Key moments, in order
The role of circadian rhythm in what bipolar disorder is keeps getting more prominent, and social rhythm therapy goes right after that basic cause of the mood disturbances. Think of a hierarchy of goals: the patient wants quality of life and function, we get there through stable mood, we get stable mood by going after the circadian rhythm, and we do that by using social rhythms.
Social rhythm therapy goes right after the circadian rhythm, a basic cause of the mood disturbances whose role in bipolar disorder keeps getting more prominent. We think of people with bipolar disorder as the most susceptible to circadian disruptions, so it helps them most, and it is not a separate therapy: it is a core ingredient of treatment for everybody.
Building structure and stability helps every aspect of mental health. It is a big focus for patients with personality disorders and trauma, not only mood disorders.
Darkness is a central ingredient in the rhythm, and except in a few places in the world we just do not get enough of it. What is natural is that it gets dark when the sun goes down; what is not natural is staying up under electric light until we choose to go to bed.
It comes in levels, from full IPSRT to SRT to a simplified version. Everyone agrees sleep is the central ingredient, so you can start with just a regular pattern of sleep.
Light is the one time giver that sets the circadian rhythm more powerfully than the rest: its appearance in the morning and its disappearance in the evening. When you eat, when you see your first person and when you get physical activity are time givers too.
Start with sleep, and with light and darkness as they set sleep timing. More darkness at night makes it easier to fall asleep at the bedtime the regular rhythm needs.
Learn how to do the simplified version. You are already encouraging a regular bedtime and a regular rise time; make it part of your standard approach to everyone with a mood disorder.
Aim for regular sleep hours: a regular bedtime and a regular rise time, about seven to eight hours, preferably a little closer to eight. Start from whatever the patient's most common bedtime is now; if it is 2 in the morning, go with that.
People with bipolarity have a looser circadian rhythm, more easily knocked around by staying up too late and particularly by light and darkness; even the retina differs in its sensitivity to light. Their clocks invite them to stay up late: night owls, not really morning people.
Lots of patients stay up late on purpose, and there is a reason for it. Telling them to go to bed at a regular, earlier time invites them to do something that is dysphoric for them.
Do not judge a very late rise time as laziness. It is part of the consequence of a shifted rhythm, and the job is to help the patient cope with it.
Keeping a regular bedtime is a common sticking point: there are zillions of reasons for it not to happen, while the rise time at least has an alarm clock and usually work, family or school behind it. Staying up late and then getting up early leaves people short of sleep and makes getting out of bed hard.
The very first question for patients, and for yourself, is how dark the bedroom is. If it is not dark, you have been working against the tide the whole time.
Light at night matters: more than about three candles' worth of light at one meter overnight (enough to just barely read by) is associated with more frequent manic episodes.
Blackout curtains or blinds work, and for renters on a tight budget tinfoil on the windows does the job.
Give patients nightlights of a kind that emits no blue light. Older patients who get up in the night to go to the bathroom should not walk into a lit room, but they should not fall on the way either.
For the morning signal, use a dawn simulator: a commercially available gizmo that gradually turns on the bedside lamp over about 30 minutes, simulating dawn. If you use a gadget to switch on a lamp, get one that turns it on gradually; that is more natural, and the brain interprets the two kinds of light differently.
Not everybody has to buy a dawn simulator. If the patient's sleep is already around 10 to 6 because they get up on a regular basis, maybe the light leaking through the windows is dawn signal enough.
Seasonal affective disorder is more common in people with bipolar disorder, who are more susceptible to seasonal changes in the rhythm of the sun.
In multiple randomized trials a dawn simulator has done better than interesting placebo arrangements for seasonal affective disorder. By fixing the time light arrives each morning, it basically prevents winter from a circadian point of view.
Getting out of bed at a regular time is the hardest part of the simple version, so make it easy: no snooze (once the alarm goes off, get up), then make the bed fully, throw pillows and all, so there is no getting back into it.
A fixed ritual the minute the patient leaves the bed, like making tea, removes the need to think when not fully awake, and it gets easier the more regular it is.
Sleep is fundamental to daytime function. Before starting a stimulant, see what targets remain once the patient gets seven and a half hours of sleep.
When sleep has shifted late, work toward an earlier bedtime and an earlier rise time. This is called a phase advance: the phase of sleep has been delayed, and you advance it in the reverse direction.
Move the rhythm earlier in really small steps: set the dawn simulator 15 minutes earlier (five minutes if that is too jangly), and keep going until bedtime allows eight hours of sleep before the simulator says it is time to get up. Rush it and it will be harder; move it slowly and it will be easier.
A patient's failure to follow the plan is the clinician's problem, not the patient's. You did not work out what was really going to happen once they left the office.
Just inviting patients to start dimming the lights after 8 p.m. for a 10 p.m. bedtime does not go very well, in our experience.
Keep evening light down, especially close to the eyes. Really bright bathroom lights (the shaving or makeup lights) while brushing your teeth right before bed are a bad idea, and close screens like an iPad or iPhone matter most, because light becomes much more powerful up close: its intensity changes with the square of distance.
Tell patients the story behind it. In our experience it holds people's attention very strongly, and when you want a story to help drive a behavior change, this one really is worth telling.
Around 2000 it was discovered that different wavelengths of light affect the brain differently, and only one of them, blue light, sets the circadian rhythm. So the absence of blue light is physiologic darkness.
Light suppresses the body's own melatonin. People kept up all night doing paper-and-pencil tests in a lit room had no rise in melatonin at all, and even a little light, more than about three candles' worth, is enough to suppress it. Wearing amber lenses through the same all-nighter, their melatonin went up when it was supposed to: if blue light sets the rhythm, the absence of blue light is physiologic darkness, even while awake.
When the same people wore amber lenses and stayed up all night doing the same tests, their melatonin rose when it was supposed to. They were in physiologic darkness even though they were awake.
Use them in a two-hour window before bedtime, such as 8 to 10 p.m. Patients can keep using electric lights then, as long as the amber lenses block the blue, and the circadian rhythm still recognizes that it is dark and time to go to sleep.
Patients will not wear the clunky plastic glasses that slip over their corrective lenses for very long. In our experience they will do it for a couple of weeks.
In our experience it works for only about half of patients. The other half come back saying it did nothing; responders call the glasses amazing and say they fall asleep almost an hour earlier, fall asleep more quickly and stay asleep better.
These are harmless and, as the research literature shows, robust treatments, with no side effects or long-term risks. Few treatments in psychiatry are this robust.
It is the most well-tolerated mood stabilizer by a long shot. Because SJS is rare, we phrase that risk to patients as an allergic reaction.
It is worth buying 10 pairs of the amber lenses you want patients to try, keeping them in the front office and selling them at your cost.
Use the idealized rhythm as the roadmap: activity through the day, sunlight slowly fading around 5 to 6 p.m., no light at all from 7 to 10, falling asleep naturally at 10 and waking to a slowly rising sun.
Compare how the patient lives with the idealized rhythm and go for the lowest-hanging fruit: the realistic change that will make the biggest difference (waking at the same time is probably the most important). See how it goes over a month; if it goes well, add the next change, and if not, work out what made it difficult and tinker.
Build motivation before giving instructions: explain why it matters, because a patient simply told to wake at the same time will ask why. Most are not motivated enough to go out after the appointment and buy a light box, dawn simulator, sunglasses and blackout shades, and buy-in usually grows once they start and see improvement.
Explaining is taking power over the relationship. Flip it so the power sits with the person who has to make the physiologic and behavior changes: start by understanding what is important to them, then remind them that they said it is important.
In a randomized trial on an inpatient unit in Norway, patients admitted with a manic episode got either amber lenses or a gray control lens that did nothing from a circadian point of view. On top of the unit's usual treatment, the amber group had half the number of antipsychotics and got out of the hospital earlier.
A fairly close replication in Canada was not so striking, which leaves one positive study and one that was basically negative.
Builders made two identical wings, one with conventional lighting and one lit at night only with amber light. Nurses completed the Broset checklist every shift, and over six months 80 people on the conventional unit had a positive checklist versus three in the amber-lit environment.
The reduction held whatever the diagnosis, except major depression, where violence did not change.
It probably helps about half of people, so keep trying different things until the patient is in the half that is helped. It might not be the amber glasses; it might be the dawn simulator.
Light is the one time giver that sets the circadian rhythm more powerfully than the rest: its appearance in the morning and its disappearance in the evening. So whatever the tool, the principle is to have light stop at a set time at night and come on at a set time in the morning.
A dawn simulator helps waking itself: in one comparison, people who had one had higher alertness scores from the moment they woke up. Even if it did nothing to the circadian rhythm, patients might like it because it makes waking up easier.
A low-hanging fruit: tell patients to get 15 minutes of sunlight within the first hour of waking up.
Indoor light, in an office building or a hospital, is about 1,000 lux. Outdoors at the same time of day it is 10,000 lux on a gray day and 100,000 lux on a blue one.
A gray rainy day is about 10 times brighter than indoors, though the eye auto-adjusts so it does not look that way. Outdoors is far better than indoors.
For someone stuck indoors, a light box at the back of a desk is probably worth it, though this has not been studied.
In bipolar disorder, a formal light box carries the same risks as antidepressants: not just hypomania or mania, but mixity and a mess of mood stability, with anxiety, irritability, agitation and attention problems.
Small morning routines make the day easier because the habit removes thinking, and they help build circadian rhythm.
The Social Rhythm Metric has five items to track, starting with when you get out of bed.
Build stability so the days have patterns. Wake up at the same time every day, with a little morning routine to get things going.
The official Social Rhythm Metric asks patients to fill out a paper form several times a day for a week or two, which can become another barrier.
Paperwork can become another barrier. Ask a patient to fill out a tracking form and a missed day turns into: I forgot to fill it out yesterday, maybe I just do not want to do this.
An occasional later night is okay, maybe an hour later, not five hours. Know that it is a risk to the rhythm, build in extra protection over the following days and get back on schedule as quickly as possible.
A simple rule: no technology invented after 1980 after 10 p.m., or maybe even 9 p.m., depending on your schedule.
Do not be paternalistic about late nights; a patient simply told no will not listen. Be clear that staying up till two with a few beers comes at a cost, leave the decision to them, and negotiate a plan through natural behavioral experiments that show how risky it is for them.
Use common sense: night shift is the worst thing a human being can do. Do not let patients who say it barely affects them convince you otherwise.
For someone working late into the night, as in a hospital, spin the whole principle of darkness and light around: start putting on the amber lenses while still at work.
For a patient on rotating shifts, a letter saying the schedule is incompatible with the illness from a medical point of view is possible, but first ask how much risk to the job they want to take.
People who work night shifts show how much rhythm matters, with signs of high cortisol and visible body changes within a few years.
In bipolar disorder, physical activity is a great tool for targeting depression in a way that does not run the risk of inducing mixed states, more cycling or mania.
Do not make people think physical activity means going to a gym. That is very low yield: few will actually sign up, let alone keep it up once they go.
Keep it small and sustainable. A two-minute walk outside five days a week is better than a plan for the perfect workout that never gets done.
Look for a physical activity the patient used to do that was fun, and work out how to build it back into their life so it is not a chore.
An exercise partner can be the thing that keeps a routine going.
Woven into medication visits, this work is psychotherapy in that respect: 25-minute visits, billed with psychotherapy codes as well as medication management codes, for nearly everybody.
Lithium scares people, and its prescription rate has gone down. It is scary the first time: all those labs and side effects to discuss.
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