Alternative Treatments for Premenstrual Dysphoric Disorder

The primary aim of this study is to examine the effects of co-administered wake therapy followed by light treatment on mood, and secondarily on circadian rhythms, to test the hypothesis that critically-timed chronotherapy improves mood by correcting phase disturbances in melatonin and sleep in women with Premenstrual Dysphoric Disorder.

Study Overview

• Status: Completed
• Conditions: Premenstrual Dysphoric Disorder
• Intervention / Treatment: Other: LWT+AM BWL; Other: EWT+PM BWL

Detailed Description

The design is a randomized cross-over contrasting Late Wake Therapy plus morning bright light (LWT+Am BWL)vs. Early Wake Therapy plus evening bright light (EWT+PM BWL)administered in the luteal phase of two separate menstrual cycles, and preceded by 2 evaluation months. To lessen the patient's burden, the 1-night EWT or LWT and the following 7-day BWL interventions will be conducted at home, given at a fixed point in each menstrual cycle, from day 1 to 7 after the mid-cycle luteinizing hormone(LH) surge (ovulation). We anticipate that LWT+7 days of AM BWL (vs. EWT+PM BWL) will produce much greater mood benefits and larger physiological responses, than the one-time light pulses used in our earlier phase-shift studies.

• Study Type: Interventional
• Enrollment (Actual): 43
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • San Diego, California, United States, 92103
      • UCSD Medical Center, Hillcrest

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 45 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• Age: 18-45 years.
• Women with regular ovulatory menstrual cycles 26-32 days in length (for at least the previous six months).
• A history of a depressive (but not bipolar) mood disorder, but not an ongoing episode (symptom free for the last 12 months).
• Patients must meet DSM-IV criteria for Premenstrual Dysphoric Disorder (that includes irritability).
• Objective ratings: mean HRSD < 7 for follicular phase (day 5-10 of cycle after menses); mean HRSD > 14 for premenstrual (luteal) phase (6 days prior to onset of menses onward).
• Subjective ratings: mean Beck Depression Inventory < 5 follicular phase; > 10 premenstrual (luteal) phase, or
• Daily ratings: minimal symptoms (mean less than 50 on 100mm scale) follicular phase; at least a 30% increase in mean affective symptom ratings, premenstrual (luteal) phase.
• By clinical assessment and ratings, the patient has reported a history (for at least the last six months) of recurrent, moderate to severe premenstrual mood symptoms that impair some aspect of social or occupational functioning and that remit within a few days after the onset of menses. This pattern is prospectively documented with subjective and objective ratings over a 2-3 month interval. Patients must demonstrate a consistency of symptoms and a long enough duration of symptoms (7-10 days) to allow for study.
• Subjects willing to endure the rigors of a long-term (up to 6 months) research study.

Exclusion Criteria:

• Subjects with significant medical illness including hepatic (abnormal liver function tests), neurological, renal, cardiac, pulmonary, hematologic, gastrointestinal, or metabolic disorders.
• Subjects who are lactating, are within 6 months postpartum, or have an irregular sleep- wake cycle, e.g., from having very young children in the home.
• Subjects who are using hormonal contraception (within six months prior to the study).
• Subjects using other medication within one month of initiating the study or anytime during the study.
• Subjects with significant psychiatric disorder (schizophrenia, bipolar disorder, anxiety disorders, eating disorders, personality disorders, sleep disorders). An ongoing major depressive episode within the last year is reason for exclusion, although a previous history of a depressive episode is not (using DSM-IV diagnostic criteria for a major depressive episode).
• Subjects with a recent history (within the past year) of drug or alcohol abuse.
• Subjects with clinically significant abnormal laboratory values.
• Subjects with irregular menstrual cycles (cycle lengths vary greater than 3 days).
• Subjects unlikely to cooperate with the requirements of the study.
• Subjects needing frequent or continuous use of any medication, including nicotine (> 5 cigarettes daily).
• Subjects whose prospective ratings do not show cyclic variation in association with the menstrual cycle (as per inclusion criteria).
• Subjects with an irregular sleep schedule, extreme chronotypes or a sleep-wake cycle that does not correspond to the environmental light-dark cycle (e.g., subjects within 2 weeks of transmeridian travel, night shift workers, or those with significant advanced or delayed sleep phase syndromes). To enhance precision of the timing of the light stimulus on circadian phase (temporal resolution), we will exclude women with habitual sleep onset times after midnight or wake times after 9 am.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: LWT+AM BWL; Late-wake therapy in combination with morning bright white light	Other: LWT+AM BWL; One night of late wake therapy (LWT)(sleep 21:00-01:00 h, followed by wakefulness) plus 7 days of morning bright white light (AM BWL)(light-emitting diode-LED administered for 60 minutes, starting within 30 minutes of habitual wake time)
Placebo Comparator: EWT+PM BWL; Early-wake therapy in combination with evening bright white light	Other: EWT+PM BWL; One night of early wake therapy (EWT) (wakefulness until 03:00 h, then sleep 03:00-07:00 h) plus 7 nights of evening bright white light (PM BWL)(light-emitting diode-LED administered 90 minutes before habitual sleep onset, for 60 minutes)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Treatment-Related Changes from baseline in mood ratings	Mood ratings include Hamilton Rating Scale for Depression (HRSD), Beck Depression Inventory (BDI), atypical depression symptoms as part of the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders version (SIGH-SAD), Beck Anxiety Inventory (BAI), mania ratings, the Psychological General Well-Being Index (PGWI) and daily mood self-ratings (DMR) that include core PMDD symptoms of anxiety and irritability as required during diagnostic evaluation, before, during and after each wake and light intervention at the same time of day (between 15:00-17:00 h). To assess more acute effects on mood that may occur more rapidly during the wake interventions, subjects will complete DMRs twice daily beginning the evening before the wake therapy intervention and continuing until the morning after the recovery night of sleep.	baseline (month 2) and 1-2 days post intervention (months 3,5)
Treatment-Related Changes from Baseline in Urinary 6-sulfatoxymelatonin (6-SMT)	6-SMT is a principal melatonin metabolite that is abundant in urine, well correlated with plasma melatonin, and serves as an excellent marker for circadian phase response.	baseline (month 2) and 1-2 days post intervention (months 3,5)
Treatment-related changes in objective and subjective sleep measures	Using actigraphy, we will obtain objective measures of the sleep/wake cycle to ensure appropriate sleep/wake times during wake therapy, and during the light interventions as it is an important biological rhythm with which to compare the intervention-induced melatonin rhythm changes. To assess subjective sleep quality, we will use the Pittsburgh Sleep Quality Index (PSQI) and a visual analogue scale.	baseline (month 2) and 1-2 days post intervention (months 3,5)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Effects of expectation, morningness/eveningness and seasonality on primary outcome measures	Prior to entering the study, subjects will complete expectation forms measuring their expectation for change with the interventions (100 mm line from "much worse" to "much better") as well as Horne-Östberg scales to assess morningness and eveningness, as these variables may mediate or moderate primary outcome measures. To determine whether seasonality affects outcome, subjects will complete the Seasonal Pattern Assessment Questionnaire (SPAQ).	baseline
Treatment-related changes from baseline in reproductive hormones	We will obtain overnight urinary samples for estradiol, progesterone, gonadotropins and prolactin (obtained at the same time of 6-SMT overnight collections in baseline and intervention months).	baseline (month 2) and 1-2 days post intervention (months 3,5)
Subjective visual analog scale-based global assessment of treatment effectiveness	Following both treatment interventions, subjects will complete a visual analog scale-based global assessment of treatment effectiveness.	1-2 days post second intervention (month 5)
Subjective assessment of side effects to treatment	Following each treatment interventions, subjects will complete an assessment of side effects using the Side Effects Checklist.	1-2 days post intervention (months 3,5)

Collaborators and Investigators

• Sponsor: University of California, San Diego
• Investigators: Principal Investigator: Barbara L Parry, M.D., University of California, San Diego

Study record dates

Study Major Dates

• Study Start (Actual): June 18, 2013
• Primary Completion (Actual): May 10, 2018
• Study Completion (Actual): July 3, 2018

Study Registration Dates

• First Submitted: February 25, 2013
• First Submitted That Met QC Criteria: February 25, 2013
• First Posted (Estimate): February 27, 2013

Study Record Updates

• Last Update Posted (Actual): February 4, 2022
• Last Update Submitted That Met QC Criteria: January 20, 2022
• Last Verified: January 1, 2022

More Information

Terms related to this study

• Keywords: Depression; Women; Chronobiology; Light therapy; Premenstrual Dysphoric Disorder; Wake therapy; Phase
• Additional Relevant MeSH Terms: Mental Disorders; Pathologic Processes; Mood Disorders; Depressive Disorder; Menstruation Disturbances; Premenstrual Syndrome; Disease; Premenstrual Dysphoric Disorder
• Other Study ID Numbers: 1R01AT007169-01A1 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No