CHRONOBIOLOGY & Its

Implications in Psychiatry

MENTOR - Dr. Arvind Kumar

PRESENTER - Dr. Trisha Gupta
 Introduction
 Chronobiology is the study of biological time.
 Different organisms have different periodicities; ‘circadian’ rhythms last about a day.
 This circadian rhythm is generated internally, and not exclusively dependent on
environmental stimuli.
 Site of primary circadian rhythm generation in mammals : Suprachiasmatic Nucleus, in
anterior hypothalamus.
 Mean circadian rhythm generated by human SCN is 24.18 hours
 Humans become out of phase and transiently nocturnal in approx. 3 months.
 Daily change in light levels act as cue to reset endogenous circadian clock.
 Known as Zeitgeibers (German: zeit; time, geiber; giver)
 Regulation of pacemaker by detecting change in illuminance requires photoreceptive
apparatus (in eyes).

(Kaplan & Saddock)

Different Rhythms & Circadian Clock

Behavior

Core Body
Drinking Temp

Circadian
Clock

Hormone
Sleep
Level

Feeding
Melatonin – Marker of Circadian Phase
 Melatonin synthesis : controlled through a multisynaptic pathway from SCN to
pineal gland.
 Serum melatonin elevated at night, return to baseline during the day.
 This nocturnal rise : marker of circadian phase.
 Exposure to light:
 Acutely suppresses elevated melatonin levels.
 Shifts the phase of the circadian rhythm of melatonin synthesis.
 Highly lipophilic, therefore crosses membranes easily, not stored.
 Photoreceptive
input to SCN from
eye

Other Rhythmic
Inputs

Master Pacemaker
in SCN
Anatomy of Circadian Pacemakers
 Suprachiasmatic Nucleus – Master Oscillator
 Slave Oscillators – Found in kidney, liver, lung, other sites of brain.
 SCNs – paired hypothalamic structures lying dorsal to optic chiasm.
 Show peak metabolic and electrophysiological activity during the day.
 SCN has neurons with individual oscillator activity resulting in a coordinated rhythmic
signal.
 Some neurons are grouped together in different “phase groupings”, these groups are
modulated by entraining agents such as light.
 This offers flexibility, such that seasonality can be incorporated into a biological system.
 Neurons of SCN:
 Among the smallest in the brain
 Short dendrites with minimal branching
 Positive for GABA (Gamma Amino Butyric Acid
 Core of SCN contains Calbindin positive neurons. Outer neurons constitute the Shell.
Afferent Projections to SCN

Afferents from
Intergeniculate Leaflet:
Primary neurotransmitter
– Neuropeptide Y

Retino Hypothalamic Tract :

Serotonergic Projections
Primary neurotransmitter – from Midbrain Raphe:
Glutamate, mediated by
Modulating effect via
Pituitary Adenylate Cyclase
5HT7, 5HT1B receptors
Activating Peptide ( PACAP)

Suprachiasmatic
Nucleus
(Rosenwasser & Turek, 2005)
Efferent Projections from SCN
(Takahashi & Ho, 2006)
 Molecular Clockwork
� PER, the protein encoded by period,
accumulated during the night and was
degraded during the day. Thus, PER
protein levels oscillate over a 24-hour
cycle, in synchrony with the circadian
rhythm.
� PER protein blocks the activity of the
period gene. Thus, by an inhibitory
feedback loop, PER protein prevents its
own synthesis and regulates its own level
in a cyclic rhythm.
� To block the activity of the period gene,
PER protein, which is produced in the
cytoplasm, has to reach the cell nucleus,
where genetic material is located.

(Liu, Zwiebel, Hinton, Benzer, Hall, and Rosbash, 1992)

 Molecular Clockwork
Michael Young discovered a second clock
gene, timeless, encoding the TIM protein
that was required for circadian rhythm.

When TIM bound to PER, the two proteins

were able to enter the cell nucleus where
they blocked period gene activity to close
the inhibitory feedback loop.

Michael Young identified another gene,

doubletime, encoding the
DBT protein that delayed the
accumulation of the PER protein. Thus, an
oscillation is adjusted to more closely match
a 24-hour cycle.

(Price, Blau, Rothenfluh, Abodeely, Kloss, and Young, 1998)

 Resetting the Circadian Clock
 Light is the most effective entraining agent but the photic sensitivities of the visual and
circadian systems are different.
 Visual system has a range of 14 log units pf light intensity, while circadian system is 3 log
units.
 The activation threshold is also much higher for the circadian system, and requires light
activation for much longer duration.
 The loss of rods and cones has no effect on the circadian clock.
Retinal Photoreceptors
 Blue wavelengths most efficiently suppresses
melatonin in humans.
 A small percentage (1-2%) of rodent retinal ganglion
cells is intrinsically photosensitive and projects
directly into SCN.
 They contain melanopsin, a photopigment.
 They are distributed all over the retina, and have vast
dendritic branching.
 Melanopsin is contained in the plasma membrane of
these cells.
 They are less sensitive to light but their entire
framework is capable of phototransduction, and thus
involves large sectors of the visual field.
 Mice with targeted disruption of both copies of
melanopsin gene are deficit of phase shifting
circadian rhythm in response to light.
Sleep and Circadian Rhythm
 Sleep is regulated by 2 processes:
 Sleep homeostat: due to accumulation and dissipation of sleep debt, encoded by Adenosine.
 Circadian rhythm maintaining arousal.
 Circadian cycle in wakefulness increases through the day, reaching a maximum
immediately before the increase in plasma melatonin.
 Arousal then decreases to coincide with the decrease in core body temperature.
 Experiments show that uninterrupted 8 hours of sleep can be obtained only if sleep is
initiated 6 hours before the temperature drop.
 This drop occurs between 5-6 AM in most humans, therefore sleep initiation between 11-
12 AM is most likely to give 8 hours of continuous sleep.
 Diurnal preferences vary amongst individuals; this preference can be quantified using the
Horne-Ostberg questionnaire.
 Circadian Sleep Disorders
 During sustained wakefulness, coupled with circadian phase misalignment, 24 hours of sleep
deprivation impairs neurobehavioral performance to a level comparable to having 0.10% blood
alcohol content (Lamond and Dawson 1999; Williamson and Feyer 2000; Falleti et al. 2003)
 PET scans show that such sleep deprivation is associated with decreased metabolism in the
thalamus, prefrontal cortex, and parietal cortex. (Thomas et al. 2000).
 Advanced sleep phase syndrome:
 Autosomal Dominant recently characterized : 4 hours advancement of daily sleep wake rhythm.
 Due to a single gene nucleotide polymorphism in gene encoding hPER2, the human homolog of Per2
clock gene.
 Delayed sleep phase syndrome:
 Due to length polymorphism in repeat region of hPER3 gene, there is a diurnal preference for sleep.
 Artificial lighting has resulted in a single shorter phase of sleep and increase in length of
productive daytime.
 Jet Lag
 Circadian clock is desynchronized from the local time. Causes elevated stress, erratic sleep
schedule, decreased cognitive function, gastric distress.
Melatonin and Seasonality
 Melatonin profile determines the reproductive axis in seasonally breeding mammals.
 Mediated through melatonin receptors in pas tuberalis of pituitary gland.
 Exact mechanism is unknown.
 Activation of these receptors is hypothesized to regulate an unidentified factor, named
Tuberalin.
 Tuberalin in turn controls gene expression and prolactin release from lactotrophs in the
adenohypophysis of pituitary.
 Humans living in usual environment have similar melatonin profiles in all seasons and
express no seasonality.
 Small percentage of these individuals exhibit melatonin profiles that track day length like
seasonally breeding mammals, and are at an increased risk of Seasonal Affective
Disorder.
Seasonal Affective Disorders
 Recurrent major depressive episodes with periods of remission occurring on a seasonal
basis.
 Specifier criteria as per DSM V:
 Regular temporal relationship between the onset of major depressive episodes and a
particular time of the year.
 Full remissions also occur at a characteristic time of the year.
 2 major depressive episodes meeting criteria A and B have occurred in the last 2 years,
and no nonseasonal episodes have occurred in the same period.
 Seasonal major depressive episodes outnumber the non seasonal episodes over the
individual’s lifetime.
 Most prevalent form of SAD : Winter SAD.
 Onset in late fall or early winter, lasting till late spring or early summer.
 Prevalence of Winter SAD is 4-9%
 Women are 4 times more likely to be affected. There is 29-43% increased risk of SAD in
relatives of patients with SAD.
Winter SAD
 Significant increase in weight, Hyperphagia.
 Increase in sleep.
 Heightened sensitivity to interpersonal rejection.
 Craving for carbohydrates.
 Gold standard treatment : Light therapy.
 45-90 minutes exposure daily to broad spectrum ultraviolet filtered white light source of
high irradiance (5,000 to 10,000 lux)
 Recent studies suggest light therapy + Cognitive behavior Therapy is more efficacious.
 Pharmacotherapy : Monoamine Oxidase Inhibitors
 Hypotheses regarding etiology:
 Patients with SAD have a longer duration of elevated melatonin that stays elevated longer,
impinging on morning hours.
 Photic insensitivity to light deprives predisposed individuals to the threshold of light required to
stave off depression.
Non seasonal depression & Circadian Rhythm

 Depression causes a phase delay of sleep.

 Total sleep depravation provides a transient antidepressant effect in 60% of depressed
patients.
 Relapse occurs following a night of sleep; even short daytime naps can cause a relapse of
depressive symptoms. Relapse tendency is highest during the early morning period.
 A meta-analysis of randomized controlled trials (RCTs) confirmed that BLT is effective in
treating seasonal MDD with a comparable effect size to antidepressant pharmacotherapies (8
studies, effect size = 0.84, 95% confidence interval = 0.60–1.08) (Golden et al. 2005) but also
in treating in nonseasonal MDD (3 studies, effect size = 0.53, 95% CI = 0.18–0.89).
Administration of Bright Light Therapy
Melatonin & other agonists in the treatment of
Depression
 Exogenous melatonin has shown efficacy in
 treating chronic insomnia with modest efficacy (Buscemi et al. 2005; Ferracioli-Oda et al. 2013);
 treating phase delay syndrome, where it is part of the therapeutic recommendations (van
Geijlswijk et al. 2010);
 improving sleep quality on a set of objective parameters such as sleep latency and total sleep
time (Ferracioli-Oda et al. 2013)
 Agomelatine, in addition to being a selective melatonin receptor agonist (MT1 and
MT2), acts as a serotonin receptor antagonist(5-HT2B and 5-HT2C) (Millan et al. 2003).
 Agomelatine, at doses of 25–50 mg, demonstrates a chronobiotic effect but also clinically
significant antidepressant and anxiolytic effects in humans (Hickie and Rogers 2011;
Dubovsky and Warren 2009; de Bodinat et al. 2010; Lôo et al. 2002)
Chronobiology in Bipolar Disorder
 Mania results in a phase advance of circadian rhythm.
 Several studies of individuals with BD demonstrate a significantly higher prevalence of
‘evening chronotypes’ than reported in healthy controls (Wood et al, 2009) or cases of
recurrent major depressive disorder (Chung et al, 2012).
 In individuals with BD, eveningness is also associated with earlier age of onset, a rapid-
cycling course, and other factors such as a reduction in the peak of the melatonin
secretion at night (Mansour et al, 2005).
 Furthermore, population-based studies demonstrate that eveningness is more common in
cyclothymic individuals (especially those with at least one prior episode of depression)
 Studies applying convergent functional genomics suggest that ARNTL1, GSK3b,RORA
and RORB are the top candidate circadian genes for Bipolar Disorder (Le-Niculescu et al,
2009; Patel et al, 2010).
Evidence from Animal Studies

 Mice with a mutation in the Clock gene (Clock.19) show manic-like behaviors, including
hyperactivity and decreased sleep.
 These Clock.19 mice have offered a helpful model to better understand the contribution of
circadian disruption in Bipolar Disorder, specifically in recognizing the potential
importance of the VTA.
 Clock.19 mice have increased dopamine synthesis in the VTA, suggesting the importance
of the Clock gene in dopaminergic activity in the VTA.
 Further, expression of CLOCK protein in the VTA rescues most of the Clock mutant mice
manic-like behavior, including hyperactivity and anxiety.
Lithium & the circadian rhythm in Bipolar
Disorder
 GSK3a and GSK3b are inhibited by lithium.
 Lithium acts on these enzymes either by direct inhibition or indirectly via other
mechanisms such as the formation of a signaling complex involving b-arrestin 2 and Akt
(Freland et al, 2012).
 Lithium and valproate may work in part via a chronobiological mechanism (McClung et al,
2007).
 Lithium has phase-delaying properties because it lengthens the circadian period in a
variety of organisms, including humans (Geoffrey et al, 2014; Abe et al, 2000).
 The amplitude of PER2 protein cycling in the central and peripheral circadian clockwork
is enhanced by lithium (Li J et al, 2012).
 Chronic administration of lithium reverses the manic-like phenotype of transgenic mice
carrying a mutation in the Clock gene (Roybal et al, 2007).
Memory and Neurocognitive Disorders
 In several studies exposing rats to photoperiod shifts, the shifts lead to poor performance
on both acquisition and retention phases of the Morris water maze task.
 Permanently arrhythmic hamsters are unable to differentiate between novel and familiar
objects 20 and 60 minutes after training, representing a significant deviation from normal
memory of previously presented objects.
 Clock gene KO mice also demonstrate abnormal memory performance, indicating the
importance of appropriate circadian alignment in normal memory performance.
� Age-related circadian changes, like decreases in amplitude, are exacerbated in age-
related neurocognitive disorders including Alzheimer disease (AD).
� For example, those with moderate dementia exhibited fragmented rhythms and
decreased amplitude in activity rhythms when compared to mild dementia and healthy
control counterparts.
� Dysregulated circadian rhythms have been found to predate the occurrence of dementia
and/or clinical diagnosis of AD and significantly predict the occurrence of AD or mild
cognitive impairment (MCI).
� Light therapy aimed to normalize an individual’s circadian rhythms has been shown to
improve AD patient’s sleep and cognitive scores.
Circadian Rhythm in Shift Workers
 Cadiovascular disease risk factors such as obesity, low HDL, high triglyceride levels are
more prevalent in shift workers than day workers.
 Women working night shifts have elevated risk of developing breast cancer
 Thus there is also an increased risk of metabolic syndrome amongst shift workers.
 Obesity & Chronobiology
 Mice that carry a mutation in their circadian clock gene, Clock, exhibit obesity and
hyperlipidemia, hepatic steatosis, hyperglycemia, and hypoinsulinemia.
 In contrast, mice null for Nocturnin Ccrn4l gene remain lean and without hepatic
steatosis, resistant to the effects of a high fat diet.

Aging and Chronobiology

 Effect of chronic jet lag on aged mice showed that only half the mice forced to phase
advance by 6 hours survive, as compared to 83% in unshifted age matched mice.
 This effect was not seen in younger mice.
Pharmacotherapy & Circadian Rhythm
 Elevated nocturnal temperatures are found in depressed patients, due to a decreased
amplitude of the master circadian oscillator in the hypothalamus that regulates body
temperature.
 Tricyclic Antidepressants and SSRIs reduce the elevated temperature, enhancing
circadian amplitude.
 Like body temperature, daily activity rhythm amplitude which is dampened in
depressed individuals, may also be regulated by SSRIs and TCAs.
Possible mechanism of Lithium to lengthen
circadian period
GSK3B is inhibited by Li.

The phosphorylation and stabilization of REV-ERBa is

prevented.

REV-ERBa is targeted for proteasomal degradation.

This degradation results in derepression of BMAL1

transcription.

CLOCK-BMAL1 complex is responsible for positive

feedback to core oscillator.
Benzodiazepines and Chonobiology

 Short acting benzodiazepines in hamsters, when administered during the middle of the day,
induce circadian phase advances.
 Brotizolam reduces the light-induced expression of clock genes Per1 and Per2 in the
SCN.
 Benzodiazepines are allosteric modulators of GABAa receptors, but an intact
serotonergic system is also required.
 When 5HT1A/7 agonist is injected into hamsters during midday, phase advances are again
seen as above.
Recreational Drugs & Circadian System

 MDMA or “ecstasy” acts as a serotonin neurotoxin.

 MDMA treated animals showed reduced phase advancement in the aforementioned
benzodiazepine experiment.
 They also exhibited a reduction of serotonergic axonal terminals in the SCN.
 Chronic administration disorganizes activity rhythms in rodents.
 However, administration of MDMA in SCN-ablated rodents, causes re-emergence of
rhythmicity.
 The mechanism behind this is unknown.
Efficacy & Toxicity of Pharmacotherapy
 There are circadian variations in the body’s ability to absorb, distribute, metabolise, and
eliminate toxic compounds.
 These processes are affected by daily variations in gastric pH, gastrointestinal mobility,
glomerular filtration rate, membrane viscosity.
 To maximise efficacy and minimize toxicity, circadian phase of administration must be
considered.
THANK YOU!