Chronotherapeutics for Affective Disorders. A Clinician’s Manual for Light and Wake Therapy. Wirz-Justice A, Benedetti F, and Terman M. Karger, 2009

When it comes to mood disorders, American psychiatry, by and large, lacks rhythm. That is, it lacks an interest in research on circadian rhythms, the relevance of circadian neurobiology for understanding the pathophysiology of affective disorders, and in the application of such studies to generating new treatment techniques. Several European countries, in contrast, appear to feel this groove and have generated decades of clinical research in this area. So what gives?

For those of us interested in this area, the source of this rhythm agnosia, apathy and apraxia has been infinitely perplexing. Is it the absence of financial support from Pharma which limits research and clinical work in this area? Is it the absence of insurance reimbursement for therapies that are neither psychotherapeutic nor psychopharmacologic? Is it the lack of cross talk between basic scientists studying human timing and clinicians treating mood disorders? Or is it the lack of sexiness in the ultra low-tech nature of these treatments? Whatever the reason, and I’m sure there are many, this book is an initial attempt to help clinicians in this country understand and better use information about biological rhythms in our clinical work with affective illness.

Having set the stage, my capsule summary: A long-overdue, wonderful first step.

Chronotherapeutics for Affective Disorders is a neat, concise book which provides a very basic review of circadian neurobiology along with a how-to section that explains both the evidence for these treatments and a simple explanation of how they are to be conducted. As per my introduction, it is no surprise that two of the three authors of this little gem are European. Collectively, they represent leaders of the field and they have an unmistakable agenda to promote the use of circadian-modifying interventions.

Chronotherapies (from Greek Mythology, Chronos, for time) are any treatment that manipulates circadian rhythms for symptomatic benefit. While the focus of this book is on their use in the treatment of affective disorders, these strategies are also used for neurologic, sleep, and other conditions. The major forms of chronotherapy used today and the ones with the most empiric validation are sleep deprivation (rechristened Wake Therapy to avoid nasty connotations), light therapy, and sleep phase advance. Each is reviewed in clear and simple language that is enhanced by helpful diagrams and figures. Think Stephen Stahl-type clarity and exposition.

Always starting with the basics, the reader is carried from what is more common knowledge to more rarefied and detailed explanation. For example, information on the use of light therapy for seasonal affective disorder is leavened with practical guidance on what types of light to use, length and timing of administration, potential side-effects and non-seasonal mood indications and contraindications for this treatment. Similarly, though most of us know that keeping our depressed patients up for a full night can effect a rapid but transient remission, this book reviews a substantial body of literature on the use of various augmenting measures (concurrent use of lithium, SSRI antidepressants, sleep phase advance and/or bright light therapy), how these measures cement and preserve the initial antidepressant response, and thus makes the case that these wake therapy packages are some of the fastest, most effective and safest methods currently available. Making their survey complete, the authors include brief sections on dark therapy, melatonin and other chronobiotics, and chronotherapeutic strategies for children and the elderly. An appendix provides valuable diagnostic instruments used to rate and track rhythm-influenced mood disorders and circadian phase status.

Shortcomings? This is a very introductory primer. Those wanting more depth will not be satisfied with this book alone. If this shoe fits you, consider The Principles and Practice of Sleep Medicine, 4th Edition; the sections on circadian rhythms provide a deeper foundation in the basic sciences.

In sum, this is a small work with a large agenda. It aims to educate mental health clinicians about the basics of circadian timing and how alterations in these intrinsic oscillations can contribute to mood disturbances. It then provides step by step guidance on how to use circadian-modifying strategies to treat depression, mania and mood instability. It’s not easy helping people develop a sense of rhythm. This book provides much-needed and elementary dance lessons for those who haven’t been able to appreciate the beat.

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