JMIR Publications

ABSTRACT

Background:

Patients with major depression exhibit circadian disturbance of sleep and mood. When discharged from inpatient wards to outpatient psychiatric services this disruption of rhythms increases the risk of relapse. To improve the transition from inpatient wards to outpatient treatment, we developed Circadian Reinforcement Therapy (CRT) as a new intervention using specialized psychoeducation on sleep timing, social contact, physical activity, diet, and daylight exposure, aiming to increase zeitgeber strength to the circadian clock.

Objective:

The aim of the study was to prevent worsening of depression in patients with major depression after discharge from inpatient psychiatric wards through implementation of the CRT to advance and stabilize sleep supported by an electronic self-monitoring system. The primary outcome was change in interviewer rated levels of depression on the Hamilton depression rating scale (HAM-D17) scores from baseline to endpoint.

Methods:

Participants were contacted while still on the inpatient ward and randomized 1:1 to a CRT or Treatment as Usual group for four weeks. In both groups, patients electronically self-monitored their daily mood, physical activity, sleep, and medication in the Monsenso Daybuilder (MDB) system. The MDB system allowed investigator and participant to simultaneous view a graphical display of registrations. An investigator phoned participants weekly to co-inspect data entry, and in the CRT group also between these scheduled calls if specific trigger points for mood and sleep were seen on the daily inspection.

Results:

In all, 103 participants were included. Participants in the CRT group had a significantly larger HAM-D17 score reduction (p=0.04) compared to the TAU group. In the self-monitored data, we found a significantly better improvement in evening mood (P=.02), sleep quality (P=.04), earlier sleep onset (P=.009) and longer sleep duration (P=.005) in the CRT group. Furthermore, the day-to-day variability of daily and evening mood, sleep offset, onset, and sleep quality were significantly lower in the CRT group (all P<.001).

Conclusions:

This is the first clinical test of the CRT method. Compared to TAU we found significantly better effect on depression and sleep and with significantly less day-to-day instability in the CRT group. The delivery of the CRT method should be further refined and tested. Clinical Trial: ClinicalTrials.gov Identifier: NCT02679768