by Robert Levitan
Department of Psychiatry and Institute of Medical Science, University of Toronto

Robert Levitan MD is a member of the CET’s Board of Advisors, and a past president of the Society for Light Treatment and Biological Rhythms.  He is the Cameron Holcombe Wilson Chair in Depression Research at the University of Toronto, and Senior Scientist in the Campbell Family Mental Health Research Institute of the Center for Addiction and Mental Health (CAMH). His primary research focus is the “atypical spectrum” of mood disorders, which encompass both depression and overeating/obesity, including seasonal affective disorder.

Chronic depression is a common and disabling disorder that is often resistant to standard antidepressant treatment. Many patients with chronic depression have a strong tendency to oversleep in the morning and prefer to be active at night, leading to difficulties getting started with daily activities. This further contributes to negative thinking and low mood.

One possible strategy to address this is regular attendance at a Day Treatment Program focused on group-based behavioral activation to enhance structure and positive rewards. One interesting question related to this program is whether the timing of treatment during the day is important or not. It could be argued that patients having difficulty getting up in the morning are better able to benefit from a Day Treatment program if they attend in the afternoon, when they have more alertness and are better able to grasp the information being provided.  Following from this argument, if asked to come in the morning, these individuals will have difficulty getting to hospital on time and attending to the sessions once there. This could unintentionally add to a sense of personal failure that could worsen rather than benefit low mood.

The opposite viewpoint is to insist that patients come for treatment when they are feeling their worst, in order to challenge pathological sleep and activity rhythms. For those with a tendency to sleep in this would involve coming to hospital for treatment in the morning as opposed to the afternoon.

We put this question to the test at the Day Treatment program for chronic mood disorders at CAMH in Toronto, Canada.  To promote the availability of this treatment to a larger number of individuals, patients come for treatment either in the morning or in the afternoon, but not both. In a recent published study we reported that patients having an evening activity preference benefitted much more if they came for treatment in the morning as opposed to the afternoon. This tells us that it is much better to challenge pathological activity rhythms using behavioral activation early in the day than to come to treatment later in the day when feeling more alert.

These findings have implications for the current COVID pandemic given that day treatment is currently being done remotely, removing the benefit of having people get up and leave their home early in the day. This makes it more difficult to challenge one’s tendency to be inactive in the morning. Strategically timed remote interactions with the treatment team can help, but are difficult to implement on an individual basis given time and resource limitations.  Where possible, roommates, family and friends might help create and implement a practical behavioral activation  protocol early in the day on a case by case basis.

Bright light therapy in the early morning is another consideration, though it requires waking up on time to initiate treatment. Physical activity can also be of benefit but can be difficult to implement for those with low motivation and energy. Whatever combination of activating strategies is used, the key point to keep in mind is that challenging one’s tendency to oversleep and avoid interactions in the morning appears to be a critical aspect of treatment for many individuals with this condition.