A Case Demonstrating Circadian Rhythm Sleep-Wake Disorder that Was Initially Treated for Treatment-Resistant Depression

Abstract

We herein report the case of a woman in her twenties with a history of being tardy for school. This issue began in junior high school and was caused by her getting up late in the morning. One or two months after obtaining a job, she began to take frequent absences due to concentration difficulties and fatigue. She was diagnosed with depression and given antidepressants, mood stabilizers, and augmentation drugs with sufficient dosages and periods, however, her depression did not improve. Consequently, she was admitted to our psychiatric ward as a treatment-resistant depression case. Following her admission, the patient was suspected of having Circadian Rhythm Sleep-Wake Disorder (CRSD) according to the results of a sleep log, actigraphy, polysomnography, and a core (deep) body temperature measurements. The administration of psychotropic drugs was thus gradually decreased and stopped, and she was thereafter provided with life therapy, which strengthens entrainment factors such as sunlight, personal contacts, and meals. Although her sleep-wake rhythm did not improve, her depressive symptoms improved. After being discharged she was prescribed a melatonin receptor agonist, Ramelteon, and started cohabitation with a male partner. She became more active and her condition continued to improve with no recurrence of the depressive symptoms. Our findings suggest that CRSD should be considered in the differential diagnosis when encountering patients with treatment-resistant depression, which may be identified by the patients' sleep logs.