Tipsheet: Sleep Disturbances in Psychiatric Illness

Most patients with psychiatric diagnoses present with sleep disturbances that can have as great an impact on health-related quality of life as the mental illness itself.¹ Here are tips on treatment and chronotherapeutic applications for major depression and other disorders.

TIPSHEET: SLEEP DISTURBANCES IN PSYCHIATRIC ILLNESS

■ Sleep disturbances are usually treated with sleep-promoting psychopharmacological agents-benzodiazepines or newer hypnotics

■ Although sleep-wake rhythm disturbances in many psychiatric illnesses are not as closely linked to causation as in bipolar disorder, there is accumulating evidence that the worse the entrainment to the 24-hour day, the worse the clinical symptoms

■ Disturbed sleep-wake cycles in patients with schizophrenia have been correlated with poor cognitive function²

■ In patients with borderline personality disorder, disturbed sleep-wake cycles have been correlated with atypical depression symptoms and daytime sleepiness³

■ The primary chronobiological postulate is that integrity of the circadian sleep-wake cycle promotes healthy functioning in all psychiatric disorders⁴

■ This postulate reformulates the classic strategy of establishing stable daily structures to support the process of clinical improvement in neurobiological terms and extends its purview to pragmatic techniques to promote re-entrainment

■ Light therapy may be a helpful additional therapeutic option³

CHRONOTHERAPEUTIC APPLICATIONS FOR MAJOR DEPRESSION

■ Light therapy for seasonal affective disorder, nonseasonal depression, depression during pregnancy

■ Light therapy as adjuvant to SSRIs (nonseasonaldepression, chronic depression, therapy-resistant depression) or lithium (bipolar disorder)

■ Total sleep deprivation (wake therapy)

■ Partial sleep deprivation in the second half of the night

■ Phase advance of the sleep-wake cycle

■ Combinations of sleep manipulations with antidepressants, lithium, light therapy

■ Dark or rest therapy to stop rapid cycling

■ Dark therapy for mania

■ Evening melatonin to enhance circadian phase advances with light

■ Melatonin for sleep disturbances in those who are blind or visually impaired

Further reading:
•www.cet.org, a non-profit Web site
•Wirz-Justice A. The implications of chronobiology for psychiatry. Psychiatr Times. 2011;28(10):56-61. (Click here for a pdf)
•Wirz-Justice A, Benedetti F, Terman M. Chronotherapeutics for  Affective Disorders: A Clinician’s Manual for Light and Wake Therapy. 2nd ed. Basel, Switzerland: Karger; 2013.

This article was originally posted on 5/28/2014 and has since been updated.

Disclosures:

Dr Wirz-Justice is Emerita Professor of psychiatric neurobiology at the Centre for Chronobiology, Psychiatric Hospitals, University of Basel, Switzerland. She reports no conflicts of interest concerning the subject matter of this article.

References:

1. Katz DA, McHorney CA. The relationship between insomnia and health-related quality of life in patients with chronic illness. J Fam Pract. 2002;51:229-235.

2. Bromundt V, Köster M, Georgiev-Kill A, et al. Sleep-wake cycles and cognitive functioning in schizophrenia. Br J Psychiatry. 2011;198:269-276.

3. Bromundt V, Wirz-Justice A, Kyburz S, et al. Circadian sleep-wake cycles, well-being, and light therapy in borderline personality disorder. J Pers Disord. 2013;27:680-696.

4. Wirz-Justice A, Bromundt V, Cajochen C. Circadian disruption and psychiatric disorders: the importance of entrainment. Sleep Med Clin. 2009;4:273-284.