At a recent conference on pediatric bipolar disorder, the topic of the seasonal aspects of the illness came up and caused a flurry of nods from the parents in the audience. These parents were aware that, despite the extraordinarily rapid daily shifts in mood, their sons and daughters did indeed have a depressive slump that began (often insidiously) in September, and sadly became fact by November or December. But, come the days of late February and March when the photoperiod lengthens and there are days punctuated by abrupt temperature changes, the parents noted a pick-up in activity and the stirrings of mania. They wryly dubbed this springtime phenomenon “March Madness.”
When it was suggested that a careful tweaking of medications as a pre-emptive strike during these periods of vulnerability be considered, one mother commented: “But I thought once you finally get them stable, you don’t dare touch the medication dosing or levels.”
We understand her thinking. Stability comes at such a very high price: so many hard-to-withstand (and witness) side effects; so much sadness and fear for the child whose pain is unrelieved or exacerbated by a failed medication trial; so many hopes dashed… Once the child really stabilizes, who would want to rock that boat?
Yet the boat rocks for many, given the nature of the change in seasons; and children and adolescents with bipolar disorder are that much more sensitive and reactive to seasonal change. Break-through depressions and manias are commonplace, and can usher in periods of instability. These seasonal vulnerabilities must be taken into consideration in the long-term treatment strategy.
The Historical Understanding of Seasonality in Bipolar Disorder
Since ancient times, remarkably regular seasonal recurrences of depression and mania have been an intriguing, but unexplained phenomenon. Hippocrates, in the fifth century, considered mania and depression to be disorders of spring, while Pinel in the 1800s wrote that “maniacal paroxysms generally begin immediately after the summer solstice…and continue during the heat of summer, and commonly terminate towards the decline of autumn.” Kraeplin, considered the father of biological psychiatry, documented seasonal episodes of illness in some manic-depressive patients with a preponderance of manic episodes in the spring, and depressive episodes in the winter.
Norman Rosenthal, M.D., a pioneer in light therapy for depression wrote in his book Seasons of the Mind:
The effects of the seasons on humans were all well known by the ancients, but have largely been forgotten by modern medical practitioners. Their importance has been kept alive only by artists, poets, and songwriters. Shakespeare, for example, observed that “a sad tale’s best for winter,” while Keats wrote of a nightingale “singing of summer with full-throated ease.”
In the past 25 years, science has caught up with the arts, and the medical importance of the seasons has been recognized anew. Surveys have shown that people experience some alteration in mood or behavior with the changing seasons, and, for as many as one in four, these changes present a problem.
A study of hospital admission rates for mania in Great Britain showed a high correlation between seasonal changes in mean monthly day length, daily hours of sunshine, and daily temperatures that correspond to the vernal and autumnal equinox.
Many children not only experience seasonal perturbations of mood, but their hour-to-hour daily variation of mood and energy change as well. During the fall, they often experience lower energy levels throughout the morning, increased irritability, greater anxiety, and lower frustration tolerance. Conversely, the evening period of activation is diminished. During the spring, this pattern is often reversed.
One mother, when writing of her young son’s seasonal mood variations said:
Oliver definitely has seasonal mania. Starting in March, when the light begins to change, his sleeping patterns go out of whack. The child who slept in the winter months like a hibernating bear, is suddenly wide-eyed at 5 A.M., or even earlier. He is up, fully dressed for school, and standing by our bedside with an armload of truck picture print-outs (his obsession), chattering about when the latest model of this or that is coming out, wholly unaware that it’s the middle of the night and people are supposed to be sleeping.
Sometimes he keeps right on going through his day, seemingly unaffected by the lack of sleep. Other times, the burst is short, and he crashes on the couch. Then we need a forklift to get him up for school. This happens in the fall as well. November / December is always a difficult time. This period is a little different, though, because he can also be more irritable, oppositional, perseverative, which we don’t see quite as much in the spring. We are acutely aware of these seasonal swings.
In a 2005 study published in the Journal of Affective Disorders, Dr. Shin Schaffer and colleagues at the University of Toronto, looked at a community sample of five diagnostic groups: normal subjects, those with non-seasonal depression, seasonal depression, non-seasonal bipolar disorder, and seasonal bipolar disorder. They found that individuals with bipolar disorder experience greater seasonality than those with depression only, or healthy controls.
These seasonal fluctuations have important implications for the management of bipolar illness: the levels of medications that previously produced stabilization, may not be as effective during these periods of change in the light/dark cycle. For many children and adolescents with bipolar disorder, stability begins to wobble or come undone as surely as March follows November. Why should this be so?
The Biological Underpinnings
Many biological mechanisms anchor human beings to the passage of time and influence our behavior. The timing of events within the central nervous system is at least as important as the special arrangements of the central neuronal activity in the brain. Neurotransmitters, neuropeptides, and hormones must not only lock into their corresponding receptor keyhole, but they must act with appropriate timing – in relation to one another and to periodic events in the environment.
Today, scientists accept that a kind of biological clock in the human organism establishes a fundamental daily rhythm for bodily functions such as temperature, the release of cortisol, rest/activity cycles, and the secretion of melatonin. But nature has built some flexibility into a human being so that the body can adjust to the ever-changing environmental rhythms such as longer and shorter days in the summer and winter.
Apparently some people do not adjust so easily.
Dr. Alfred Lewy, director of the Sleep and Mood Disorders Laboratory at Oregon Health and Science University, hypothesized that certain people with depression have a desynchronization in their 24-hour internal clock rhythms. For instance, their sleep, temperature, and cortisol cycles may be in synchrony with each other, but be out of step with other 24-hour rhythms, thus causing their internal rhythms to run a few hours behind or ahead of schedule. They either start and stop releasing melatonin earlier than usual (leading to evening sleepiness and early-morning awakening), or start and stop releasing melatonin later than usual (leading to difficulty sleeping at night as well as difficulty getting up in the morning).
The idea that depression and mania can result from abnormalities of photoperiodic regulation draws support from the known therapeutic effects of bright light treatment in seasonally-cycling bipolar patients, as well as from Dr. Lewy’s studies. He found that, compared to nonbipolar subjects, bipolar patients exhibited an abnormality in their capacity to suppress melatonin when exposed to bright light, suggesting that these patients may be more sensitive to the effects of changes in the intensity of light and to seasonal changes in the photoperiod.
The steady, measured effects of the clocks that time us and the capacity to adjust to ever-changing light/dark cycles, and ambient temperature fluctuations, may be perturbed in kids with bipolar disorder.
Seasonal Depression and Light Therapy
In 1984, Dr. Norman Rosenthal, then of the National Institute of Mental Health, published a ground-breaking article about the seasonal pattern of depression and bipolar disorder that he coined “Seasonal Affective Disorder” (SAD). Seasonal Affective Disorder is today described in the DSM-IV as a “regular temporal relationship” between the onset of major depression and the time of year (fall or winter), accompanied by a full remission (or change to mania or hypomania) in the spring.
Dr. Rosenthal reported on the positive reactions of depressed patients when they were exposed to bright light therapy on a daily basis in fall and winter days: Their symptoms of depression improved.
Today, the therapeutic value of light therapy is readily acknowledged. A 2005 systematic statistical review – a meta-analysis – of 20 randomized, controlled studies previously reported in the literature, showed that light therapy using light boxes or dawn simulators was as effective as conventional medications for the treatment of seasonal depression.
Since children with bipolar disorder often slide into autumnal and winter slumps, close monitoring of this potential pattern of annual relapse needs to be documented. Usually, if a pattern is recognized, the occurrence repeats itself, sometimes to within a week year-to-year. Light therapy tends to work better as a preventative treatment; so knowing the periods of vulnerability affords an opportunity to intervene in advance.
What Are Light Boxes and Dawn Simulators?
A light box is a metal fixture approximately two feet long and one and a half feet high. It contains ordinary white fluorescent lightbulbs set behind a plastic diffusing screen, which becomes a film that filters out most of the ultraviolet (UV) rays from the bulbs.
Typically, the light emitted from these boxes varies between 2,000-to-10,000 lux in intensity. (Lux is a unit used to measure the intensity of light. Indoor light levels range from 200 to 700 lux; outdoor levels on a sunny spring day range from 2,000 to well beyond 10,000 lux.)
A child should sit approximately one to two feet from the light source and look up for a few seconds towards the light every several minutes or so. A youngster can play video games in front of the light, watch television, or read.
Initially, one has to be cautious about reaching an effective daily duration of exposure – usually 20-to-30 minutes. Rarely, less than 10 minutes may trigger a brief period of activation which is readily abolished by reducing the duration of exposure.
It is thought that early-morning treatment is optimal, but given the sleep inertia these children and adolescents suffer (see The Bipolar Child Newsletter called “The Morning Battleground” at http://bipolarchild.com), afternoon therapy may be just as therapeutic for some children. We also know parents who install a light box in the resource room of their children’s schools and they receive the therapy while working with the resource teacher.
A dawn simulator is a small electronic timer that can be plugged into an ordinary bedside lamp with a 60- to 100-watt-intensity bulb. It can be programmed to create an artificial dawn lasting between sixty to ninety minutes. In other words, if your child has to get up at 6:30 A. M. to make the school bus, the timer should be set at 5:00 or 5:30 A.M.
There are many manufacturers of light boxes, but three reliable manufacturers are: Apollo Light Systems; Northern Light Technologies; and The Sunbox Company.
Light boxes cost somewhere between $160 and $300; and a dawn simulator costs approximately $150. Some insurance companies may pay for light boxes and dawn simulators if the child’s doctor writes a letter detailing its medical necessity.
Special Seasonal Considerations with Lamictal and All Mood Stabilizing Treatments
Treatment strategies may need to be revised during these periods of seasonal vulnerability. The doses of some medications may need to be adjusted upwards or downwards, depending on the attributes of the drug and the pattern of seasonal symptom change.
If springtime mania is a part of a child’s calendar year, than most mood stabilizing agents and atypical neuroleptics with antimanic properties may require upward adjustments in dose. Certainly, obtaining serum levels prior to peak periods of vulnerability will alert vigilant clinicians to the need to adjust dosages as a protective measure and potentially abort an unwanted seasonal recurrence of symptoms.
Special consideration for the anticonvulsant-mood stabilizer, Lamictal (lamotrigine), may be warranted, given its unique antidepressant properties. The drug is frequently effective for controlling rapid-cycling and mixed bipolar states, but, unlike other mood stabilizers that work most effectively against acute mania and prevent future episodes of mania and depression, Lamictal has robust antidepressant effects that work in the depressed phase of the disorder. This attribute, however, can produce activation as the photoperiod shifts to longer daylight hours. Thus, the Lamictal may need to be lowered in advance of the shift of seasons in order not to induce or exacerbate breakthrough agitation and irritability that accompany a resurgence of hypomanic or manic symptoms. A reduction of only 5 to 10 mg may suffice; but some children may require a larger decrease in their daily dose.
Clinically, a similar phenomenon has also been observed with bright light treatment. A reduction in duration of exposure to light by even 10 minutes may avert activation.
We spent time, recently, with a man who was discussing his bipolar disorder and his treatment regimen. He said that Lamictal had been a miracle drug for him; it had given him back his life. But about eight months later, he told us, it had stopped working. When we asked him what month he noticed the Lamictal “punk out,” he responded, “In April. I became increasingly speeded up and manicky, so I had to go off of it.” (He was so relieved to learn that a reduction of the dose in the early spring may have averted the hypomania, and that he can possibly restart the medication in the early fall so as to avoid his lifetime pattern of fall and winter depression.)
A month after that conversation, the mother of a 14-year-old son who was taking Lamictal told us:
Henry was doing so well through the fall and winter – better than he’s ever been – but around mid-March he got very agitated, unreasonable, and physically aggressive, and it just kept getting worse. He was flipping the coffee table over, destroying other pieces of furniture, and he said to me: “You have to do something; I don’t feel I can make it stop!”
I suspected it was the Lamictal, as I am on it myself. It has made a huge difference in my life, but I know that I become speeded up in the spring, and my doctor lowers the dose. Henry’s doctor lowered his dose of Lamictal as well, and raised his Risperdal for just a few days. Each day we went in the right direction, and after a week we had our Henry back.
All dosages of all mood stabilizers have to be judged against the seasonal changes. The mother in the beginning of this newsletter who wrote about her son Oliver’s seasonal changes said: “We are acutely aware of these seasonal swings, and we are always ready to increase his lithium in the spring. He goes back to his regular dose before September. Right now, in May, he is still in a pretty manic phase. We are now rechecking the levels.”
Children are growing taller and putting on weight all through their growing up. Good clinical practice would be for the treating physician to look at the levels of the mood stabilizer before the lengthening days of spring and the shortening days of autumn and notate what levels produced stability. Then, preemptively, the doctor can reproduce those levels, which, due to the increase in height and weight, will no doubt need to be increased. There may be times where a slight increase in an atypical antipsychotic might need to be raised also to tamp down a tendency to swing too high.
A parent should be in close contact with the treating physician during the times of seasonal change.
In Conclusion
It is obvious that children – up against seasonal and growth patterns – are moving targets when it comes to treatment strategies. Because of the sensitivity these children have to seasonal change, treatments may have to be calibrated and adjusted to accommodate these vulnerabilities. Some children will experience instability if prescriptions and doses remain etched in stone.
It behooves all physicians and parents to examine the children’s seasonal patterns and, if necessary, institute preemptive adjustments of the medications, or a trial of light therapy in the fall, to stave off breakthrough episodes that threaten stability.
So when parents ask “Is stability a possibility for children with bipolar disorder?” the answer may be that the correct medications, and careful consideration of seasonal vulnerability and timely medical interventions, certainly boost the chances.
As always, we enjoy hearing from you. May the summer days bring brightness and warmth to your households, and happiness and stability to your children.
We send you our best,
Janice Papolos and Demitri Papolos, M.D.
Acknowledgments
The authors wish to thank Cheryl Matalene and Karen Williams for their help in the preparation of this newsletter.
Bibliography
Golden, R. et al.”The efficacy of light therapy in the treatment of mood disorders: A review and meta-analysis of the evidence.” American Journal of Psychiatry 2005; 162:656-662.
Lewy, A, et al. “Bright light, melatonin, and biological rhythms.” Psychpharm. Bull., 1986: 368-372.
Matalene, C. E-mail of May 18, 2005.
Papolos, DF. “Serotonin, Seasonality, and Mood Disorders” in The Role Of Serotonin in Psychiatric Disorders, edited by Serena-Lynn Brown and
Herman M. van Praag. New York: Brunner/Mazel, Inc. 1991.
Papolos, D and J Papolos. The Bipolar Child, Revised. New York: Broadway Books, 2002.
Rosenthal, NE. Seasons of the Mind. New York: Bantam Books, 1989.
Rosenthal, NE, Sack, DA, et al. Seasonal affective disorder: a description of the syndrome and preliminary findings with light therapy. Archives of General Psychiatry 1984; 41: 72-80.
Williams, K. Telephone Interview of May 23, 2005.