Bipolar disorder (BD) is a major mood disorder that is characterized by manic and depressive symptoms which fluctuate in severity and over time. The affective burden of the illness is compounded by cognitive, psychosocial, and occupational dysfunction, along with increased rates of suicide, medical comorbidity, and premature mortality. [1][2][3][4][5][6][7] Current guidelines for the management of BD include treatments that are limited by suboptimal efficacy rates, medication intolerance, delayed onset of action, iatrogenic mood switches, and variable patient acceptability. There is a pressing public health need for measures to combat these shortcomings. The fields of chronobiology and chronotherapy offer alternative treatment strategies which may address these limitations. The primary aim of this project was to systematically review efficacy and tolerability evidence of the major chronotherapies for BD and propose practice recommendations based on this review. This commences with a brief introduction to chronobiology to provide a rudimentary overview of the basic science which underlies this field of treatment. | Introduction to the circadian systemThe basic science of chronobiology is the study of biological rhythms, biological timekeeping systems, and their effects on human health and disease. 8 The human time-keeping system is a strongly conserved, phylogenetically ancient, hierarchically organized, and open neurobiological network. It evolved to enable organisms to anticipate and coordinate their internal physiology

Successful mood stabilizing treatments reduce intracellular sodium in an activity-dependent manner. This can also be achieved with acidification of the blood, as is the case with the ketogenic diet. Two women with type II bipolar disorder were able to maintain ketosis for prolonged periods of time (2 and 3 years, respectively). Both experienced mood stabilization that exceeded that achieved with medication; experienced a significant subjective improvement that was distinctly related to ketosis; and tolerated the diet well. There were no significant adverse effects in either case. These cases demonstrate that the ketogenic diet is a potentially sustainable option for mood stabilization in type II bipolar illness. They also support the hypothesis that acidic plasma may stabilize mood, perhaps by reducing intracellular sodium and calcium.

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The Diagnostic Guidelines Task Force of the International Society for Bipolar Disorders (ISBD) presents in this document and this special issue a summary of the current nosological status of bipolar illness, a discussion of possible revisions to current DSM-IV and ICD-10 definitions, an examination of the relevant literature, explication of areas of consensus and dissensus, and proposed definitions that might guide clinicians in the most valid approach to diagnosis of these conditions given the current state of our knowledge.

The bipolar spectrum model suggests that several patient presentations not currently recognized by the DSM warrant consideration as part of a mood disorders continuum. These include hypomania or mania associated with antidepressants; manic symptoms which fall short of the current DSM threshold for hypomania; and depression attended by multiple non-manic markers that are associated with bipolar course. Evidence supporting the inclusion of these groups within the realm of bipolar disorder (BP) is examined. Several diagnostic tools for detecting and characterizing these patient groups are described. Finally, options for altering DSM-IV criteria to allow some of the above patient presentations to be recognized as bipolar are considered. More data on the validity and utility of these alterations would be useful, but limited changes appear warranted now. We describe an additional BP Not Otherwise Specified (BP NOS) example which creates a subthreshold hypomanic analogue to cyclothymia, consistent with existing BP NOS criteria. This change should be accompanied by additional requirements for the assessment and reporting of non-manic bipolar markers.