Cases That Test Your Skills The bedtime solution Mitchell Levy, MD, and Kimberly McLaren, MD Depressed and suicidal, Ms. W had not found relief after How would you years of medication trials and electroconvulsive therapy. handle this case? Visit CurrentPsychiatry.com Then her psychiatrists tried a novel intervention. to input your answers and see how your colleagues responded CASE Refractory depression • nortriptyline for migraine headache pro- Ms. W, age 38, is brought to the emergency de- phylaxis. partment after her son fi nds her unresponsive Some medications were not tolerated, pri- ® and calls 911. Suff ering from worsening depres- Dowdenmarily because Health of increased Media anxiety. Those sion, she wrote a note telling her children good- that were tolerated were adequate trials in bye, and overdosed on zolpidemCopyright from anFor old personalterms of dose titrationuse andonly length. High-dose prescription and her daughter’s opioids. After fl uoxetine (80 mg/d) augmented by risperi- being evaluated and medically cleared in the done (0.375 to 0.5 mg/d) produced the most emergency department, Ms. W was admitted to reliable and signifi cant improvement. the psychiatric unit. Ms. W had 2 courses of electroconvulsive Ms. W has a history of recurrent major de- therapy (ECT) totaling 30 treatments—most pressive disorder that developed after she was recently in 2007—that resulted in signifi cant sexually abused by a relative as a teen. She also memory loss with limited benefi t. Premen- has bulimia nervosa, alcohol dependence, and strual worsening of depression and suicidality posttraumatic stress disorder. She was hospital- were noted. In collaboration with her gynecolo- ized twice for depression and suicidality but had gist, Ms. W was treated with a 3-month trial of not previously attempted suicide. In the mid- leuprolide to suppress her ovarian axis, which to-late 1990s, she had trials of paroxetine, clomi- was helpful. In 2008 she underwent bilateral pramine, lithium, and bupropion. oophorectomy. She has not had symptoms of She was seen regularly in our outpatient mood elevation or psychosis. Family history in- psychiatry clinic for medication management cludes schizophrenia, depression, anxiety, and and supportive psychotherapy. Since being fol- alcoholism. lowed in our clinic starting in early 2005, she has In the months before hospitalization, Ms. had the following medication trials: W had been increasingly depressed and in- • fl uoxetine, citalopram, venlafaxine XR, termittently suicidal, although she did not and duloxetine for depression endorse a specifi c plan or intention to harm • atomoxetine, buspirone, liothyronine, herself because she was concerned about risperi done, and aripiprazole for anti- the impact suicide would have on her chil- depressant augmentation dren. Weight gain with risperidone had reac- • lorazepam, clonazepam, and gabapentin for anxiety Dr. Levy is assistant professor and Dr. McLaren is acting assistant professor, department of psychiatry, University of Washington, Current Psychiatry • zolpidem and trazodone for insomnia Seattle, WA. Vol. 8, No. 12 91 For mass reproduction, content licensing and permissions contact Dowden Health Media. 091_CPSY1209 091 11/16/09 12:12:26 PM Cases That Test Your Skills tivated body image issues, so Ms. W stopped gested that rates of total sleep deprivation- taking this medication 2 weeks before hos- induced mania are likely to be similar to pitalization. Her depression became worse, or less than those reported for antidepres- and she began using her husband’s hydroco- sants. Because sleep deprivation can induce done/acetaminophen prescription. seizures, this therapy is contraindicated for patients with epilepsy or those at risk for What depression treatment would you con- seizures.4 sider next for Ms. W? a) retrial of fl uoxetine and an atypical What adjuncts could help sustain a antipsychotic with a lower potential for depressed patient’s response to partial weight gain, such as aripiprazole sleep deprivation? b) lithium with a tricyclic antidepressant a) light therapy c) bilateral ECT b) lithium Clinical Point d) chronotherapy utilizing sleep deprivation c) antidepressants Sleep deprivation d) sleep-phase advance The authors’ observations e) all of the above is a rapid, eff ective Approximately 40% of patients with ma- treatment for jor depression fail to respond to an initial Researchers have successfully explored depression but antidepressant trial.1 An additional 50% of strategies to reduce the rate of depressive up to 80% of these patients will be treatment-resistant relapse after sleep deprivation, including 1 patients experience to a subsequent antidepressant. Patients coadministering light therapy, antidepres- may be progressively less likely to respond sants, lithium (particularly for bipolar depressive relapse to additional medication trials.2 depression), and sleep-phase advance.4 One of the most rapid-acting and effec- Sleep-phase advance involves shifting the tive treatments for unipolar and bipolar de- sleep-wake schedule to a very early sleep pression is sleep deprivation. Wirz-Justice time and wake-up time (such as 5 PM to et al3 found total or partial sleep depriva- midnight) for 1 day, and then pushing back tion during the second half of the night this schedule by 1 or 2 hours each day until induced rapid depression remission. Re- the patient is returned to a “normal” sleep sponse rates range from 40% to 60% over schedule (such as 10 PM to 5 AM). Research- hours to days.4 Sleep deprivation also can ers have demonstrated that sleep-phase reduce suicidality in patients with season- advance can have antidepressant effects.7 al depression.5 This treatment has not been widely employed, however, because up to 80% of patients who undergo sleep depri- TREATMENT Sleep manipulation vation experience rapid and signifi cant de- Ms. W is continued on fl uoxetine, 80 mg/d. pressive relapse.4 We opt for a trial of partial sleep deprivation Sleep deprivation usually is well toler- and sleep-phase advance for Ms. W because ated. Potential side effects include: of the severity of her depression, her mul- • headache tiple ineff ective or poorly tolerated medica- • gastrointestinal upset tion trials, and limited benefi t from ECT. This • fatigue treatment involves instituting partial sleep • cognitive impairment. deprivation the fi rst night and subsequently Less often, patients report worsening of advancing her sleep phase over the next sev- depressive symptoms and, rarely, suicidal eral days (Table 1, page 96). ideation or psychosis.4 Mania or hypoma- Although she is sleepy the morning after nia are potential complications of sleep partial sleep deprivation, Ms. W reports a loss for patients with bipolar or unipolar marked improvement in her mood, decline Current Psychiatry 92 December 2009 depression. In a review, Oliwenstein6 sug- in hopelessness, and absence of suicidal continued on page 96 092_CPSY1209 092 11/16/09 12:12:30 PM Cases That Test Your Skills continued from page 92 Table 1 Ms. W’s chronotherapy protocol: Hours permitted for sleep* Day number 12345 Sleep deprivation 9 PM to 2 AM Sleep-phase 5 PM to 7 PM to 9 PM to 10 PM to advance midnight 2 AM 4 AM 5 AM *Treatment was implemented while Ms. W was hospitalized ideation. She continues the sleep-phase previously responded to antidepressant aug- advance protocol for the next 3 nights and mentation with an atypical antipsychotic we participates in cognitive-behavioral therapy add aripiprazole and titrate the dosage to 7.5 groups and ward activities. Psychiatric unit mg/d. We also continue fl uoxetine, 80 mg/d, staff support her continued wakefulness dur- and add trazodone, 100 mg at bedtime, and ing sleep manipulation. Because Ms. W had hydroxyzine, 25 mg as needed. MAINTAINING WELLNESS IN PATIENTS WITH BIPOLAR DISORDER moving beyond eff icacy to effectiveness FREE 2.0 CME CREDITS FREE PARTICIPATING FACULTY SUPPLEMENT TO Sponsored by 2.0 CME S. Nassir Ghaemi, MD, MPH Available at www.currentpsychiatry.com credits A DOWDEN PUBLICATION October 2009 Director, Mood Disorders and Psychopharmacology Maintaining wellness in Available at Programs patients with Professor of Psychiatry CurrentPsychiatry.com Tufts Medical Center bipolar disorder: Boston, Massachusetts MOVING BEYOND EFFICACY TO Robert M. A. Hirschfeld, MD EFFECTIVENESS Titus H. Harris Chair FACULTY Harry K. Davis Professor S. Nassir Ghaemi, MD, MPH Robert M. A. Hirschfeld, MD Professor and Chairperson Claudia F. Baldassano, MD Department of Psychiatry and Behavioral Sciences University of Texas Medical Branch Galveston, Texas This supplement was submitted by SciMed and supported by an educational grant from AstraZeneca. It was peer Claudia F. Baldassano, MD reviewed by CURRENT PSYCHIATRY. Supported by an educational grant from Assistant Professor of Psychiatry Director, Bipolar Outpatient Program Hospital of the University of Pennsylvania A CME-certifi ed supplement enduring from the 2009 CURRENT PSYCHIATRY/AACP Symposium. Philadelphia, Pennsylvania This activity is sponsored by SciMed and supported by an educational grant from AstraZeneca. It was peer reviewed by CURRENT PSYCHIATRY. 096_CPSY1209 096 11/17/09 2:45:39 PM Cases That Test Your Skills The authors’ observations Table 2 Chronotherapy incorporates manipulations Sleep deprivation for depression: of the sleep/wake cycle such as sleep depri- Possible mechanisms vation and dark or light therapy. It may use combinations of interventions to generate Mechanism Components and sustain a response in