Background. Research on mood disorders has progressively focused on the study of seasons and on the mood in association with them during depressive or manic episodes yet few studies have focused on the seasonal fluctuation that characterizes the patient's clinical course both during an illness episode and during euthymic periods. Methods. 113 euthymic outpatients 46 affected by major recurrent depression and 67 affected by bipolar disorder were recruited. We evaluated the impact of clinical “rhythmical” factors: seasonality, sleep disturbance, and chronotype. Patients completed the SPAQ questionnaire, the MEQ questionnaire, and the medical outcomes study (MOS) sleep scale. We used t-test analyses to compare differences of clinical “rhythmical” and sociodemographic variables and of differences in the assessment scales among the diagnostic groups. Results. Patients reporting a family history for mood disorders have higher fluctuations throughout seasons. Sleep disturbance is more problematic in unipolars when compared to bipolars. Conclusions. Sleep, light, and seasonality seem to be three interconnected features that lie at the basis of chronobiology that, when altered, have an important effect both on the psychopathology and on the treatment of mood disorders. 1. Introduction The degree to which seasonal changes affect mood is known as seasonality. The periodical pattern of recurrence is a biological feature of mood disorders, and the recovery from the first episode of illness is followed by a subsequent recurrence in about 90% of affected patients during their lifetime [1]. In addition, the occurrence of diurnal variations in mood and of distressful and pervasive disruption in sleep suggests a primary disturbance of biological rhythms for mood disorders [2]. The typical pattern of recurrence of mood disorder follows interindividual rules, since each patient presents their own specific pattern with a few episodes during their life, or more than four episodes each year (rapid cycler). Some authors have stressed the concept of seasonality, as many patients show critical months of the year when they tend to have a new recurrence independent of polarity [3]. The recurrence pattern is also affected by external factors, such as exposition to light which appears to have an antidepressant effect both on its own and when associated to acute pharmacological treatments, which shorten the subsequent cycle of illness [4] and maintenance treatments, which are expected to decrease the episode rates. Mood stabilizers, the first choice of treatment for bipolar disorder,
References
[1]
M. B. Keller, R. W. Shapiro, P. W. Lavori, and N. Wolfe, “Relapse in major depressive disorder. Analysis with the life table,” Archives of General Psychiatry, vol. 39, no. 8, pp. 911–915, 1982.
[2]
T. A. Wehr and F. K. Goodwin, Stress, Circadian Rhythms and Affective Disorders. Stress and Coping. Unit I: Psychophysiology, SmithKline Coroporation, Philadelphia, Pa, USA, 1981.
[3]
B. Barbini, D. Di Molfetta, M. Gasperini, M. G. Manfredonia, and E. Smeraldi, “Seasonal concordance of recurrence in mood disorder patients,” European Psychiatry, vol. 10, no. 4, pp. 171–174, 1995.
[4]
M. Maj, F. Veltro, R. Pirozzi, S. Lobrace, and L. Magliano, “Pattern of recurrence of illness after recovery from an episode of major depression: a prospective study,” American Journal of Psychiatry, vol. 149, no. 6, pp. 795–800, 1992.
[5]
F. Benedetti, B. Barbini, C. Colombo, and E. Smeraldi, “Chronotherapeutics in a psychiatric ward,” Sleep Medicine Reviews, vol. 11, no. 6, pp. 509–522, 2007.
[6]
E. Smeraldi, F. Benedetti, B. Barbini, E. Campori, and C. Colombo, “Sustained antidepressant effect of sleep deprivation combined with pindolol in bipolar depression: a placebo-controlled trial,” Neuropsychopharmacology, vol. 20, no. 4, pp. 380–385, 1999.
[7]
F. Benedetti, B. Barbini, A. Lucca, E. Campori, C. Colombo, and E. Smeraldi, “Sleep deprivation hastens the antidepressant action of fluoxetine,” European Archives of Psychiatry and Clinical Neuroscience, vol. 247, no. 2, pp. 100–103, 1997.
[8]
K. Martiny, “Adjunctive bright light in non-seasonal major depression,” Acta Psychiatrica Scandinavica, Supplement, vol. 110, no. 425, pp. 7–28, 2004.
[9]
R. W. Lam, T. A. Bowering, E. M. Tam et al., “Effects of rapid tryptophan depletion in patients with seasonal affective disorder in natural summer remission,” Psychological Medicine, vol. 30, no. 1, pp. 79–87, 2000.
[10]
A. Wirz-Justice, W. Puehringer, and Q. Hole, “Sleep deprivation and clomipramine in endogenous depression,” Lancet, vol. 2, no. 7991, p. 912, 1976.
[11]
S. Elsenga and R. H. van den Hoofdakker, “Clinical effects of sleep deprivation and clomipramine in endogenous depression,” Journal of Psychiatric Research, vol. 17, no. 4, pp. 361–374, 1982.
[12]
H. Kuhs, D. F？rber, S. Borgst？dt, S. Mrosek, and R. T？lle, “Amitriptyline in combination with repeated late sleep deprivation versus amitriptyline alone in major depression. A randomised study,” Journal of Affective Disorders, vol. 37, no. 1, pp. 31–41, 1996.
[13]
F. Benedetti, E. Campori, B. Barbini, M. C. Fulgosi, and C. Colombo, “Dopaminergic augmentation of sleep deprivation effects in bipolar depression,” Psychiatry Research, vol. 104, no. 3, pp. 239–246, 2001.
[14]
F. Benedetti, C. Colombo, A. Pontiggia, A. Bernasconi, M. Florita, and E. Smeraldi, “Morning light treatment hastens the antidepressant effect of citalopram: a placebo-controlled trial,” Journal of Clinical Psychiatry, vol. 64, no. 6, pp. 648–653, 2003.
[15]
J. I. Nurnberger Jr., S. Adkins, D. K. Lahiri et al., “Melatonin suppression by light in euthymic bipolar and unipolar patients,” Archives of General Psychiatry, vol. 57, no. 6, pp. 572–579, 2000.
[16]
S. Kasper and T. Kamo, “Seasonality in major depressed inpatients,” Journal of Affective Disorders, vol. 19, no. 4, pp. 243–248, 1990.
[17]
G. Murray, N. B. Allen, and J. Trinder, “Seasonality and circadian phase delay: prospective evidence that winter lowering of mood is associated with a shift towards Eveningness,” Journal of Affective Disorders, vol. 76, no. 1–3, pp. 15–22, 2003.
[18]
V. Natale, A. Adan, and P. Scapellato, “Are seasonality of mood and eveningness closely associated?” Psychiatry Research, vol. 136, no. 1, pp. 51–60, 2005.
[19]
C. A. Perlman, S. L. Johnson, and T. A. Mellman, “The prospective impact of sleep duration on depression and mania,” Bipolar Disorders, vol. 8, no. 3, pp. 271–274, 2006.
[20]
P. A. Madden, A. C. Heath, N. E. Rosenthal, and N. G. Martin, “Seasonal changes in mood and behavior: the role of genetic factors,” Archives of General Psychiatry, vol. 53, no. 1, pp. 47–55, 1996.
[21]
K. L. Jang, R. W. Lam, W. J. Livesley, and P. A. Vernon, “Gender differences in the heritability of seasonal mood change,” Psychiatry Research, vol. 70, no. 3, pp. 145–154, 1997.
[22]
V. Natale, E. Danesi, and P. Scapellato, “Validazione della versione italiana del Seasonal Pattern Assessment Questionnaire (SPAQ),” Testing Psicometria Metodologia, vol. 10, no. 1-2, pp. 33–42, 2003.
[23]
S. Kasper, T. A. Wehr, J. J. Bartko, P. A. Gaist, and N. E. Rosenthal, “Epidemiological findings of seasonal changes in mood and behavior. A telephone survey of Montgomery county, Maryland,” Archives of General Psychiatry, vol. 46, no. 9, pp. 823–833, 1989.
[24]
J. A. Horne and O. Ostberg, “A self assessment questionnaire to determine Morningness Eveningness in human circadian rhythms,” International Journal of Chronobiology, vol. 4, no. 2, pp. 97–110, 1976.
[25]
I. Chelminski, F. R. Ferraro, T. Petros, and J. J. Plaud, “Horne and Ostberg questionnaire: a score distribution in a large sample of young adults,” Personality and Individual Differences, vol. 23, no. 4, pp. 647–652, 1997.
[26]
V. Natale and P. Cicogna, “Morningness-eveningness dimension: is it really a continuum?” Personality and Individual Differences, vol. 32, no. 5, pp. 809–816, 2002.
[27]
V. Natale, “Validazione di una scala ridotta di Mattutinità (rMEQ),” Bollettino di Psicologia Applicata, vol. 229, pp. 19–26, 1999.
[28]
A. L. Stewart, R. D. Hays, and J. E. Ware Jr., “The MOS short-form general health survey. Reliability and validity in a patient population,” Medical Care, vol. 26, no. 7, pp. 724–735, 1988.
[29]
D. L. McEachron, D. F. Kripke, R. Hawkins, et al., “Lithium delays biochemical circadian rhythms in rats,” Neuropsychobiology, vol. 8, no. 1, pp. 12–29, 1982.
[30]
A. Wirz-Justice and R. H. Van Den Hoofdakker, “Sleep deprivation in depression: What do we know, where do we go?” Biological Psychiatry, vol. 46, no. 4, pp. 445–453, 1999.
[31]
S. S. Campbell, J. C. Gillin, D. F. Kripke, D. S. Janowsky, and S. C. Risch, “Lithium delays circadian phase of temperature and REM sleep in a bipolar depressive: a case report,” Psychiatry Research, vol. 27, no. 1, pp. 23–29, 1989.
[32]
M. S. Kafka, A. Wirz-Justice, D. Naber, et al., “Effect of lithium on circadian neurotransmitter receptor rhythms,” Neuropsychobiology, vol. 8, no. 1, pp. 41–50, 1982.
[33]
P. Morin, “Serotonin and the regulation of mammalian circadian rhythmicity,” Annals of Medicine, vol. 31, no. 1, pp. 12–33, 1999.
[34]
W. E. Bunney and B. G. Bunney, “Molecular clock genes in man and lower animals: possible implications for circadian abnormalities in depression,” Neuropsychopharmacology, vol. 22, no. 4, pp. 335–345, 2000.
[35]
H. Klemfuss, “Rhythms and the pharmacology of lithium,” Pharmacology & Therapeutics, vol. 56, no. 1, pp. 53–78, 1992.
[36]
O. C. Ikonomov and H. K. Manji, “Molecular mechanisms underlying mood stabilization in manic-depressive illness: the phenotype challenge,” American Journal of Psychiatry, vol. 156, no. 10, pp. 1506–1514, 1999.
[37]
T. H？t？nen, S. Forsblom, T. Kiesepp？, J. L？nnqvist, and T. Partonen, “Circadian phenotype in patients with the co-morbid alcohol use and bipolar disorders,” Alcohol and Alcoholism, vol. 43, no. 5, pp. 564–568, 2008.
[38]
H. A. Mansour, J. Wood, K. V. Chowdari et al., “Circadian phase variation in bipolar I disorder,” Chronobiology International, vol. 22, no. 3, pp. 571–584, 2005.
[39]
C. Johansson, M. Willeit, C. Smedh et al., “Circadian clock-related polymorphisms in seasonal affective disorder and their relevance to diurnal preference,” Neuropsychopharmacology, vol. 28, no. 4, pp. 734–739, 2003.
[40]
E. W. Lamont, D. Legault-Coutu, N. Cermakian, and D. B. Boivin, “The role of circadian clock genes in mental disorders,” Dialogues in Clinical Neuroscience, vol. 9, no. 3, pp. 333–342, 2007.
[41]
L. M. Giglio, P. V. Magalh？es, M. L. Andersen, J. C. Walz, L. Jakobson, and F. Kapczinski, “Circadian preference in bipolar disorder,” Sleep and Breathing, vol. 14, no. 2, pp. 153–155, 2010.
[42]
J. Taillard, P. Philip, and B. Bioulac, “Morningness/eveningness and the need for sleep,” Journal of Sleep Research, vol. 8, no. 4, pp. 291–295, 1999.
[43]
M. A. Carskadon and W. C. Dement, “Cumulative effects of sleep restriction on daytime sleepiness,” Psychophysiology, vol. 18, no. 2, pp. 107–113, 1981.
[44]
K. Shin, A. Schaffer, A. J. Levitt, and M. H. Boyle, “Seasonality in a community sample of bipolar, unipolar and control subjects,” Journal of Affective Disorders, vol. 86, no. 1, pp. 19–25, 2005.
