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Although the DSM-5 diagnostic criteria for a major depressive episode are the same for unipolar and bipolar disorders, these episodes differ in their natural past history (ie, patients with bipolar disorders will have discrete episodes of hypomanias or manias), age of onset, suicide risk, associated comorbidities, and biological correlates. And, most importantly, they differ dramatically in the medications that are effective. Thus, it is critical to diagnose them correctly.

To do so, you must take a good history for 

, because this is where diagnostic error commonly occurs. Start by informing the patient how important it is to have the correct diagnosis for effective treatment and that being wrong about the diagnosis can lead to the wrong treatment—which is at best ineffective and at worst very harmful (eg, antidepressants can cause a malignant transformation in bipolar disorder to a rapid cycling and treatment-resistant condition).

 This warning to the patient hopefully overrides their potential reluctance to disclose manic symptoms because of the stigma of the diagnosis, their enjoyment of the experience, or their belief that it represents their normal mood and energy that they would like to return to and maintain.

 or hypomania. Patients often wake up feeling, for no particular reason, unusually energetic, with thoughts racing about millions of things they want to get done. They want to start new projects, clean and organize the house, add to their possessions, contact neglected friends. They set out to do those projects and then they go-go-go day and night, feeling a lessened need for sleep or maybe skipping sleep completely for a night or so. They almost invariably spend money to fund the ventures or add to hobbies, clothes, or possessions. Often, they already have plenty of what they are buying and they later recognize that the purchases were unnecessary. They discount the importance of other bills, thinking they will figure out how to pay those at some future date, believing the new purchases to be more important.

Explain that during mania their speech is accelerated and increased in quantity and volume. This tends to be noticed by others, who will advise them to “slow down” so they can be understood. Friends and family may see their plans as impractical, unrealistic, or risky, but patients in the grip of mania will ignore this feedback and often lash out and become irritable and defensive. At work, if there are disagreements with the boss, there can be loud arguments, and the person with mania can impulsively quit or get fired, which they later regret.

Their disinhibited speech can also include embarrassing self-disclosures, undiplomatic criticisms of others, or inappropriate sexualized content. Their property can be littered with tools and supplies for projects that were never finished, because when the manic episode ends, they lose all interest in the activity. Parts of their house may be partly demolished in preparation for the project and then stay that way for years, because when the next manic episode begins, they usually start an entirely different project. Make it clear to the patient that the episodes you are talking about last at least a few days and nights, often more.

At this point, stop and see if the patient recognizes these behavioral patterns. If it is unclear, bring up some additional symptoms: social overactivity, hazardous driving patterns, uncharacteristically starting conversations with strangers, and commonly sexual preoccupations and overactivity (this is a cause, although not the only one, of infidelity in established relationships, often resulting in the end of the primary relationship). It is often best to leave inquiries about sexual indiscretions to a later time due to possible embarrassment for them, but by the time you bring it up, you might get a very emphatic response of “absolutely!” about this symptom.

If the patient reports that these events do occur, get details about how long they last, how frequently the behaviors occur, and whether they cause significant impairment in social or work relationships, have legal consequences, or result in financial hardship. This will determine whether the patient meets the criteria for bipolar I or II, and rapid versus nonrapid cycling.

If the patient does not report criteria-meeting manic episodes, it is possible that they have prebipolar depression and could have a hypomanic or manic episode in the future.

 Initial manias have occurred in elderly patients after decades of depressions. A number of factors may predict when a unipolar major depressive disorder diagnosis could change to a bipolar disorder (

 If enough predictors are present, including failure on previous antidepressant trials, consider treating the depression as a 

 and taper off any antidepressants as you do so.

is associate professor of psychiatry at Harvard Medical School and co-director, US Department of Veterans Affairs National Bipolar Disorders Telehealth Program. The author reports no conflicts of interest concerning the subject matter of this article.

Preventing the malignant transformation of bipolar disorder.

2. El-Mallakh RS, Ghaemi SN, Sagduyu K, et al; STEP-BD Investigators. 

Antidepressant-associated chronic irritable dysphoria (ACID) in STEP-BD patients

3. El-Mallakh RS, Vöhringer PA, Ostacher MM, et al. 

Antidepressants worsen rapid-cycling course in bipolar depression: a STEP-BD randomized clinical trial.

4. Faedda GL, Baldessarini RJ, Marangoni C, et al. 

An International Society of Bipolar Disorders task force report: precursors and prodromes of bipolar disorder. 

Major depressive episode and bipolar disorders: same DSM-5 diagnostic criteria, but very different disorders. 

Bipolar Depression: How Not to Miss the Diagnosis

Michael E. Thase, MD; Theresa Cerulli, MD; Gustavo Alva, MD, DFAPA; and Tina Matthews-Hayes, DNP, FNP, PMHNP, provide insight on the role of telemedicine in improving outcomes for patients with bipolar disorder.

Role of Telemedicine in Bipolar Disorder

A panel of experts in psychiatry consider the use of a novel second-generation antipsychotic for the management of treatment resistant depression.

Patient Case #2 Continued: Novel Second-Generation Antipsychotics

Michael E. Thase, MD, presents the case of a 47-year-old man with treatment resistant bipolar depression.

Patient Case #2: 47-Year-Old Man With Treatment Resistant Depression (TRD)

Psychiatric experts consider mood stabilizers when treating bipolar disorder and review the role of antidepressants in disease management.

Treatment Options for Bipolar Disorder

Theresa Cerulli, MD, and Tina Matthew-Hayes, DNP, FNP, PMHNP, review diagnostic difficulties of the patient’s primary care physician in patient case #1 and share optimal approaches to the diagnosis and treatment for patients with bipolar disorder.

Diagnosis of Bipolar Disorder

Tina Matthews-Hayes, DNP, FNP, PMHNP, comments on screening tools for bipolar disorder and Gustavo Alva, MD, DFAPA, shares his impressions from patient case #1.

Clinical Impressions From Patient Case #1

 Let’s move on to our next polling question. The patient in case 1 is currently not taking any mood stabilizing medication. Which of the following treatment options would you have most likely started with this patient? a. lithium, b. quetiapine, c. divalproex, d. lurasidone, or e. cariprazine.

Why don’t we go ahead and talk some about our patient. Gus, join me, if you will.

: What do you think the clinical significance is of making the diagnosis of bipolar disorder in this patient?

: It’s quite significant. Obviously, this is a terrific example of the fact that sometimes people go about life without necessarily receiving an appropriate diagnosis for a while. We know that based on the literature, sometimes people go 5 to 10 years before ascertaining the appropriate diagnosis. Part of the problem with that is that oftentimes people are challenged by additional problems because of the fluctuation with their mood and their inability to reach the goals that they’re after, whether it be socially, occupationally, interpersonally.

This case is really interesting, but obviously, we would want to find out a bit more information about what’s been happening with her. The fact that she’s been, again, having difficulties or problems brought about by the antidepressant choices that she’s received previously become sort of a common theme that we oftentimes see in the clinical setting.

Oftentimes, when people experience mood oscillation or fluctuation and the mixed symptomatology that she’s having right now, these are sort of characteristic of the complexity of symptomatology that patients will present with.

Now, we obviously know that there’s a 17% lifetime prevalence rate for major depressive disorder, and that bipolar disorder pales in comparison based on percentages. Literature would suggest this is, at the most generous, up to 4% if you were to lump in bipolar I and II together. However, when we consider somebody with a major depressive episode, a differential diagnosis of bipolar disorder and a depressive episode is certainly one that we should be considering.

I think that this particular case is quite interesting in that it brings so many different elements to the forefront that help us, along the lines of medication misadventures and the possibility of barking up the wrong tree and not necessarily addressing the underlying issues that we need to be getting to.

: Thanks, Gus. Theresa, this young woman has an antecedent history of ADHD [attention-deficit/hyperactivity disorder].Do you find that surprising?

: Not at all, Dr Thase, not at all. I’m a neuropsychiatrist in clinical practice in the Boston area, and this case is so illustrative of most of the patients I’m getting referrals on.

I have had an area of interest within ADHD for years, and many of my patients with bipolar disorder are those who were previously diagnosed in childhood with ADHD. This is more common than not. The comorbidities with bipolar disorder are so elevated, it is one of the reasons it is so difficult to make this diagnosis accurately. As Gus already explained, we are now looking at a 5- to 10-year delay in making the diagnosis of bipolar disorder accurately. There is so much need for patient education and clinician education alike to help raise awareness of what this really looks like in clinical practice.

The comorbidities that are most common, certainly the differential between bipolar disorder and major depressive disorder, is a tough one. Most patients are coming in depressed, as our hypothetical patient in this case. They often do have features, in this case some of the reasons it’s hard to differentiate and diagnose our young woman, our 27-year-old, is the history of her ADHD, and the fact that she has had recurrent depressive episodes with some mixed features that could be mixed up with things like the reactivity, the higher energy, the irritability of ADHD.

It is easy to miss that this was actually a bipolar picture if not yet having seen the full manic symptoms. We’re really looking at risk factors to be able to help identify who the patients are who are truly, in the history, the longitudinal perspective, at risk for bipolar as opposed to unipolar depression or just an ADHD anxious, irritable picture, which is so commonly where these folks get lumped into.

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

A panel of experts in psychiatry share insights on the challenges and importance of making an accurate diagnosis of bipolar disorder.

Clinical Significance of Bipolar Disorder

, “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Last month we taught you how evening light can worsen mood. Today we teach you how to fix that. 

, "the voice of psychiatry." With thoughtful insights into the world of mental health, this podcast provides timely clinical commentary and practical cutting-edge pearls for you and your practice. We hope you enjoy.

I’m Chris Aiken, the Mood Disorders Section Editor for 

, and I’m Kellie Newsome, a psychiatric NP and the cohost of the 

: Evening light worsens sleep and mood, and 

 we unraveled the biology behind that association. To recap, evening light – particularly the blue wavelength suppresses melatonin, worsening 2 systems that are already fragile in people with mood disorders: sleep and circadian rhythms. In animal studies it even altered the core architecture of the brain – shrinking the dendritic spines that 

But you don’t have to go into the woods and live deliberately to fix this problem. Today, we’ll teach you how to use blue light filters to stabilize the circadian rhythms that regulate mood and sleep, and how to use them in 

: There are 2 well-known photoreceptors in the eye. The rods see black and white, and the cones add color vision. But in the 1990s a new photoreceptor was discovered – melanopsin – which only responds to the blue wavelength of light. This photoreceptor doesn’t help us see, but it does regulate our circadian rhythm. In the past, this system worked well because we didn’t have much blue light in the evening. There were candles, starlight, fireplaces – all yellow light.

: Except once a month when the blue moon was full. And it’s no coincidence the word lunatic arose in the middle ages as a term for mental illness. It was believed that some people went into temporary bouts of insanity that followed the lunar cycle – the moon. Seven hundred years later, 

 linking the full moon to worsening of psychiatric disorders continue to roll in.

: And in today’s world, every night is a full moon, because cell phones, plasma TVs, and energy efficient bulbs emit a lot of blue light. But technology has also come to the rescue in the form of blue light filtering glasses. These are amber colored glasses, and when you wear them they filter out close to 100% of blue light. They’ve gained popularity among sports figures and celebrities, because wearing them at night improves sleep – which then raises cognitive and athletic performance. But most models out there do not filter enough blue light to make a meaningful difference in psychiatric disorders. We recommend the glasses that were used in the clinical research – and there are 2 types. Some studies have used Uvex glasses, which are $10 to 15 dollars on Amazon. Any pair on that site will work, and these are much better quality for a higher price, around $50.

: I keep a pair of these glasses at my desk for patients to try on. They’re usually surprised to see the world looks quite pleasant through them. They don’t make things dark, but give the world a relaxing, yellow hue. Some patients find them so soothing that I have to warn patients not to wear them during the day, because doing so will flip their circadian rhythm in the wrong direction. When you wear them, your brain will think it’s in pitch darkness, and we only want that effect at night.

: Wearing them has real biological effects. When you put them on, your melatonin starts to rise, the same as it does in a 

 Sometimes patients ask if they can just take melatonin instead, but that doesn’t have the same effect. In a recent randomized controlled trial, taking artificial melatonin did nothing to stabilize mood in bipolar disorder.

 So it’s not enough to have melatonin drizzled on the brain. There are other biological effects involved in pumping out the brain’s indigenous melatonin that are necessary here.

If you want to know more about the biological effects of light and darkness listen to our August 2nd podcast on 

Blue Light, Depression, and Bipolar Disorder

. Now, let’s move on to the clinical research.

: In the 1980s Thomas Wehr, MD, and Norman Rosenthal, MD, made a surprise discovery while working at the National Institute of Mental Health (NIMH). Some patients had worsened depression in the wintertime that improved with light therapy. Their research suggested that circadian rhythms played a strong role in mood disorders, something that was already hinted at by the high rates of insomnia in major depression and the fact that a night without sleep often triggered an episode of mania. So, Wehr turned his attention from morning light to evening darkness. He began with normal subjects and placed them in a pitch-dark room for 14 hours overnight, imitating a dark winter night where the sun goes down at 6 PM and rises at 8 AM. The subjects were a little sleep deprived before the experiment, getting about 7 hours per night, something Wehr thought might be due to the artificial evening light of modern life. After a few weeks in the dark bedroom, their 

 to 8 hours and 15 minutes per night, closer to the recommended amount an adult needs.

: Then in 1994 a man came to the NIMH seeking help for rapid cycling bipolar disorder. Most patients don’t call up the NIMH to get help, so we can imagine this man had a pretty bad case. He was a successful engineer with a hyperthymic temperament, but in his 40s he became depressed and started fluoxetine and nortriptyline. He got better on this combination, but then went into a 4-year bout of rapid cycling moods cycling in and out of depression and hypomania every 1 to 2 months. Mood stabilizers did not help, so he came to the NIMH. Wehr knew that sleep disruption could trigger rapid cycling, and he wondered if his super-dark room could stabilize it. He put the patient through the same protocol he used for sleep, placing him in a pitch dark room for 14 hours each night. With this dark therapy, he improved so rapidly that they eased the schedule from 14 hours of darkness to 10 hours each night (10:00 PM to 8:00 AM). He stayed well with that regimen, and that is how dark therapy was 

: But the treatment didn’t really take off. First, it’s hard to get patients in a pitch-dark room overnight. We’re talking so dark that you can’t see your hands in front of your face. Second, we need more than an intriguing case report to put this into practice. The first problem was resolved in the early 2000s by James Phelps, MD.

Phelps was working in private practice in Oregon when he chanced upon 3 discoveries that would open up new therapeutic doors in bipolar disorder. First, he learned about Wehr’s research on dark therapy. Then he learned about the new photoreceptor, melanopsin, that set the circadian rhythm by responding to blue light. He wondered if dark therapy could be accomplished by blocking only the blue wavelength of light, and that brought him to the third piece of the puzzle: blue light filtering glasses. Other fields of medicine had already raised alarms about the hazards of evening blue light (such as increased risk of cancer and heart disease) and a company was manufacturing these to improve sleep and health. Phelps called this 

 and tried the glasses out on his patients. For some, the glasses did nothing, but about half of his patients reported their sleep was better when they wore the glasses 1 to 2 hours before bed.

He then discovered that welders used the same blue-light filters to protect their eyes at the local welding shop, and this opened the door to more treatments because these factory grade lenses were only $7. Phelps tested them and the fit the bill. 

later ran tests of blue light blockers and also concluded that the Uvex safety lenses he was using were among the strongest filters.

Phelps tested the waters, but the definitive study was a full-scale randomized trial in patients who were hospitalized for mania. In addition to treatment as usual, half wore amber lenses in the evening, and half wore (placebo) gray lenses, until sleeping in a pitch-dark room. The improvements were dramatic over the first week, with a large effect size of 1.9, while the control group barely changed.

You don’t need to be in the hospital to do this therapy. Phelps has had success using it in an outpatient practice, and we have as well. Here’s how you do it.

The original protocol required manic patients to be in either pitch darkness or virtual darkness (that is, with the amber glasses on) for 14 hours, from 6:00 PM to 8:00 AM. It took about a week for the mania to improve, and as it did the protocol was relaxed a bit, from 14 hours per night to 10 hours per night. So instead of putting the glasses on at 6 PM, they’d put them on at 7:00 PM, then 8:00 PM, and for prevention thy would move it to 9 or 10 PM. They don’t wear the glasses while asleep. That’s what the pitch-dark bedroom is for. But they do put them on if they are awake and the lights are on.

And the pitch darkness really does matter. Even light as dim as a nightlight on can interfere with melatonin secretion. In a large epidemiologic study of older adults, sleeping with a night light on doubled the risk of depression over 2 years compared to a pitch-dark bedroom.

But how do they get their bedroom pitch dark in this electric light world? 

, electrical tape over LEDs, towels or draft snakes under doors, or sleeping in the basement. If there is still stray light, patients can also sleep with a good eye mask.

: One problem we run into is patients who feel they can’t sleep without the TV on. Usually the reason is depressive rumination. These patients rely on the TV to distract them from their negative, ruminating thoughts. If that’s the case, we recommend ambient music or boring audiobooks instead. Another problem is patients who are afraid of the dark, such as those with PTSD. Here we have a technological solution. They can use amber colored nightlights that don’t emit any blue light. They are available for around $12.

: One modification we don’t recommend is to rely on blue-light filters on laptops and cell phones. Most devices have a setting that turns down the blue in the evening, and no doubt this is certainly a good thing and we’d recommend it in conjunction with dark therapy, but it doesn’t filter 100% and it isn’t going to take care of the background lights. You can find this feature in your smart phone’s settings, or if you’re using a laptop try downloading f.lux (spell it out) for windows or Candlelight by Oliver Denman for Mac.

But what if your patient can’t put the glasses on at 6 PM? Remember the 14-hour protocol was used for hospitalized mania, and they loosened it up as the patient got better. In practice, you might use dark therapy for hypomania, mild mixed states or as an intervention for early signs of mania. In those cases, putting the glasses on 2 hours before bed might be enough.

: It’s also important to set up expectations. Tell your patient that dark therapy is going to help stabilize their mood, but it may not help them fall asleep. Here’s an interesting pearl from that controlled trial. The patients who got better with the dark therapy didn’t actually sleep more. They slept a little less than the placebo group, but their sleep did get more regular. It went from sleeping and waking at random times to a more steady, stable circadian pattern.

 A lot of times patients will give up on dark therapy because they think it is supposed to help them sleep.

: Dark therapy improves mania, but what does it do to sleep? We found 3 randomized controlled trials that tested them out in insomnia, and they had a large effect, helping patients stay asleep longer, fall asleep earlier, and deepening sleep quality.

 One of them used the blue light blockers as an adjunct to CBT-insomnia, where half the patients had the behavioral therapy with placebo glasses and half used the blue-light blockers. Not only did sleep improve with the blockers, but so did anxiety and depression.10 Another study looked at performance on cognitive tests after wearing the glasses, and that got better as well, probably because the patients were sleeping better.

 In the sleep studies, patients put the glasses on 1.5 to 2 hours before bedtime.

Blue light blockers have been used successfully in jet lag, and they tend to help night owls fall asleep earlier.

: I wear them myself and I can attest to that. I’m more patient and have better attention, a little quicker on my feet, the next day if I wore them before bed.

: Blue light blockers have a big effect in mania and rapid cycling, and for sleep they deepen sleep quality and turn night owls into morning people. But can they help depression? We know from animal studies and epidemiologic studies that blue light causes depression, but when it comes to clinical studies using blue light blockers to treat depression the results are mixed. In that CBT-insomnia study, they did improve depressive symptoms, but those patients had clinical insomnia, not clinical depression.

 Beyond that, we have only 2 controlled trials, 1 positive, 1 negative. The positive one was small (n = 27) and centered on postpartum depression, where nocturnal awakening is the norm. Women who used blue-light blockers and low-blue light bulbs had greater improvements than those who used placebo glasses and bulbs.

 The negative study was also small (n = 20) and included depressed patients with insomnia. The investigators suspected that the glasses might not have worked because the patients found them uncomfortable and did not wear them as much as they should.

: When worn at night, blue light filters have beneficial, biological effects, but can they have side effects? Nothing major showed up in the studies. Possibly headaches, and there are reports of depression in some patients. This usually improves by putting the glasses on later, say, 7 PM or 8 PM instead of 6 PM. Although you can see pretty clearly through the glasses, color vision is distorted so we don’t recommend them while driving.

: We have links to recommended brands of blue-light blockers in the text to this podcast. We hope to see you again on 

, and you can also catch us every Monday on the 

is the Mood Disorders Section Editor for 

 He has written several books on mood disorders, most recently

 with his cohost Kellie Newsome, PMH-NP. The author does not accept honoraria from pharmaceutical companies but receives royalties from PESI for

and is also a practicing psychiatric mental health nurse practitioner in Winston Salem, NC, at the Mood Treatment Center. Raised in Tasmania, Australia, Kellie moved to the United States in 1998.

1. Bedrosian TA, Vaughn CA, Galan A, et al. 

Nocturnal light exposure impairs affective responses in a wavelength-dependent manner.

2. Henriksen TE, Skrede S, Fasmer OB, et al. 

Blue-blocking glasses as additive treatment for mania: a randomized placebo-controlled trial.

Lunar cycle and psychiatric hospital admissions for schizophrenia: new findings from Henan province, China.

4. Kayumov L, Casper RF, Hawa RJ, et al. 

Blocking low-wavelength light prevents nocturnal melatonin suppression with no adverse effect on performance during simulated shift work.

5. Quested DJ, Gibson JC, Sharpley AL, et al. Melatonin In Acute Mania Investigation (MIAMI-UK). 

A randomized controlled trial of add-on melatonin in bipolar disorder.

6. Barbato G, Barker C, Bender C, et al. 

Extended sleep in humans in 14 hour nights (LD 10:14): relationship between REM density and spontaneous awakening.

7. Wehr TA, Turner EH, Shimada JM, et al. 

Treatment of rapidly cycling bipolar patient by using extended bed rest and darkness to stabilize the timing and duration of sleep.

Dark therapy for bipolar disorder using amber lenses for blue light blockade.

Bedroom light exposure at night and the incidence of depressive symptoms: a longitudinal study of the heijo-kyo cohort.

10. Janků K, Šmotek M, Fárková E, Kopřivová J. 

Block the light and sleep well: Evening blue light filtration as a part of cognitive behavioral therapy for insomnia

11. Zimmerman ME, Kim MB, Hale C, et al. 

Neuropsychological function response to nocturnal blue light blockage in individuals with symptoms of insomnia: A pilot randomized controlled study.

12. Shechter A, Kim EW, St-Onge MP, Westwood AJ. 

Blocking nocturnal blue light for insomnia: A randomized controlled trial.

13. Bennett S, Alpert M, Kubulins V, et al. 

Use of modified spectacles and light bulbs to block blue light at night may prevent postpartum depression.

14. Esaki Y, Kitajima T, Takeuchi I, et al. 

Effect of blue-blocking glasses in major depressive disorder with sleep onset insomnia: A randomized, double-blind, placebo-controlled study.

Bipolar Disorder