Jonathan S. Emens

Circadian misalignment in major depressive disorder

It has been hypothesized that the circadian pacemaker plays a role in major depressive disorder (MDD). We sought to determine if misalignment between the timing of sleep and the pacemaker correlated with symptom severity in MDD. Depression severity correlated with circadian misalignment: the more delayed, the more severe the symptoms.

Photic Resetting of the Human Circadian Pacemaker in the Absence of Conscious Vision

Ocular light exposure patterns are the primary stimuli for entraining the human circadian system to the local 24-h day. Many totally blind persons cannot use these stimuli and, therefore, have circadian rhythms that are not entrained. However, a few otherwise totally blind persons retain the ability to suppress plasma melatonin concentrations after ocular light exposure, probably using a neural pathway that includes the site of the human circadian pacemaker, suggesting that light information is reaching this site. To test definitively whether ocular light exposure could affect the circadian pacemaker of some blind persons and whether melatonin suppression in response to bright light correlates with light-induced phase shifts of the circadian system, the authors performed experiments with 5 totally blind volunteers using a protocol known to induce phase shifts of the circadian pacemaker in sighted individuals. In the 2 blind individuals who maintained light-induced melatonin suppression, the circadian system was shifted by appropriately timed bright-light stimuli. These data demonstrate that light can affect the circadian pacemaker of some totally blind individuals— either by altering the phase of the circadian pacemaker or by affecting its amplitude. They are consistent with data from animal studies demonstrating that there are different neural pathways and retinal cells that relay photic information to the brain: one for conscious light perception and the other for non-image-forming functions.

Circadian Uses of Melatonin in Humans

Melatonin in humans can be an independent or dependent variable. Measurement of endogenous melatonin levels under dim‐light conditions, particularly the dim‐light melatonin onset (DLMO), has received increasing attention among researchers, and for clinicians it may soon become a convenient test that can be done at home using saliva collections in the evening, without interfering with sleep. Melatonin, even at low physiological doses, can cause advances (shifts to an earlier time) or delays (shifts to a later time) depending on when it is administered on its phase‐response curve (in most sighted people, these times are approximately in the p.m. and in the a.m., respectively). Although both bright light and melatonin can be used separately or together in the treatment of circadian phase disorders in sighted people—such as advanced and delayed sleep phase syndromes, jet lag, shift‐work maladaptation, and winter depression (seasonal affective disorder, or SAD)—melatonin is the treatment of choice in totally blind people. These people provide a unique opportunity to study the human circadian system without the overwhelming effects of ocularly mediated light, thus permitting us to establish that all blind free‐runners (BFRs) studied under high resolution appear to have phase‐advancing and phase‐delaying responses to as yet unidentified zeitgebers (time givers) that are usually too weak to result in entrainment.

Melatonin entrains free-running blind people according to a physiological dose-response curve

The specific circadian role proposed for endogenous melatonin production was based on a study of sighted people who took low pharmacological doses (500 µg) of this chemical signal for the “biological night”: the magnitude and direction of the induced phase shifts were dependent on what time of day exogenous melatonin was administered and were described by a phase‐response curve that turned out to be the opposite of that for light. We now report that lower (physiological) doses of up to 300 µg can entrain (synchronize) free‐running circadian rhythms of 10 totally blind subjects that would otherwise drift later each day. The resulting log‐linear dose‐response curve in the physiological range adds support for a circadian function of endogenous melatonin in humans. Efficacy of exogenous doses in the physiological range are of clinical significance for totally blind people who will need to take melatonin daily over their entire lifetimes in order to remain entrained to the 24 h day. Left untreated, their free‐running endocrine, metabolic, behavioral, and sleep/wake cycles can be almost as burdensome as not having vision.

Low, but not high, doses of melatonin entrained a free-running blind person with a long circadian period

In a previous report, we were unable to entrain one out of seven totally blind people with free-running endogenous melatonin rhythms to 10 mg of exogenous melatonin. This person had the longest circadian period (24.9 h) of the group. We now find that this person can be entrained to 0.5 mg of melatonin, but not to 20 mg. These results are consistent with the idea that too much melatonin may spill over onto the wrong zone of the melatonin phase–response curve.

Eventual Entrainment of the Human Circadian Pacemaker by Melatonin is Independent of the Circadian Phase of Treatment Initiation: Clinical Implications

About 15% of the legally blind completely lack light perception. Most of these individuals have abnormally phased circadian rhythms and many free-run. Light treatment is not an option for them. However, melatonin treatment can be highly effective. A daily dose of 0.5 mg of melatonin usually results in entrainment. It has been suggested that treatment in individuals with circadian periods > 24 h should be initiated on the advance zone of the melatonin phase response curve, which was based on findings in which melatonin initiated on the delay zone were less likely to result in entrainment, even though treatment continued across all circadian phases. In the present study, 7 totally blind people started low-dose melatonin treatment (0.5 mg; 1 person was given 0.05 mg) on the delay zone. All entrained as circadian phase free-ran and the advance zone of the melatonin phase response curve coincided with the time of melatonin administration. These results are consistent with studies in other mammals. It does not appear that low-dose melatonin treatment needs to be initiated on the advance zone to induce eventual entrainment in blind people with free-running rhythms > 24 h. Therefore, it is not essential that circadian phase be ascertained before starting low-dose melatonin treatment of blind people.

Phase Angle of Entrainment in Morning‐ and Evening‐Types under Naturalistic Conditions

Differences in morningness‐eveningness among humans are commonly ascribed to circadian parameters, such as circadian period and responsivity to environmental time cues, as well as homeostatic sleep drive. Light is the primary synchronizer of the human biological clock, and if circadian differences exist between morning and evening types, they should have different phase angles of entrainment to the light/dark cycle; that is, morning and evening types should have different patterns of light exposure relative to endogenous circadian phase (ECP). When phase angle of entrainment is strictly defined as the relationship between a marker of ECP and the timing of light exposure, such differences have been demonstrated in the laboratory under controlled light/dark cycles and have recently been shown under conditions of spring and summer light exposure outside the laboratory, taking into account the variable intensity of light. Here, we report similar results from a large (n=66), diverse cohort of morning and evening types across the age span studied at all different times of the year. Differences between morning and evening types in light exposure relative to ECP, indicative of a difference in the phase angle of entrainment to the external light/dark cycle, were found. Specifically, evening types, compared to morning types, had a higher ratio of phase advancing to phase delaying by light. We interpret this as indicating a longer circadian period (τ) in evening types.

Zeitgeber Hierarchy in Humans: Resetting the Circadian Phase Positions of Blind People Using Melatonin

Four blind individuals who were thought to be entrained at an abnormal circadian phase position were reset to a more normal phase using exogenous melatonin administration. In one instance, circadian phase was shifted later. A fifth subject who was thought to be entrained was monitored over four years and eventually was shown to have a circadian period different from 24 h. These findings have implications for treating circadian phase abnormalities in the blind, for distinguishing between abnormally entrained and free‐running blind individuals, and for informing the debate over zeitgeber hierarchy in humans.

Relative Coordination to Unknown “Weak Zeitgebers” in Free-Running Blind Individuals

Light is the primary synchronizer of the human biological clock. In more than half of those blind individuals who completely lack light perception, the absence of photic input to the hypothalamic circadian pacemaker results in rhythms that free-run (blind free-runners [BFRs]) with a period typically greater than 24 h. The remainder are entrained, although sometimes at an abnormal phase angle. It is presumed that weak as-yet-to-be-identified time cues provide the necessary resetting stimulus in these entrained individuals. These weak zeitgebers might be expected to modulate the observed circadian period in blind people who are not actually entrained by them. The authors report here the results from 5 BFRs (average linear regression period ±SD of 24.31 ± 0.06 h) who had high-resolution (many and frequent) phase assessments. All 5 subjects demonstrated a similar and reproducible pattern of changes in observed period (period response curves) indicative of relative coordination. The precise shape of the period response curve to weak zeitgebers has implications for the entrainment of BFRs using exogenous melatonin administration or other nonphotic stimuli. Sighted individuals may also be affected by such weak zeitgebers, which may be obscured by the stronger light/dark cycle.

Pretreatment circadian period in free-running blind people may predict the phase angle of entrainment to melatonin.

To date, we have entrained (synchronized) eight totally blind people with free-running circadian rhythms to a nightly dose of 10 mg of melatonin. Each person entrained at a different phase angle of entrainment (PAE), which is the interval in hours between the time of the melatonin dose and the time of the endogenous melatonin onset. When the PAE was plotted against the pretreatment free-running (i.e. slightly different than 24.0 h) circadian period (tau), the fitted regression line revealed a significant correlation, which is consistent with previous findings on light entrainment of rest-activity rhythms in free-running rodents [Pittendrigh and Daan, J. Comp. Physiol., 106 (1976) 291-331].