Chronopsychiatry –
Help the body reset its healthy cycles in recovery from depression
Depression can feel like a roller coaster of moods. It often starts with weeks or months of low mood in episodes that are initially brief (hours) but become long (days) and return with increasing frequency and severity over time. In part, this creates a dangerous situation – someone may decide to seek help one day, but wake up feeling ok the next. Not feeling great, but good enough to decide to put off the phone call. As other periods of low mood come up, there are also often periods of ok mood in between. All to often this goes on for too long, and the severity starts to raise significant risk, losses of friendships and relationships, problems at work, and neglect in care for one’s self.
The roller coaster analogy is in some ways a misconception. Many think of depression as a time when brain activity and a person’s behavior seem unfocused and poorly organized, just scattered with a loss of organizing activity. In some ways, that’s true, but when viewed in another way depressive symptoms are more about a loss of healthy variability and rhythms in our brain activity and the resulting behaviors. Evidence suggests that healthy systems – in the brain and also throughout the body – are constantly doing their own roller coaster. Each system has its own rhythm, like 24 hours for sleep/wake cycles; every 4-6 hours for appetite while awake; or every 90 minutes for nighttime dream cycles. These cycles need to be coordinated with each other. In depression, instead of having more scatter with the diminished focus, many systems lose these normal, healthy fluctuations. When they’re not actively cycling, and essentially flat or unchanging, they’re no longer coordinated with each other. Healthy variability in brain activity is adaptive – each cycle of a rhythmic change in brain chemistry provides a new perspective on life problems and allows satisfaction of bodily needs like sleep and eating cycles. Instead of becoming stuck, the healthy brain is changing constantly, and sometimes simply stumbles along to find better alternatives.
This view makes sense when the diagnostic symptoms are examined and the common theme becomes a loss of variability in function. In depression, sleep is either impoverished or excessive, as is appetite. People hyper-focus and ruminate on a single theme such as guilt or even darker thoughts, or they lose the ability to concentrate and enjoy or develop hobbies. Sometimes people become very slow in their movements, raising their heads in my waiting room as though they were swimming in molasses. Others are restless and pacing, having difficulty sitting still. All of these are extremes of the normal levels of activities that healthy people encounter in life, and they’re stuck.
Fortunately, we have treatments that can help. As people get better, they are sometimes surprised that the response is not steady. The stuck, low moods come back during recovery, but they gradually become fewer and farther between. Someone may start to respond, feel pretty good for a few days and then wake up feeling that the treatment has suddenly stopped working. But instead of three days, the low period lasts a half-day. It continues, generally, to improve in the presence of a good response. Eventually, the low period is but a short blip of symptoms – a reminder of the problem without becoming burdensome.
Many studies have shown the benefits of various activities, from improved sleep hygiene to regular eating and exercise habits. The present discussion may seem obvious, but the importance of restoring these habits – and restoring the rhythms associated with them can’t be overemphasized.
Planning a little bit can help these rhythms recover when in treatment for depression. Sleep clocks appear to be set best by a consistent wake-up time, with bedtime determined by whenever fatigue sets in. This assumes that TV and other screens are not interfering, and that bedtime routines are helping create the feeling of sleepiness. Morning light exposure helps teach the body that nighttime chemicals should shut off and the daytime chemicals should switch on. Body rhythms are also determined by eating healthy meals on a regular schedule. Exercising at appropriate times – away from bedtime, helps the body establish healthy rest-activity cycles. Work times – as regularly scheduled as possible, are also important parts of these rhythms, including a weekly pattern of workdays with a day or two of relative rest to break things up a bit.
So, as a treatment progresses, don’t be discouraged if depression is still like a roller coaster for a while. After all, it was a roller coaster before treatment started, and it will still be one for a while as it heals. Help the rhythms reset themselves by actively setting a daily schedule and sticking to it.
You’ll feel better, faster!
Music City Psychiatry 