Table 3 Therapeutic approaches for sleep and circadian disruptions in association with major depression
Therapeutic approach | Target and rationale |
|---|---|
Psychoeducation | ● Understanding sleep-wake and circadian regulation mechanisms and the processes through which sleep and circadian disturbances can be initiated and maintained |
● Linking changes in sleep quality, quantity and 24-hour sleep-wake cycles to onset and relapse of mood disorders | |
● Promoting awareness of how daytime and nighttime behaviors and environmental factors influence sleep-wake and circadian rhythms (that is, sleep hygiene) | |
N.B. These interventions are not considered to be efficient when used by themselves, but can be helpful in conjunction with other cognitive-behavioral interventions | |
● Identifying and adjusting dysfunctional beliefs contributing to the maintenance of sleep difficulties | |
● Understanding the influence of perceptions on sleep quality and daytime functioning | |
● Establishing realistic expectations about sleep | |
● Learning techniques to prevent evening/nighttime ruminations | |
● Stimulus Control Therapy | |
Aiming to reestablish positive associations between the bedroom and sleeping by: a) keeping the bedroom solely for sleep and sexual activities; and b) leaving the bedroom if awake for more than 15 minutes | |
● Bed Restriction Therapy | |
Using sleep pressure to enhance sleep consolidation by: a) limiting the sleep opportunity window to the habitual time spent asleep; and, b) increasing this window progressively as sleep efficiency (that is, ‘total sleep time’/‘time in bed’) improves | |
● Rescheduling | |
Progressive delay/advance of the sleep-wake and light–dark cycles | |
● Regularization of wake-up times (emphasizing the importance of keeping the same wake-up times on weekends) | |
● These techniques provide patients with simple therapeutic tools that can subsequently be used independently in case of relapse | |
● Can induce acute antidepressant effect | |
● Can be used prior to sleep-wake rescheduling to facilitate sleep-wake phase shifting | |
● May be useful to hasten and potentiate the response to phototherapy or cognitive-behavioral therapy | |
N.B. Caution is warranted as sleep loss can trigger mania/hypomania episodes in patients with unipolar or bipolar depression | |
Intensive Sleep Retraining [292] | ● While being monitored with polysomnography over a 25-hour protocol, patients are repeatedly given short sleep opportunities, each time being awoken shortly after achieving sleep (the progressive increase of sleep pressure is believed to facilitate multiple experiences of rapid sleep onset) |
● This novel conditioning technique may be especially promising for patients with depression and sleep/circadian disturbances because of the combined effects of acute partial sleep deprivation and subsequent improvement of sleep onset and other sleep parameters | |
N.B. Caution is warranted as sleep loss can trigger mania or hypomania episodes | |
Social rhythms therapy for bipolar disorder [265] | ● Integrated behavioral, interpersonal and psychoeducational therapy focusing on: |
- Regularizing daily activity rhythms (that is, eating, sleeping, leisure/work activities, social meetings) | |
- Managing biological or psychosocial factors susceptible of dysregulating biological rhythms | |
● Based on a model of bipolar disorder in which a genetic predisposition to circadian disturbances contributes to bipolar symptoms | |
● Techniques commonly used for insomnia include: progressive muscle relaxation, diaphragmatic breathing, autogenic training and imagery training | |
● Exposure to bright light (especially in the short blue to green wavelengths) has antidepressant and chronobiotic effects | |
● To advances circadian rhythms: | |
Morning exposure to bright light and evening exposure to dim light | |
● To delay circadian rhythms: | |
Evening exposure to bright light and morning exposure to dim light | |
● Extended exposure to darkness can reduce manic symptoms in bipolar disorders | |
● Actimeters with light sensors can be used to monitor adherence | |
Hypnotics/Sedatives | ● In those with delayed circadian rhythms, can be used in the short-term to help realign the sleep phase to a regular schedule |
Stimulant-wakefulness agents | ● In those with daytime fatigue, low energy, reduced locomotor activity and daytime sleeping can been used to increase the wake period |
● Modafinil, a unique wakefulness agent, has been proposed as a treatment for bipolar disorder – including bipolar depression | |
● Often result in longer-term correction of sleep-wake cycle and circadian phase after recovery from depression – assumed via monoamine related mechanisms | |
● Traditionally result in REM-sleep suppression and in the short-term may disturb sleep architecture | |
● Those with more obvious noradrenergic properties have been used (with daytime or morning administration) to also promote daytime activity and arousal and help reduce subjective fatigue | |
● Those with classical serotoninergic properties, when given at night, may increase arousal and wakefulness. While serotoninergic inputs to the SCN are expected to increase wakefulness, selective serotonin reuptake inhibitors (SSRIs) have not proved to be very useful in the management of more prolonged fatigue states compared with either nighttime sleep-promoting agents or daytime stimulants | |
● Inhibits GSK-3β, a kinase involved in the circadian regulation of the SCN | |
● Modulates circadian rhythms (possibly by lengthening the circadian period or delaying endogenous rhythms) | |
● Can enhance the therapeutic effects of combined sleep deprivation and phase advance in people with bipolar disorders | |
● Known to decrease retinal sensitivity to light and could possibly influence melatonin’s sensitivity to light | |
● Can advance sleep onset in those with delayed sleep phase syndrome | |
● Could possibly improve the sleep-wake rhythm and prolong sleep in elderly people with advanced sleep phase syndrome (insufficient empirical data) | |
● Reduce sleep onset latency and improve sleep efficiency (most consistent effects in elderly insomniac) | |
N.B. Not recommended for children and adolescents under 18 years of age because of insufficient safety data (MIMS online) | |
● Direct effects on sleep onset with potential additional effects via other monoamine related mechanisms | |
● Can reduce sleep onset latency and increase sleep duration in patients with insomnia | |
● Could possibly be used to phase shift endogenous melatonin rhythms | |
● Could possibly improve subjective sleep and increase sleep consolidation and SWS in patients with major depression | |
● Can advance endogenous rhythms in older adults | |
N.B. Not recommended for children and adolescents under 18 years of age because of insufficient safety data (MIMS online) |