The chronotherapeutic treatment of bipolar disorders: A systematic review and practice recommendations from the ISBD task force on chronotherapy and chronobiology

Abstract

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

Efficacy and safety of bright light therapy for manic and depressive symptoms in patients with bipolar disorder: A systematic review and meta‐analysis

“…As an alternative chronotherapy, SD is also used for bipolar depression, and has been recommended by the ISBD Task Force. 19 Its effectiveness has also been demonstrated by a meta-analysis. 44 Furthermore, BLT may be performed in combination with SD to enhance and maintain the effect of SD.…”

“…The result of our sensitivity analysis was consistent with the ISBD Task Force's recommendations. 19 The lack of a significant antidepressant effect in our review may stem from the inclusion of only RCT, as well as the small sample sizes and high heterogeneity of the studies. Additional well-designed studies will be required in order to conclusively demonstrate the potential of BLT as an effective chronotherapeutic treatment option for bipolar depression.…”

“…The results of this study, which suggest that BLT does not have a significant antidepressant effect, are inconsistent with those of a previous meta-analysis by Tseng et al and a recent systematic review by the ISBD Task Force, which suggested that BLT is an effective treatment for bipolar depression. 19,21 Among the 11 studies 20,22,[34][35][36][37][38][39][40][41][42] included in the meta-analysis by Tseng et al, 21 seven were not RCT and had a single-arm design 35,36,[38][39][40][41][42] and six studies combined BLT and SD without an SD-only control group. [35][36][37][38]40,41 Moreover, 70% of the subjects in one study had major depressive disorder, 22 which might have affected the results.…”

“…The systematic review conducted by the ISBD Task Force also included non-RCT, and their recommendations were derived from the consensus opinions of the authors, which were based on a synthesis of the efficacy and tolerability data generated from their review. 19 In contrast, our meta-analysis evaluated only RCT and only trials with at least 80% of patients with BD. We also made sure that the control group treatment conditions were similar to those of the intervention group.…”

“…The International Society of Bipolar Disorders (ISBD) Task Force on Chronobiology and Chronotherapy recommended BLT for the acute phase of bipolar depression, and concluded that BLT had the strongest evidence among current chronotherapeutic options. 19 However, only one meta-analysis has examined the effects of BLT on bipolar depression. 20 Tseng et al reported that treatment with BLT had statistically significant antidepressant effects and did not increase mood polarity compared to treatment without BLT.…”