Introduction and Overview
We use a combination of wake and bright light therapy along with sleep phase advance – termed triple chronotherapy – as our standard protocol whenever wake therapy is prescribed. This treatment is a full, three-day process during which all waking hours are spent under our care and the prescribed sleeping periods take place in private apartments adjacent to the clinic area or hotels in the immediate vicinity.

The following section describes the evaluation and treatment process in detail.

Assessment Process
All individuals not currently being treated in our practice will begin with a 2 to 4 session comprehensive, diagnostic evaluation with Dr. Gottlieb.

These evaluation sessions may be supplemented by additional history-taking, data-gathering and questionnaire completion by other program staff.

When completed, we will share our impressions with you and determine if chronotherapeutic treatment is appropriate.

Treatment Requirements
To minimize side-effects and optimize treatment response, we require all individuals with bipolar depression to be on mood-stabilizing medication in order to undergo this procedure.

Triple Chronotherapy Process
These treatment process takes place over a three day period. During this time, all of your waking hours will be spent under our care. The treatment begins with one cycle of wake therapy, which is then followed by three days of early morning bright light and three days of sleep phase advance.

Staffing
Individuals undergoing wake therapy are monitored, evaluated, and assisted by our program staff throughout the entire process. Our staff includes psychiatric nurses and graduate students in clinical psychology who have received training in chronotherapy and biological rhythms. They are also experienced in the assessment of subtle mood changes.

The staff has several responsibilities during their shifts. These include helping to support wakefulness, monitoring for the development of psychiatric side-effects, administering light therapy, completing mood and behavior questionnaires, structuring the night and following daytime hours, and planning the post-discharge sleep-wake cycle.

In addition to the program staff, a psychiatrist remains on call and available for emergencies throughout the entire treatment process.

Activities during Wake Therapy
Given the resource-rich facility we use, patients are free to spend their time in a number of ways including reading, watching TV or movies, work or play on the computer, exercising, showering, eating, playing board games, and interacting with the staff.

Patients are also free to work during their cycles of treatment. Making phone calls is fine.

The one activity that is not encouraged is sleep. This also applies to even brief dozing. Remaining awake throughout the process is essential to obtain a robust antidepressant response. To this end, coffee and tea are available. The psychiatrist may also prescribe a wakefulness-promoting medication (modafinil) for those struggling to remain awake and receptive to pharmacologic support.

Bright Light Therapy
Bright Light Treatment will be administered in the early morning hours by the program staff.

Special 10,000 lux light boxes, that supply broad-band, UV-filtered light, specifically designed for phototherapy will be used. The timing and duration of treatment will be individually tailored for each patient but will usually vary between 30 to 60 minutes per morning, occurring between 5 to 7am, depending on a person's chronotype (a classification of the timing of one's circadian rhythms which is determined through a questionnaire).

When receiving light therapy, patients will sit approximately 12" from the light box, facing the illumination and glancing at the light occasionally. Patients are encouraged to read, watch TV or work on a computer while the bright light is directed at their eyes.

Sleep Phase Advance
Following the first night and subsequent day of wakefulness, sleep onset will be advanced to 6 p.m. with awakening 7 hours later at 1 a.m. The following day, sleep times will extend from 8 p.m. to 3 a.m. On the last day, sleep will start at 10 p.m. and finish at 5 a.m.

Schedule
After thorough instruction and preparation for the process, patients will check in for their first cycle of therapy at 10:30pm. For the purpose of explaining the treatment process, an arbitrary start day of Friday will be used in this section. In practice though, treatments can be started on any of several days each week.

Day 1:
Check in Friday 10:30pm. Stay awake from 10:30pm Friday, the entire night and the entire next day. Bright light therapy administered at phase-appropriate time in early morning. Discharge from clinic at 5:30pm on Saturday. Person will be escorted to their private apartment or hotel room.

Recovery night sleep on Saturday night, from 6pm until 1am Sunday. Program staff will meet and accompany person back to clinic.

Day 2:
Start at 1:30am Sunday. Stay awake from 1:30am, the entire night and the entire day. Bright light therapy administered at phase-appropriate time in early morning. Discharge from the clinic at 7:30pm Sunday evening. Person will be escorted to their private apartment or hotel room.

Recovery night sleep on Sunday night, from 8pm until 3am on Monday. Program staff will meet and accompany person back to clinic.

Day 3:
Start at 3:30am Monday. Stay awake from 3:30am Monday, the entire night and the entire day. Bright light therapy administered at phase-appropriate time in early morning. The person will be discharged from the clinic at 9:30pm on Monday evening. This marks the end of the formal treatment process.

The final night of recovery sleep starts at 10pm on Monday and ends at 5am on Tuesday. At this point, people are free to return to work or home responsibilities.

Completion, post-treatment evaluation, and discharge.
At the end of the procedure, the program staff will assess the person's condition, administer some final questionnaires, and complete a summary of the overall treatment process. Reports with recommendations for future treatment will be forwarded to the person's referring clinician.

Research
In conjunction with the Department of Psychology at Illinois Institute of Technology and C.E.T., we are conducting outcome research on triple chronotherapy. Participation in the research arm of the protocol is entirely optional. This is not comparative treatment research where patients are assigned to one group vs. another. Rather, it is outcome research designed to assess overall response rates to treatment, which patients respond best to triple chronotherapy (i.e., those with bipolar vs unipolar depression; those with early-onset vs later-onset depression) and the mechanism and time course of the improvement in mood state. Participation in this research entails approximately one additional hour during the initial evaluation, completion of brief questionnaires and follow-up interviews conducted by phone. There is no extra cost associated with participation in the research arm of this protocol. Research reports will not identify participants by name or other personal information.