Psychiatry 2008 - September 2008 - (Page 49)

[research to practice] “astonishing” improvements— typically within hours—in approximately 60 percent of patients with major depression, independent of diagnostic subgroups.11 One of the reasons WT has not been widely adopted, despite its well-established therapeutic benefits in depression, is that the benefits of a single episode of WT tend to be transitory and patients typically relapse within the following 24 hours, usually when they resume sleep. I have witnessed dramatic and rapid antidepressant effects induced by WT to be totally reversed with nothing more than a brief nap. However, what many clinicians in our field may not know is that there have been significant recent advances in developing ways to obviate or limit the relapse proclivity associated with WT-induced mood enhancement. Treatment effects may be stabilized by antidepressant drugs, lithium, shifting of sleep time (i.e., phase advancing), or morning light therapy.11,12 While it would be very difficult for even motivated patients to self administer WT, it is quite easily administered and monitored in motivated patients on an inpatient unit where 24-hour nursing is available. review of BLT studies concluded, “Overall, bright light therapy is an excellent candidate for inclusion into the therapeutic inventory available for the treatment of nonseasonal depression today as an adjuvant therapy to antidepressant medication.”17 BLT and WT are collectively referred to as “chronotherapy.” BLT has been found to be beneficial in elderly patients with behavioral and mood disorders,18 and when our department recently opened a specialized geriatric psychiatry inpatient unit at UCSD Medical Center, the utilization of chronotherapy was taken to a new level through the incorporation of therapeutic level lighting throughout the common areas. MULTIMODALITY TREATMENT PROTOCOL When combined, pharmacotherapy and chronotherapy have multidirectional synergistic effects: BLT enhances and speeds the onset of action of the antidepressant medication, WT “jump-starts” the depression recovery process induced by BLT and the antidepressants, and inpatient wards into the vision of centers of psychiatric excellence as I propose in this article. Among these barriers is the current restrictive posture among the public and private sector third-party healthcare payers who promote a very parochial definition of medical necessity for psychiatric hospitalization (i.e., imminent danger to self, others, or grave disability). Furthermore, there is no doubt that therapeutic holding of patients in a safe and secure physical environment will continue to be a crucial function of inpatient pscyhiatry units. Nevertheless, research and technology are advancing in our field, and the prospect of implementing more assessment and treatment options suited specifically for inpatient settings is likely to grow. Recent promising findings using intravenous ketamine to induce rapid depression recovery and portable actigraphy to objectively assess sleep and activity of inpatients are other examples of auspicious tools for the hospital-based psychiatry service.22 Therefore, despite the obstacles, I believe that it is worthwhile for those in our field, particularly the growing group of psychiatric hospitalists and BRIGHT LIGHT THERAPY The first evidence of the antidepressant properties of bright light therapy (BLT) came from studies of seasonal affective disorder. However, more recent research suggests that BLT may have therapeutic benefit in all subtypes of depression.13 The strongest evidence are those that indicate BLT has a synergistic adjunct effect with antidepressant medication. Studies have generally shown that concomitant BLT enhances and accelerates the response to antidepressants.14–16 As a recent I believe that it is worthwhile for those in our field to seek to expand the role of psychiatric inpatient care and stake out a place for it at the leading edge, rather than the trailing edge of psychiatric care. the typical rapid loss of WT benefits are counteracted by concomitant administration of BLT and medication.19–21 What is remarkable is that the cost and difficulty involved in implementing such a multimodal treatment protocol on an inpatient ward are negligible. administrators, to seek to expand the role of psychiatric inpatient care and stake out a place for it at the leading edge, rather than the trailing edge of psychiatric care. REFERENCES 1. Carroll BT, Thalassinos A, Fawver JD. Loading strategies in acute mania. CNS Spectr. 2001;6(11):919–922, 930. Miller BP, Perry W, Moutier CY, et al. CONCLUSION No doubt there are many barriers to transforming acute psychiatric 2. [SEPTEMBER] Psychiatry 2008 49

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Psychiatry 2008 - September 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Letters to the Editor Use of Benzodiazepines in the Treatment of Anxiety Functional Neurosurgery in the Treatment of Severe Obsessive Compulsive Disorder and Major Depression: Overview of Disease Circuits and Therapeutic Targeting for the Clinician Treatment of Comorbid Adolescent Cannabis Use and Major Depressive Disorder Risperidone Long-acting Injections: Successful Alternative Deltoid Muscle Injections for Refractory Schizophrenia Alcohol/Substance Misuse and Treatment Nonadherence: Fatal Attraction Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting Journal Watch Classified Advertising Information for Authors

Psychiatry 2008 - September 2008

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