Circadian Rhythm Chronotherapy for Depression Treatment

In one of our previous post we discussed an unusual approach to the depression treatment through sleep deprivation. This method shows very encouraging results in the critical conditions, but is difficult to apply and the received positive effects are usually not sustainable. While the related research is still ongoing, there is no doubt that sleep and depression have tight links, and there is a good potential for the further remedy for the patients.

Chronotherapy is one of the new therapies, applying developed knowledge on the connection between natural biorhythms and well-being to the depression treatment. It is using the circadian rhythm-altering interventions that treat depression by adjustments of the sleep-wake cycle and daily light exposure. In a way, it is theory combining the sleep regulation and light therapy for the patients’ treatment.

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Indications for Chronotherapy

Chronotherapy has been found to benefit most forms of depression including:

In addition to these diagnostic indications, chronotherapy is also useful in the following circumstances:
  • When there is a need for a rapid antidepressant response; in other words, when someone needs to get better quickly
  • Inability to tolerate or preference to avoid medication.
    Most often, chronotherapy is used along with antidepressant or mood-stabilizing medication. It can, however, be used on its own, especially when several different forms of chronotherapy are used in combination.

This option allows for a fully non-pharmacologic treatment for those who are sensitive to, or need to minimize medication side-effects; for example, those with other medical illnesses, the elderly, and for antepartum and post-partum depressions.

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Contraindications to the use of Chronotherapy

  • Psychotic Depression.
    People who are experiencing hallucinations or delusions while depressed (or when manic) should not receive chronotherapy.
  • Mixed States (the simultaneous co-occurance of both manic and depressive states) or depressive states with significant anxiety or other manic symptoms (relative contraindication).
    Chronotherapy, like all other biological forms of antidepressant treatment, can cause emotional side effects. About 7% of patients treated with wake therapy will develop hypomanic symptoms. Patients experiencing manic or significant anxiety symptoms as part of their depression are at a higher risk of having this reaction. It is therefore contraindicated in this group.
  • Certain eye conditions may limit the use of bright light treatment.
    Retinal problems, macular degeneration and the use of photosensitizing medications may complicate or prevent the use of light treatment.
  • The presence of epilepsy or a seizure disorder is a relative contraindication for wake therapy.
    The use of antipsychotic drugs, sleep medications (sedatives), or certain anti-anxiety agents can interfere with the action of wake therapy and may need to be discontinued or temporarily suspended.

Chronotherapy Types

Chronotherapy is basically therapy using manipulation of sleep, wake and light. There are different types of Chronotherapy:
  1. Light therapy - this is dosed precisely and at exact times. This therapy is well-known in the treatment of seasonal affective disorder (SAD).
  2. Wake therapy – use of prolonged periods of wakefulness.
  3. Sleep phase advancement – moves the time of the sleep forward to early evening to improve antidepressant action.
  4. Triple chronotherapy – a combination of the above three.
  5. Dawn simulation – gradual light before waking.
  6. Chronobiotics – use of circadian rhythm-modifying compounds such as melatonin.
  7. Social rhythm therapy – schedules daily activities.

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How Chronotherapy Works?

As with most complicated things in life, scientists and doctors admit that the picture is far from being clear. What they are pretty sure about though is that natural circadian rhythms for different mental illnesses are often disturbed.

So, in the average person, they want to sleep at night and be awake during the day. They also want to sleep around eight hours a night and wake and sleep at about the same time each day. This rhythm can be interrupted by normal, life events, but the person will regain their rhythm once circumstances allow.

The problem with different mental illnesses is that people sleep too much, we don’t sleep enough, or they able to get sleep at the wrong times. It’s one of the reasons so many of the many of the people are hooked on the various sleeping medication.

The idea of Chronotherapy then, is to reinstate a natural sleep rhythm, or to manipulate the sleep rhythm for the positive therapeutic effect.

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Triple Chronotherapy

“Triple chronotherapy is a natural, ultra-rapid therapy that typically reduces depressive symptoms within one-to-two days,” explains Northwestern Medicine psychiatrist John Gottlieb, MD, who is an assistant clinical professor of psychiatry and behavioral science at Northwestern University Feinberg School of Medicine. “This approach doesn’t require medications, but it’s every bit as biologically active as antidepressant medications.”

Circadian rhythms are the fluctuations of certain physiological variables that occur over a 24-hour period, like sleeping, for instance. Circadian-shifting approaches, like bright-light therapy and dawn stimulation, have long been proven to effectively treat depression and other emotional disorders. Triple chronotherapy is no different, and has been used in Europe for nearly two decades in the successful treatment of unipolar and bipolar depression, as well as seasonal affective disorder. However, due to the intensiveness of the approach, patients were required to remain in the hospital during treatment. For the first time, the triple chronotherapeutic protocol is being administered on an outpatient basis, and Northwestern Medicine is one of few centers to offer this in the US.

“Chronotherapy has been demonstrated to be effective,” said Gottlieb. “However, it is not used for patients with psychotic depression or for patients who are bipolar and not on medication. Additionally, patients with eye disorders may be unable to undergo light therapy.”

As he explains, the first part involves wake therapy which requires a period of extended wakefulness over one night and the following day. This acts as an antidepressant response-inducer, jump starting an improvement in mood. Following wake therapy, patients move their sleep period earlier (sleep phase advance) and begin using bright light at prescribed times.

Chronotherapeutic treatments can also be used with antidepressant and other psychiatric medications. These combinations can both enhance and expedite treatment response. According to Gottlieb, standard, pharmacological therapy for depression takes between two to eight weeks before significant improvement occurs. Bright light therapy generally produces an antidepressant response within one to two weeks, while triple chronotherapy can induce remissions within hours.

“Triple chronotherapy provides a faster and lasting antidepressant option for many people who struggle with depression.” Gottlieb said.


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