Role of adjunctive nonpharmacological strategies for treatment of rapid-cycling bipolar disorder

Table 2 Studies of adjunctive chronotherapy in rapid-cycling bipolar disorder

Ref.	Sample	Results
Case reports
Christodoulou et al[131], 1978	26-yr-old woman with rapid-cycling episodes of severe recurrent depression resistant to medications	Inpatient and outpatient total sleep deprivation every week for 36 wk led to remission for a period of 10 mo. The patient committed suicide after stopping the maintenance sleep deprivation treatments
Lovett Doust and Christie[132], 1980	48-yr-old woman with medication-resistant RCBD	Five nights of total sleep deprivation combined with medications during depressive episodes for 8 mo led to reduction in intensity and duration of depression. Switches into hypomania were recorded
Churchill and Dilsaver[133], 1990	47-yr-old woman with rapid-cycling episodes of severe recurrent depression	Partial sleep deprivation on alternate nights combined with an antidepressant led to complete remission from depression for 6 wk
Benjamin and Zohar[58], 1992	45-yr-old man with treatment-resistant RCBD resistant to antidepressants	One night of sleep deprivation was successful in aborting depressive episodes, but led to prolonged hypomania on one occasion and did not prevent the rapid-cycling pattern
Gann et al[134], 1993	64-yr-old man with ultradian-RCBD	Total sleep deprivation for 3 nights led to reduction of depressive symptoms for 2 wk. Further improvement occurred with carbamazepine
Eagles[135], 1994	50-yr-old man with medication-resistant ultradian-RCBD	Daily morning BLT for 2 mo produced sustained remission without hypomanic switches
Kusumi et al[136], 1995	2 patients with medication-resistant RCBD and nonseasonal depressions	Morning BLT led to improvement in sleep and mood. Withdrawal of BLT did not result in relapse. Remission was maintained for several months
Wehr et al[137], 1998	51-yr-old man with medication-resistant RCBD treated with 10–14 h of darkness, rest, and sleep over 1.5 yr	Dark therapy helped in stabilizing sleep, reducing hypomanic symptoms, and attenuating rapid cycling for the period of treatment. Lower doses of antipsychotics were required and hospital stay was shorter
Wirz-Justice et al[138], 1999	70-yr-old woman with medication-resistant ultra-RCBD	Rapid-cycling ceased on initiation of 10–14 h of darkness, rest, and sleep. Depression improved with mid-day BLT and remission was achieved with morning BLT. Patient remained on valproate and was stable for a year
Leibenluft and Suppes[127], 1999	42-yr-old woman with medication resistant ultra-RCBD	A lifestyle intervention that ensured a regular sleep–wake schedule in combination with medications led to decrease in rapid cycling
Observational studies
Papadimitriou et al[139], 1981	5 patients with treatment-resistant RCBD	Weekly regimens of total sleep deprivation administered over several months reduced relapses and increased the duration of remissions
Wehr et al[140], 1982	9 patients with RCBD treated with 1 night of total sleep deprivation during depressive episodes	Depressive symptoms improved in 8 patients with sleep deprivation but 7 developed mania or hypomania
Papadimitriou et al[141], 1993	5 medication-free patients with RCBD treated with total sleep deprivation twice a week for 4 wk	All 5 patients responded to sleep deprivation treatment with > 50% improvement in depressive symptoms and remained in remission for a year with weekly sleep deprivation treatments. Rapid-cycling, young age, female sex, family history of mood disorder and illness duration < 10 yr predicted response. Hypomania was observed in 1 patient
Gill et al[142], 1993	3 patients with treatment-resistant RCBD treated with total sleep deprivation and mood stabilizers and antidepressants	Duration of response was significantly better when sleep deprivation treatment was administered late rather than early in the depressive episodes
Leibenluft et al[143], 1995	9 patients with RCBD treated with 3 mo of BLT and medications versus 3 mo of only medication treatment	Mid-day BLT was more effective in reducing depressive symptoms and days spent depressed than morning or evening BLT. Morning BLT precipitated hypomanic switches
Koukopoulos et al[70], 2003	2 women with RCBD	Sleep deprivation resulted in a temporary improvement of depression

BLT: Bright light therapy; RCBD: Rapid-cycling bipolar disorder; Ultra-RCBD: Ultra-rapid-cycling with shorter cycles of days to weeks; Ultradian-RCBD: Ultradian rapid-cycling with episodes lasting less than a day; Partial sleep deprivation: Sleep deprivation during the second half of the night; Total sleep deprivation: Sleep deprivation for 36 h.