days.

 Sleep timing on free days can give a sense of endogenous circadian timing, although sleep on free days can also be influenced by alarm clock use, or by recovery from sleep deprivation that may have built up over the work/school week. More easily, the MCTQ can help assess for social jet lag as the difference between usual sleep timing on work/school days versus usual sleep timing on free days.

Sleep timing and social jet lag can also be assessed over the short term with a 7-day sleep diary. For patients with shifting or irregular work schedules, a work diary (with commute times if they are long) can be also be useful.

A more recent questionnaire, SATED (Satisfaction, Alertness, Timing, Efficiency and Duration) may be useful to assess sleep and circadian issues.

 This brief questionnaire may pinpoint the sleep and circadian factors most bothersome to the patient. In general, asking patients about daily routines, what changes they would like to make to their sleep schedule, and what social factors affect their sleep times will be useful.

Overall, striving for bright light during daytime and minimizing nighttime light promotes wakefulness during the day and sleep at night and leads to a more robust circadian rhythm. Specific first-line treatments for circadian rhythm disorders include strategically timed light therapy and melatonin.

 Circadian treatments work best when they are integrated into the patient’s regular routine. A summary of circadian treatments and their effects is shown in 

A first step in treatment is to stabilize sleep timing as much as possible and ensure that the patient has the opportunity to get 7 to 9 hours of sleep. It may also be necessary to slowly shift the sleep schedule in the desired direction (~15-30 min/d), as the associated changes in light/dark exposure will help shift the circadian clock.

Furthermore, light exposure across waking hours should be considered. If trying to shift rhythms earlier, evening light should be minimized; to shift rhythms later, morning light should be minimized. For example, older adults with ASWPD should be instructed to minimize light exposure prior to their desired wake time. Light exposure can be minimized by staying indoors, dimming room lights and light-emitting devices, wearing commercially available blue light blocking amber glasses, and of course by sleeping/keeping eyes closed.

Light therapy, which is indicated for ASWPD, DSWPD, and ISWRD in adults with dementia, is typically administered for 30 to 60 minutes using a bright light box or a wearable light device that permits ambulation during the light treatment (eg, Re-Timer). To shift circadian rhythms earlier (ie, for DSWPD treatment), light therapy should be administered in the morning, ideally at habitual wake time. Timing is adjusted as the wake time is advanced. To delay circadian rhythms (ie, for ASWPD treatment), light therapy should be used in the evening.

Contraindications for light therapy include eye disease, conditions that cause photosensitivity (eg, lupus), phototoxic medication use, and a history of hypomania/mania (unless patients are very carefully monitored).

Supplemental melatonin is available over the counter in the US and can be used to assist with phase shifting, particularly in DSWPD, although the phase shifts are smaller than those seen with light. Low doses (≤ 0.5 mg) of melatonin are usually recommended to avoid the soporific effects seen with higher doses.

 Morning melatonin can shift rhythms later, whereas melatonin taken about 5 hours before usual sleep onset time can shift rhythms earlier.

Melatonin use is contraindicated in the elderly because of increased risk for falls and mood changes as well as patients with epilepsy, those taking anti-hypertensive medications or blood-thinners, and women who are pregnant or breastfeeding.

Circadian treatments can be difficult to implement because the treatment needs to be timed according to the individual’s endogenous circadian timing. Incorrect timing of treatment can worsen circadian rhythm disorders. For example, in an individual who habitually wakes around 7 am, light exposure at 7 am would be biologically interpreted as morning light, and result in phase advances. However, in an individual who habitually wakes at 11 am, 7 am light exposure could be biologically interpreted as late night light, and possibly result in phase delays. For this reason, we do not initiate morning light treatment any earlier than 1 hour before habitual wake time.

Physical activity may also shift circadian timing, although findings indicate that the effects of a 1-hour high intensity exercise on subsequent circadian timing were small.

 While meal timing may not shift circadian timing, restricting eating to during the biological day can lead to weight loss.

Social rhythms therapy, a treatment for mood disorders, focuses on regulating daily activities with potential impact on circadian timing such as closely scheduling the timing of bed/wake, meals, exercise, first social contact, and start of work so that these events occur at a consistent time and do not vary significantly day-to-day.

 The therapy is considered potentially effective, although more comparative efficacy trials are needed.

Circadian health is a key pillar of well-being. Exposure to bright light during the daytime and minimizing light during the night can help strengthen circadian rhythmicity. Circadian rhythms change across the lifespan; adolescents and younger adults are more likely to experience circadian phase delays, whereas older adults are more vulnerable to circadian phase advances. Disruptions in the circadian system and its alignment with the sleep-wake cycle can contribute to psychiatric illness.

Treatment of circadian rhythm disorders can improve mental health. Treatments include bright light therapy and melatonin; however, the timing of such interventions is critically important to their success.

We thank Muneer Rizvydeen for his help with creating the figure.

Dr Burgess is Professor, and Dr Swanson is Associate Professor, Sleep and Circadian Research Laboratory, Department of Psychiatry, University of Michigan, Ann Arbor, MI. Dr Burgess reports that she is a consultant for Natrol, LLC and MovingMindz, Pty, Ltd; Dr Swanson reports no conflicts of interest concerning the subject matter of this article.

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Circadian rhythms have a profound effect on our mental and physical health. Indeed, mental health and circadian health are tightly entwined, and circadian interventions can improve mood and well-being, even in healthy people.

Circadian Rhythms Across the Lifespan

 pandemic poses a serious health threat to the world population. In response, governments are implementing a variety of new policies including self-quarantine, self-isolation and social distancing. While medically necessary to limit spread, these new social policies can disrupt many of the stabilizing factors in our lives that support mental health.

One of the most important brain systems contributing to daily wellbeing is the body’s internal biologic clock. This system of clocks keeps our body and our behavior synchronized with the 24-hour cycle of light and dark. Predictable daily schedules and regular routines help to keep the body clock running smoothly. When our body clocks run smoothly, we feel better. Research shows that disrupted body clocks are associated with many physical and mental health conditions, including depression, diabetes, obesity, and cancer.

Recommendations from the International Society of Bipolar Disorders Task Force on Chronobiology and Chronotherapy and the Society for Light Treatment and Biologic Rhythms.

Circadian Rhythm Sleep Disorders

Sleep Attitudes Influence Sleep More than Knowledge

Sleep Patterns in Borderline Personality Disorder

Sleep Disorders: A Wake-Up Call

The Strong Relationship Between Sleep and Suicide

Circadian Rhythms Across the Lifespan

The COVID-19 Pandemic and Emotional Wellbeing: Tips for Healthy Routines and Rhythms During Unpredictable Times

Screentime Solutions for Depression and Bipolar

Sleep Hygiene: Tips on Getting a Restful Night's Sleep

Sleep Disturbances After Traumatic Brain Injury

The Body Clock and Its Discontents