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The Effect of Chronotherapy on Depressive Symptoms

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The Effect of Chronotherapy on Depressive Symptoms Review Article The effect of chronotherapy on depressive symptoms Evidence-based practice Anas H. Khalifeh, MSN, CNS. ABSTRACT From the Department of Nursing, Prince Hamzah Hospital, Ministry of Health, Amman, Jordan. ,Address correspondence and reprint request to: Dr. Anas H. Khalifeh النسبة العامليه لالكتئاب تتزايد, مع معدالت العجز املرتبط Department of Nursing, Prince Hamzah Hospital, Ministry of Health, Amman, Jordan. E-mail: [email protected] باالكتئاب والوفيات, مما يجعل االكتئاب قضية صحية عامة. عالج ORCID ID: http://orcid.org/0000-0002-5649-5124 الساعة البيولوجية تشمل مجموعة متنوعة من االستراتيجيات التي تتحكم في التعرض للمؤثرات البيئية التي تنظم الساعة البيولوجية, مثل احلرمان من النوم )SD (أو عالج االستيقاظ )WT(, مرحلة النوم epression is a complex disorder involving املتقدم )SPA , (و عالج الضوء و الظالم )LT, DT(. الهدف من ,Dthe interaction of genetic, physiological ورقة املمارسة القائمة على األدلة هو اإلجابة على أسئلة )PICOT( psychological, and environmental factors, resulting in من خالل استعراض فعالية تدخالت عالجات الساعة البيولوجية ,clinical manifestations that include a variety of affective على أعراض االكتئاب عند االكتئاب واالكتئاب ضمن االضطراب ,cognitive, somatic, and behavioral symptoms.1 As such الثنائي القطب. وتشير دراسات سابقة فعالية احلرمان من النوم أو individuals experiencing depressive episodes exhibit عالج االستيقاظ, مرحلة النوم املتقدم, و عالج الضوء أو الظالم, ,variations in sleep/wake patterns )sleep architecture كشفت املزيد من البحوث التي أجريت مؤخراًاالختالفات في فعالية التدخالت املنفردة واملشتركة التي تنطوي على مكونات كل من sleep disturbances( and daily mood, in addition to عالجات الساعة البيولوجية والدوائية. هذا العالج خفض مدة البقاء abnormal levels of adrenocorticotropic hormone and في املستشفى, حتسن التعافي, وخفض تغير في وصفات الدوائية. cortisol secretion. Such depressive episodes are also The global prevalence of depression is increasing, characterized by impaired attention, altered food intake, along with rates of depression-associated disability learning and memory dysfunction, psychological and mortality, rendering depressive disorders a major public health issue. Chronotherapy involves a variety stress, and decreased psychomotor functioning. These of strategies that control exposure to environmental alterations are collectively referred to as chronobiological stimuli that influence the biological clock, such as sleep disruption.1-3 deprivation )SD( or wake therapy )WT(, sleep phase Major depressive disorder )MDD( is characterized advance )SPA(, and light and dark therapy )LT, DT(. The purpose of this Evidence-Based Practice )EBP( by the presence of persistently depressed mood )low paper is to answer PICOT questions by a review the mood(; loss of interest or pleasure; feelings of grief, effectiveness of chronotherapeutics interventions on guilt, or worthlessness; decreased energy, disturbed sleep depressive symptoms with depression and the depressive 4,5 episode in the course of bipolar disorder. Early studies or appetite; poor concentration; and hopelessness. suggested the effectiveness of LT, SD, and SPA, more According to the Fifth Edition of the Diagnostic and recent research has revealed differences in the efficacy Statistical Manual of Mental Disorders )DSM-5(, of single and combined interventions involving both depression is diagnosed when the patient presents chronotherapeutic and pharmacological components. This therapy reduced dura tion of hospitalization, with substantial changes in functioning lasting at least improvement recovery, and reduced for changes in drug 2 weeks )mood, pleasure, social, occupational, and prescriptions. psychomotor function(.5 In 2010, the Global Burden of Disease Study Saudi Med J 2017; Vol. 38 (5): 457-464 concluded that depression was the second greatest cause doi: 10.15537/smj.2017.5.18062 of disability worldwide, affecting an estimated 300 OPEN ACCESS www.smj.org.sa Saudi Med J 2017; Vol. 38 )5( 457 Choronotherapy and depressive symptoms ... Khalifeh million people globally.6 Similarly, the World Health of strategies that control exposure to environmental Organization )WHO( reported depressive disorder stimuli that influence the biological clock, such as sleep as a leading cause of disability worldwide, and that deprivation )SD( or wake therapy )WT(, sleep phase the condition affects an estimated 350 million people advance )SPA(, and light and dark therapy )LT, DT(.21 worldwide.4 Furthermore, the global prevalence of Several studies have reported that chronotherapy is depression is increasing, along with rates of depression- effective in the treatment of mood and sleep disorders, associated disability and mortality, rendering depressive including depression.22 disorders a major public health issue.4,7 Briley and According to Wirz-Justice and Terman,23 Lépine8 reported that approximately 10-15% of people chronotherapeutics refers to nonpharmaceutical worldwide and 3-9% in Japan are affected by depression. treatments designed to control exposure to external Moreover, Samuels et al9 stated that depression is the environmental stimuli that act on biological rhythms. most common psychiatric condition in the United Chronotherapy interventions are based on circadian States, with a prevalence as high as 18.9%. In addition, rhythms, which direct a variety of biological processes on a the symptoms of depression exert a substantial near-24-hour cycle.24 Circadian rhythms are responsible impact on occupational and social functioning, for generating biologic rhythms and variations in the potentially increasing the economic burden. Indeed, a function of physiological and biochemical processes, previous study estimated that the cost of treatment is such as the activity of the sleep-wake cycle and approximately $2000 per citizen.10 emotional state.25 These rhythms drive and synchronize Although the fundamental treatment for depression neurotransmitter and hormone secretion, body involves pharmacotherapy,11,12 many people do not seek temperature, and day-to-day stability according to formal treatment with anti-depressive agents13 due to pre-programmed patterns.26,27 The suprachiasmatic the high costs and risk of side effects, which can also nucleus )SCN( is considered the circadian pacemaker.28 prevent adherence once treatment has been initiated.14 and contains high concentrations of serotonin and Thus, individuals with depression may seek to decrease melatonin receptors.29 Chronotherapy aims to restore their symptoms via complementary and alternative the balance of these neurotransmitter systems by medicine )CAM(, which may be associated with fewer resynchronizing circadian rhythms.30-32 Indeed, research side effects. Samuels et al9 reported that the use of has indicated that such treatment exerts a positive CAM is increasing, especially in patients diagnosed impact on depressive symptoms.33 with anxiety and depression. However, there is no clear Although the author was unable to find studies definition of what constitutes CAM.15 Furthermore, the regarding the prevalence of depression in Jordan, National Health Service )NHS( has stated that there is Hamid34 reported that the prevalence of depression no universally accepted definition of CAM,16 which was higher than 30% among 493 randomly selected often differs among various countries.17 female patients. Additional studies have reported However, CAM has recently been defined to that depression is a major public health concern in encompass therapies, interventions, and products developing countries,35 suggesting that the prevalence that are regarded as equal in efficacy to conventional of depression may be high in Jordan. pharmacotherapy, with increased adherence and fewer Methodology. PICOT Question Structure. Recently, side effects.18 Such treatments are often perceived as mental health research has focused on the use of evidence- more natural, economical, and are available without based practice )EBP( for the development, promotion, the need for a prescription. According to the National and management of mental health treatment.36 Cleary37 Center for Complementary and Alternative Medicine defined EBP as the combined use of evidence from )NCCAM(, CAM includes a variety of medical and research and clinical experiences to aid in the clinical health care systems, interventions, and products not decision-making process. evidence-based practice considered part of conventional medicine.19 provides clinicians with guidance regarding the most Research has indicated that certain psychosocial appropriate and effective treatment interventions,38 therapies and interventions may be as effective as also, the potential contribution of 4 types of evidence in medication in treating symptoms of depression,20 such the delivery of care: research, clinical experience, patient as chronotherapy. Chronotherapy involves a variety experience, and information from the local context.39 458 Saudi Med J 2017; Vol. 38 )5( www.smj.org.sa Choronotherapy and depressive symptoms ... Khalifeh Essential competency for nurses today is EBP to alter exposure to the light/dark cycle.22 Research has improve quality health care and increasing provider increasingly focused on the use of these techniques in accountability, and PICOT question is one of the clinical practice as a result of their efficacy, rapidity first EBP processes )P = population; I = intervention of action, lack of side effects, low risk, and low or area of interest; C = comparison; O = outcomes; cost. Furthermore, the combined use of multiple T = timeframe in which to accomplish the
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