| November 4, 2008 | 0 Comments

Psychiatry (Edgemont) 2008;5(11):15-16


Dear Editor:

As an inpatient psychiatrist, I was intrigued to read in the September issue of Psychiatry 2008 Feifel’s article on wake therapy as a viable intervention in the management of patients hospitalized with treatment-resistant depression (“Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting”).[1] Dr Feifel correctly reiterates that wake therapy is the most rapidly acting antidepressant strategy.[2] Yet it is sadly underutilized. Sixty percent of depressed patients experience substantial improvement after a total night of sleep deprivation. However, the antidepressant effect is lost the following day. Berger et al[3] described a procedure wherein the antidepressant benefits derived from a single night of sleep deprivation were sustained with a simple sleep phase advance intervention. In their wake therapy protocol, conducted on an inpatient psychiatric unit in Freiburg, Germany, patients diagnosed with major depressive disorder were kept up on Day 1. On Day 2, they went to bed from 5:00 pm to 12:00 midnight, and gradually postponed their bedtime by an hour each subsequent night, till they arrived at a bedtime of 11:00 pm to 6:00 am. The process was completed in eight consecutive days. This is a longer interval than the average length of stay for patients hospitalized with depression in the US. On the inpatient psychiatry unit at St. Lawrence/Sparrow Hospital in Lansing, Michigan, we abbreviated the sleep phase advance procedure to four days, by postponing sleep time by two hours rather than one hour each day. Following a night of total sleep deprivation, the patients were asked to go to bed at 5:00 pm, 7:00 pm, and 9:00pm on Days 2, 3, and 4, respectively, seeking to sustain the antidepressant benefit. We permitted the use of caffeine and hypnotics to facilitate the procedure. We encountered obstacles: Patients hospitalized on inpatient psychiatric units are required to adhere to a highly regimented sleep-wake schedule. The necessary 15-minute visual patient safety checks and environmental noise often disrupted sleep continuity. The introduction of a wake-therapy intervention required a change of mindset. Nevertheless, considering the limited efficacy of antidepressant medications[4] in treatment-resistant depression, wake therapy needs to be more widely employed as a viable therapeutic option.

1. Feifel D. Transforming the psychiatric inpatient unit from short-term pseudo-asylum care to state-of-the-art treatment setting. Psychiatry (Edgemont). 2008;5(9):47–50.
2. Wirz-Justice A, Benedetti F, Berger M, et al. Chronotherapeutics (light and wake therapy) in affective disorders. Psychologic Med. 2005;35(7):939–944.
3. Berger M, Vollmann J, Hohagen F, Konig A: Sleep deprivation combined with consecutive sleep phase advance as a fast-acting therapy in depression: an open pilot trial in medicated and unmedicated patients. Am J Psychiatry. 1997; 154:870–872.
4. Warden D, Rush AJ, Trivedi MH, et al. The STAR*D Project results: a comprehensive review of findings. Curr Psychiatry Rep. 2007;9(6):449–459.

With regards,
Dale A. D’Mello, MD
Associate Professor, Department of Psychiatry, Michigan State University, East Lansing, Michigan; MSU, Inpatient Psychiatry Service, St. Lawrence/Sparrow Hospital, Lansing, Michigan

Author Reponse

Dr. D’Mello raises good points in his letter. Sleep phase-advance is one of the procedures being explored to counter the transitory benefit of wake therapy as is the morning light therapy we employ at UCSD. His use of caffeine and hypnotics to facilitate sleep advance is interesting. We have recently begun to utilize modafinil with success to facilitate wake therapy in consenting patients. Given its documented antidepressant-augmenting effect, the use of modafinil in this way seems rational.

Kudos to Dr. D’Mello for striving to impliment procedures such as this to enhance the treatment of inpatients admitted to his hospital unit as we are at UCSD Medical Center. As Dr. D’Mello points out, these nonpharmacological techniques, so highly suitable for an inpatient setting, are underutilized, especially given their favorable benefit to risk and cost ratio. We need more inpatient psychiatrists to become aware of and willing to impliment these available interventions in order to advance and elevate the standard of care for inpatient psyhiatric units.

With regards,
David Feifel, MD, PhD
Professor, Department of Psychiatry, Director, Neuropsychiatry and Behavioral Medicine Program, Director, UCSD Adult ADHD Program, University of California, San Diego Medical Center, California


Dear Editor:

The article by Sansone and Sansone in the September issue of Psychiatry 2008 (“Alcohol/Substance Misuse and Treatment Adherence: Fatal Attraction”)[1] was quite interesting and topical. It was informative in regard to the impact that substance abuse has on nonadherence with medical treatment.
In addition to alcohol and substance misuse being an important factor in nonadherence with medical treatment, several studies have highlighted the direct impact of several illicit drugs on medical conditions themselves. The direct impact of these illicit substances on conditions like hepatitis and human immunodeficiency virus (HIV) have been shown in several studies, even when the patient is adherent with medical treatment.

Methamphetamine has been shown to inhibit the innate immunity in host cells leading to increased replication of hepatitis C virus (HCV) in human hepatocytes. Methamphetamine has also been shown to compromise the anti-HCV effect of recombinant interferon alpha.[2]

Other studies have also indicated that in addition to leading to increased risk of HCV, chronic opiate abuse also enhances HCV replication, increases liver injury, and increases hepatic fibrosis.[3] Opioid exposure in vitro has been associated with increased replication of HIV-I and impaired lymphocyte function. Studies have shown that irrespective of nonadherence to HAART medications, a study found that HCV co-infection with HIV was associated with an impaired CD4 cell response to HAART compared to those with HIV without hepatitis co-infection.[4]

A study by Hezode et al[5] indicated that long-term daily cannabis smoking appeared to accelerate and worsen fibrosis progression in individuals with chronic hepatitis C.

The ideal treatment model to address the nonadherence with medical treatment raised by the authors would be a system that integrates both the medical model , i.e., continuing care system, with that of substance abuse treatment. There obviously would be some difficulty bridging both systems as both systems have differences in priority, philosophy, funding, and training.

A strong case management model making social services a core of the plan would be required. This would be essential as basic needs like housing, food, funds, and work would need to be addressed in this model to foster adherence with medical treatment.[6] Workers from each side, that is the medical and substance abuse sides, should be willing to cross agency lines to collaborate on behalf of their clients.

Comprehensive programs like methadone maintenance treatment programs have led to better adherence to medical treatments, and better still the fact that buprenorphine in combination with naloxone can be dispensed within primary health clinics would further help with the integrated model where both the medical illness and the substance abuse, in this case opioids, could be addressed.

With regards,
Adegboyega Oyemade, MD
Addiction Psychiatrist, Heritage Behavioral Health Center, Inc., Decatur, Illinois

1. Sansone R, Sansone L. Alcohol/substance misuse and treatment adherence: fatal attraction. Psychiatry (Edgemont) 2008;5(9):43–46.
2. Ye L, Peng JS, Wang YJ, et al. Methamphetamine enhances Hepatitis C virus replication in human hepatocytes. J Viral Hepat. 2008;15(4):261–270.
3. Moore K, Dusheiko G. Opiate abuse and viral replication in hepatitis C. Am J Pathol. 2005;167(5):1189–1191.
4. Lucas G, Griswold M, Gebo K, et al. Illicit drug use and HIV-1 disease progression: a longitudinal study in the era of highly active antiretroviral therapy. Am J Epidemiol. 2006;163:412–420.
5. Hezode C, Roudot-Thoraval F, Nguyen S, et al. Daily cannabis smoking as a risk factor for progression of fibrosis in chronic hepatitis C. Hepatology. 2005;42(1):63–71.
6. Substance abuse treatment for persons with HIV/AIDS. Treatment Improvement Protocol (TIP)Series 37. http://ncadi.samhsa.gov/govpubs/BKD359/37h.aspx. Accessed 10/09/2008.

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Category: Letters to the Editor, Mood Disorders, Past Articles, Psychiatry

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