Pending enough primary studies, we invite reviews on this topic to be conducted. Alternatively, we will endeavour to conduct our own review to fill this gap in the Library.

November 2021

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Exposure to blue light affects circadian rhythm, and night time exposure can lead to insomnia via dysregulation of melatonin. Blue light blocking glasses have been found to prevent light-induced suppression of melatonin release. The glasses are worn continuously for two to three hours before turning the lights off to sleep with the aim of improving sleep. It is thought this may also improve mood in people with bipolar disorder. 

What is the evidence for blue light blocking glasses?

Moderate to low quality evidence suggests blue light blocking glasses may improve mania symptoms and sleep in people with bipolar disorder, although sample sizes are small. More research is needed.

Also see the topic on melatonin for the symptoms of bipolar disorder.

November 2021

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Bright light therapy, also called phototherapy, involves the use of a bright artificial light to improve depressive mood. It has long been used in psychiatric practice, usually for the treatment of seasonal affective disorder. The mechanism by which bright light therapy regulates mood is unclear. It has been suggested to have modulating effects on serotonin and melatonin and on the synchronisation of circadian rhythms, which is why it is often accompanied by sleep deprivation. This topic assesses the use of bright light therapy for depressive symptoms of bipolar disorder.

What is the evidence for bright light therapy?

Moderate to high quality evidence finds a medium-sized improvement in depression symptoms with bright light therapy compared to placebo. There was no increased risk of shifting to a manic state with bright light therapy.

Moderate quality evidence finds greater improvements in depression symptoms in studies using <10 hours compared to >10 hours of bright light therapy, in studies using morning plus night exposure compared to morning exposure only, and in studies with adjunctive sleep deprivation and/or lithium. There were no differences in studies with or without other psychotropic medications, in studies using colour temperature < vs. >4500k, in studies using light intensity < vs. >5000lux, or in studies using white or green light thera

November 2021

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In ECT, a seizure is electrically induced after the patient has been given a short-acting anesthetic and is asleep. Although viewed as controversial, ECT is a well established psychiatric treatment with good evidence to support its effective and safe use. ECT is most often used as a treatment for severe depression that has not responded adequately to other treatments. It is also used as a first line treatment in depression where an urgent response is required as it works more quickly than medications. ECT’s efficacy and safety are affected by a number of factors such as where electrodes are placed, the frequency of treatment, the degree to which the stimulus dose exceeds the seizure threshold and the dose and duration of concurrent medication.

What is the evidence for ECT for people with bipolar disorder?

High quality evidence suggests a small effect of greater response to ECT treatment in people with bipolar depression compared to people with major depression (77% vs. 74% responded). Moderate to high quality evidence suggests fewer number of sessions are required for bipolar depression than for major depression. There were no differences in remission rates between these groups.

High quality evidence suggests longer duration of depressive episode and non-response to medication are associated with medium-sized effects of poorer response to ECT treatment. Moderate quality evidence suggests comorbid psychotic features may be associated with a small effect of poorer response to ECT treatment, and increasing age may be associated with a small effect of better response to ECT treatment.

November 2021

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People with serious mental illnesses are more likely to be sedentary than the general population and are consequently at high risk for chronic medical conditions associated with inactivity (see the related physical activity topic). Physical activity reduces the risk of these medical conditions, and positive psychological effects have also been reported, including improved quality of life. Exercise also has the potential to alleviate secondary symptoms including low self-esteem and social withdrawal.

What is the evidence for exercise therapy?

Low quality evidence is unable to determine the benefits of exercise specifically for the symptoms of bipolar disorder. More research is needed.

November 2021

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Sleep deprivation, or ‘wake therapy’, involves being deprived of total sleep for approximately 36 hours straight, or partially sleeping for only 3 to 4 hours followed by 20 to 21 hours of wakefulness. This therapy has been associated with rapid improvements in depressed mood but may also trigger mania. Studies have used various treatment formats in the number, timing, and duration of sleep deprivation cycles to determine which works best for people with bipolar disorder.

What is the evidence for sleep deprivation in people with bipolar disorder?

Moderate quality evidence shows total sleep deprivation can improve depression in around half of people receiving the treatment. It is particularly effective when accompanied by mood stabilizers or antidepressants. There were no further improvements when adding sleep phase advance or bright light treatment, or when adding more than one sleep deprivation exposure.

Moderate to low quality evidence finds a medium-sized improvement in depression with total sleep deprivation plus medication compared to medication alone. This effect may remain for up to 4 weeks post-treatment. Adding mood medication after 10 days of total sleep deprivation treatment improved depression and increased rates of remission by 3 months. Around 4% of patients had an episode of mania or hypomania with total sleep deprivation.

August 2021

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tDCS is a non-invasive form of brain stimulation similar to transcranial magnetic stimulation, but instead of using magnets, it uses a low-intensity, constant current applied through scalp electrodes. Generally, anodal stimulation induces an increase of cortical excitability, whereas cathodal stimulation decreases cortical excitability, with effects that last beyond the stimulation period. Dose involves current intensity, duration of stimulation and size of electrodes. The use of tDCS in bipolar disorder is in the early stages of investigation for relief of symptoms in people who are not satisfied with their response to medication.

What is the evidence for tDCS?

Moderate quality evidence finds no differences between active and sham tDCS in the rates of treatment-emergent mania or hypomania. We found no reviews that assessed tDCS for symptom improvement.

November 2021

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TMS is a non-invasive method to stimulate nerve cells in superficial layers of the brain. Traditionally, studies assessing the effectiveness of TMS have been limited by small samples, a range of stimulation parameters and most studies lack long-term follow up assessments. Control comparisons also differ – ‘sham’ TMS may involve tilting the stimulation coil against the scalp by 45 or 90 degrees, thus reducing the degree of brain stimulation, or use of a “placebo” coil of identical appearance. These placebo methods usually involve a ‘click’ noise but no magnetic field and no twitching sensation on the scalp. Comparison groups may receive active TMS applied to other brain regions. The effects of differing dosage and duration of concurrent medication on TMS response is unclear.

What is the evidence for TMS for people with bipolar disorder?

Moderate quality evidence finds improved clinical response, particularly for depression following high frequency (10 Hz) repetitive TMS over the left dorsolateral prefrontal cortex. There was no benefit for mania and little risk of switching to mania in people with bipolar depression.

Moderate to low quality evidence finds improved cognition post-treatment with high-frequency repetitive TMS over the left dorsolateral prefrontal cortex, although the findings were not significantly different to the improvements reported in sham conditions.

November 2021

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VNS provides indirect modulation of brain network activity through the stimulation of cranial nerves. Invasive VNS involves surgical implantation of a small pulse generator under the skin which is programmed to deliver long-lasting, intermittent electrical stimulation of the vagus nerve. Non-invasive stimulation involves attaching a stimulator to the outer ear close to the ear canal, which delivers electrical impulses through the skin to the vagus nerve.

What is the evidence for VNS?

Low quality evidence is unable to determine any benefit of invasive VNS for bipolar disorder. More research is needed.

November 2021

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