Table 4 Planning an individualized sleep and circadian intervention

 1. Clinical assessment of depression

Assessment for key features indicative of circadian-dependent mood disorders including:

● Positive family history of mania or circadian rhythm sleep disorders

● Diurnal or seasonal sensitivity

● Easy destabilization by changes in time-zones or changes in regular sleep pattern

● Non-restorative sleep

● Daytime fatigue

● Difficulty falling asleep

● Late morning rising or waking up early in the morning

● Oversleeping

● Overeating or weight gain

● Screen for other sleep disorders, such as restless legs syndrome or sleep apnea

 2. Evaluation of key sleep and circadian phenotypes

Self-report/self-monitoring over two-weeks (see Figure 4) using smart phone or paper-pencil, particularly focusing on:

● Chronotypes on morningness-eveningness scales

● work/schooldays and weekend schedules

● Duration of sleep

● Waking from sleep

● Pre-sleep hyperarousal symptoms

● Night sweats – raised temperature during sleep

● Timing and level of daytime physical activity

● Atypical circadian mood variations

Objective measures including:

● Two-weeks of continuous actigraphy/sleep diaries

● Dim light melatonin onset assays

B) Information and treatment planning sessions

 1. Psychoeducation with regards to the human sleep and circadian systems

Key elements include:

● Explanation of the biology of the human clock

● Illustration of the normal 24-hour cycle in sleep and activity and synchronization with hormonal, immune, body temperature and other key physiological elements

● Emphasis on setting the clock through morning rising, appropriately timed light exposure, regularity of activity cycles, daytime physical activity, bedtime schedules and nighttime practices

● Linking to eating behavior and risks to obesity and metabolic function

 2. Set specific behavioral elements

Key decisions include:

● Set sleep offset time (or schedule for gradual phase advance/delay relative to current waking time) with special care to avoid sleep loss induced mania/hypomania episode in people at risk for bipolar disorder

● Set daily activity schedules

● Emphasize morning light exposure (natural or through specific devices with special care to avoid bright light induced mania/hypomania in people at risk for bipolar disorder)

● Discuss regular sleep onset time expectations

● Set sleeping conditions relative to light exposure and temperature

 3. Introduce self-report or objective measurement techniques for this period

Key elements include (see Figure 4):

● Daily monitoring of actual sleep onset /offset, sleep duration and sleep quality

● Continuous recording of actual daytime physical activity

● Daily mood and fatigue monitoring

● Monitoring of substance use and eating behavior

● Monitoring of other behaviors that could adversely affect sleep including excessive or poorly timed napping

C) Review progress at two weeks

Key elements are:

● Adherence to sleep offset time, light exposure and degree of actual physical activity

● Evaluate changes in daily mood, fatigue, sleep quality

D) If inadequate clinical progress:

Consider:

● Adherence and planning issues

● Adjunctive strategies to be considered:

- Earlier/later or augmented light exposure

- Melatonin supplementation with careful planning of ingestion time

E) Review progress at four weeks

If inadequate clinical progress:

Consider:

● Adherence and planning issues

● Adjunctive strategies to be considered:

- Melatonin-based antidepressant strategies

- Other conventional antidepressant strategies

- Alternative daytime stimulant or nighttime sedation strategies

F) Review progress at six- to eight-weeks