Chronotherapeutics for Affective Disorders: A Clinician's Manual for Light and Wake Therapy

129 Pages·2009·5.61 MB·English

by  Anna Wirz-Justice

Chronotherapeutics for Affective Disorders
Supported by a grant from the
www.veluxstiftung.ch
Dedicated to research in the areas of daylight,
medicine and biology, and the preservation
of the ecological stability of nature.
Frank Gehry (from a studio work session with Michael Terman, Santa Monica, Calif., USA, 1988).
Visions of Bedroom Dawn Simulation and Bright Light Therapy. © Frank Gehry.
II
Anna Wirz-Justice
Francesco Benedetti
Michael Terman
Chronotherapeutics for
Affective Disorders
A Clinician’s Manual for Light and Wake Therapy
33 figures, 21 in color, 10 tables, 2009
Basel • Freiburg • Paris • London • New York • Bangalore •
Bangkok • Shanghai • Singapore • Tokyo • Sydney
III
Anna Wirz-Justice A project of the
Centre for Chronobiology
Center for Environmental Therapeutics
Psychiatric University Clinics
www.cet.org
Basel, Switzerland
An independent, non-profit
Francesco Benedetti professional agency dedicated to education and
Department of Clinical Neurosciences research on the new environmental therapies.
Scientific Institute and
Board of Directors:
University Vita-Salute San Raffaele
Michael Terman, PhD (president)
Milano, Italy
Gustave Manasse, PhD
Dan Oren, MD
Michael Terman
Elaine Tricamo, RN
Department of Psychiatry
Anna Wirz-Justice, PhD
Columbia University
New York, N.Y., USA
Library of Congress Cataloging-in-Publication Data
Wirz-Justice, Anna.
Chronotherapeutics for affective disorders : a clinician‘s manual for
light and wake therapy / Anna Wirz-Justice, Francesco Benedetti, Michael
Terman.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-3-8055-9120-1 (pbk. : alk. paper)
1. Affective disorders--Alternative treatment. 2. Clinical chronobiology.
3. Circadian rhythms--Therapeutic use. 4. Sleep deprivation--Therapeutic
use. 5. Light--Therapeutic use. I. Benedetti, Francesco, 1966- II. Terman,
Michael. III. Title.
[DNLM: 1. Mood Disorders--therapy. 2. Chronotherapy--methods. 3.
Phototherapy--methods. 4. Sleep Disorders--therapy. WM 171 W799c 2009]
RC537.W575 2009
616.85‘2706--dc22
2009000805
Disclaimer. The statements, opinions and data contained in this publication are solely those of the individual authors and contributors
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to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are
in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in govern-
ment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package
insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when
the recommended agent is a new and/or infrequently employed drug.
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Printed in Switzerland on acid-free and non-aging paper (ISO 9706) by Reinhardt Druck, Basel
ISBN 978–3–8055–9120–1
e-ISBN 978–3–8055–9121–8
IV
Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IX
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI
List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XII
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Unmet Needs in the Treatment of Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Role of Biological Rhythms in Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Principles of Circadian Timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.4 Principles of Sleep Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.5 Mood Level Varies with Time of Day and Duration of Wakefulness . . . . . . . . . . . . . . . . . . . . 8
1.6 Sleep Deprivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.7 How It All Began: Light Therapy for Seasonal Affective Disorder . . . . . . . . . . . . . . . . . . . . . . . 10
1.8 Light Therapy – Beyond SAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.9 What Is Chronotherapeutics? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2 Individual Chronotherapeutic Elements: Light, Wake Therapy and
Sleep Phase Advance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1 Efficacy of Bright Light Therapy for SAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2 Timing of Bright Light Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.3 Dawn (and Dusk) Simulation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.4 Efficacy of Bright Light Therapy for Non-Seasonal Depression . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.5 Dark Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.6 Wake Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.7 Phase Advance of the Sleep-Wake Cycle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.8 Negative Air Ionisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3 Integrative Chronotherapeutics: Combinations of Light, Wake Therapy
and Sleep Phase Advance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.1 A Note on Diagnostic Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.2 Bright Light Augmentation of Antidepressant Drug Treatment . . . . . . . . . . . . . . . . . . . . . . . . 26
d
n
3.3 Wake Therapy Added to Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 u
o
3.4 Wake and Light Therapy Added to Antidepressant Drugs or Mood Stabilisers . . . . . . . . . 29 r
g
k
3.5 Wake, Light, and Sleep Phase Advance Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 c
a
3.6 Repeated Wake Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 B
V
4 Inpatient Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4.1 Response Assessment and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4.2 Light Therapy Timing and Duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.3 Exceptions to the Early Morning Light Rule for Bipolar 1 Disorder . . . . . . . . . . . . . . . . . . . . . 35
4.4 Beginning with Light Therapy (± Medication) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.5 Wake Therapy + Light Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.6 Wake Therapy + Light Therapy + Sleep Phase Advance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.7 Three Alternate Nights of Wake Therapy + Light Therapy + Freely Chosen Sleep
Phase Advance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.8 Variations on the Theme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.9 Maintenance Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.10 Drug Tapering to Discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5 Practical Details for Wake Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.1 Which Patients Are Suitable? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.2 Predictors of Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.3 Medication Allowances and Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.4 What to Tell Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.5 Setting and Structure for the Night Awake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.6 Staff Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.7 Nurses on the Night Shift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.8 Nurses on the Day Shift after Wake Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.9 Structure of the Day After . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.10 Phase Advance of Sleep following Wake Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.11 The Doctor’s Tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.12 Is One-Time Wake Therapy Enough? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.13 Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.14 Special Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.15 If There Is No Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.16 At the End of One Week of Chronotherapeutics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.17 In Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
6 Practical Details for Light Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
6.1 Criteria for Light Box Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
6.2 Using the Light Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
6.3 Side Effects of Light Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6.4 Cautionary Notes about Bright Light Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6.5 Before Beginning Light Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
6.6 In Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
s
d
7 Outpatient Treatment Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 o
h
7.1 Light Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 t
e
M
7.2 Wake Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
VI
8 Range of Chronotherapeutic Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
8.1 Antepartum Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
8.2 Premenstrual Dysphoric Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
8.3 Bulimia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
8.4 Attention Deficit/Hyperactivity Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
8.5 Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
8.6 Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
8.7 Shift Work and Jet Lag Disturbance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
9 Light Therapy for Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
s
n
o
10 Light and Wake Therapy for Older Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 ti
a
c
di
n
11 The Visually Impaired: More Sleep Disturbances, More Depression . . . . . . . . . . . 65 I
12 Endogenous and Exogenous Melatonin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
12.1 The Physiological Effects of Melatonin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
12.2 Melatonin in Circadian Sleep-Wake Cycle Disturbances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
12.3 Melatonin for Depression? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
y
13 Drugs That Affect Rhythms (Chronobiotics) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 g
o
13.1 Melatonin Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 ol
c
a
13.2 Chronobiology of Lithium and Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 m
r
13.3 Clock Genes in Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 a
h
13.4 Caffeine, Modafinil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 P
14 Social Rhythm Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 s
t
c
e
p
15 Chronobiology in Everyday Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 os
r
15.1 Know Your Chronotype . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 P
e
15.2 Timing of School and Work Schedules versus Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 ur
t
15.3 Light and the Built Environment: Implications for Architecture . . . . . . . . . . . . . . . . . . . . . . . . 79 u
F
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

VII
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
1 Morningness-Eveningness self-assessment questionnaire (chronotype), with
scoring and interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
2 Personal Inventory for Depression and SAD (diagnostic status), with scoring and
interpretation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
3 25-item expanded Hamilton Depression Scale with atypical symptoms (current level
of depression), self assessment questionnaire with scoring and interpretation . . . . . . . . . 102
4 6-item Hamilton Depression Scale, core symptoms (for monitoring
short-term changes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
5 Daily sleep and medication logs, and mood and energy ratings . . . . . . . . . . . . . . . . . . . . . . 111 x
di
6 Chronotherapeutics information to outpatients and clinicians following n
e
hospital discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 p
p
7 Center for Environmental Therapeutics clinical assessment tools . . . . . . . . . . . . . . . . . . . . . . 114 A
Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
VIII
Foreword
Sun worship has existed since the beginning of yond the core depressive disorders, we consider
human life on earth. Light is our source of energy, a broader range of current and potential appli-
of warmth, of spiritual and emotional sustenance. cations (Indications), introduce melatonin and
Light is the major synchroniser of the biological drugs that affect rhythms (Pharmacology), end-
clock. It is no surprise to see light enter psychia- ing with a discussion of social issues that impinge
try as a practical treatment. Sleep deprivation has on rhythmic structure and everyday well-being
been investigated for three decades: the instanta- (Future Prospects).
neous, overnight remission of severe depression Outpatients with affective disorders can learn
remains one of the most striking phenomena in to use light therapy – and even wake therapy – at
psychiatry. Sleep deprivation did not enter the home, but they must have directive coaching by
therapeutic armamentarium because patients the clinician. The current mode – ‘Go buy/try a
usually relapse after recovery sleep, or even a nap. light box, see if it works. (Period.)’ – is a formula
Now we have learned how to sustain the effect for disappointment, and discredits the solid clin-
with morning light therapy, sleep phase advances ical research of more than 20 years. Clinicians
and a variety of medications. Practical experi- need to learn the timing principles of the circa-
ence shows that major depression can indeed re- dian clock’s response to light, and carefully dose
mit quickly and remain remitted even in other- the treatment as they would a medication.
wise refractory cases. Not to give up medication, though: the combi-
Here, we combine the elements of chronother- nation of light therapy with antidepressants can
apeutics in a new synthesis. We hope that the provide a potent enhancement over either one
methods will be widely explored on inpatient alone. The lucky minority – as we have seen in
units, with the prospect of higher success rates, seasonal depression – will be able to taper drugs
real remissions without ominous residual symp- to discontinuation and remain euthymic under
toms, and shorter hospital stays. maintenance light monotherapy.
We designed this manual as a source book for A new therapeutic paradigm often seeks a new
clinicians. Readers can choose which category generation of clinicians, and we especially encour-
to read. We begin by presenting the insights of age psychiatric residents to get these principles un-
chronobiology and sleep research that provide der their belt – to help the field identify limitations
the scientific basis, followed by an overview of and refinements, and to view each case as an im-
the clinical literature, which justifies the treat- portant learning experience for all of us. As we
ments (Background). We then describe the prin- emphasize in the Manual, there are significant
cipal therapeutic procedures with practical de- loose ends that can and should be resolved before
tails for both inpatients and outpatients, and for we contemplate a second, revised edition. Feed-
younger and older individuals (Methods). Be- back from the field is now our priority.
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