Brief reportRate of switch from depression into mania after therapeutic sleep deprivation in bipolar depression
Introduction
The potential usefulness of sleep deprivation in the treatment of bipolar depressed patients has been suggested (American Psychiatric Association, 1995). A common risk when treating bipolar depression is the occurrence of a switch from depression into mania, and in bipolar patients a close relationship has been observed between sleep loss and the onset of mania (e.g. Wehr, 1992, Barbini et al., 1996). Few data are available, however, on the rate of switch from depression into mania after therapeutic sleep deprivation in bipolar patients.
In their review on the effects of sleep deprivation in depression, Wu and Bunney (1990) cited 10 studies that had reported switches from depression into hypomania or mania, with a 30% rate of switch after therapeutic sleep deprivation in bipolar depressed patients. Years of publication of the 10 studies ranged from 1974 to 1982. In more recent studies on the effects of sleep deprivation, switches into mania disappear except for rapid-cycling bipolar patients. Wehr et al. (1982) report the spontaneous occurrence of sleep deprivation before the switch into a manic phase in 13/15 rapid-cycling bipolar patients, while therapeutic sleep deprivation caused 7/9 drug-free depressed rapid-cycling bipolar patients to switch into mania. More recently, the relationship between sleep loss and the onset of mania in patients with rapid-cycling bipolar disorder has been well established (Leibenluft et al., 1996).
A major problem in the literature about sleep deprivation is the diagnostic heterogeneity of the samples, because many of the study groups included patients with endogenous, reactive, unipolar, bipolar, secondary, and schizoaffective depression (Leibenluft and Wehr, 1992). Therefore, on the basis of the available data, the rate of switch from depression into mania that should be expected after sleep deprivation in non-rapid-cycling bipolar patients cannot be reliably estimated. In the present study, we report the rate of switches from depression into mania observed in a sample of 206 bipolar depressed inpatients treated with therapeutic sleep deprivation.
Section snippets
Methods
During the years 1994–1998, 206 bipolar depressed inpatients were treated with serial repetition of total sleep deprivation (TSD) at our research center for mood disorders. On the basis of DSM-III-R and DSM-IV criteria, patients were diagnosed as bipolar disorder, depressive episode without psychotic features. Patients were treated according to experimental protocols aimed at sustaining the transient antidepressant effects of TSD (e.g. Benedetti et al., 1996, Benedetti et al., 1997, Benedetti
Results
During the TSD treatment, we observed 10 (4.85%) switches into a manic phase, and 12 (5.83%) switches into a hypomanic phase. The rate of switches was not associated with current medication status (switches into mania: χ2=5.33, d.f.=4, P=0.255; switches into hypomania: χ2=1.45, d.f.=4, P=0.836; all switches together: χ2=5.20, d.f.=4, P=0.268).
Since manic symptoms appeared during hospitalization, patients were immediately administered an antimanic treatment. Restoration of night-time sleep with
Discussion
Treatment-induced switches from depression into mania have long engendered debate (e.g. Lewis and Winokur, 1982, Wehr and Goodwin, 1987), and some authors suggest that clinicians must be prepared for bipolar depressed patients to switch polarity regardless of treatment status (Angst, 1985, Solomon et al., 1990). Bunney (1978) reported a 9.5% switch rate in depressed patients treated with tricyclic antidepressants or monoamine oxidase inhibitors. A recent review of clinical trials (Peet, 1994)
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