Today's Green Journal had an interesting letter to the editor. "Ivan," a 19 y/o, had a history of a pineal gland tumor (the pineal gland secretes melatonin) that had been resected in 2001. In order to decrease building pressure in his brain, he had a second surgery for a VP shunt to drain his cerebrospinal fluid into his abdominal region. After the second surgery, he had insomnia, a disturbed sleep-wake cycle, and fragmented sleep. In June 2004 he began to exhibit paranoia and other classic signs of bipolar disorder. By 2007 he was on several psychiatric medications, and he was not able to continue school due to severe fatigue and bipolar symptoms. A sleep study showed an irregular sleep/wake cycle, and 24 hour urine measure of a melatonin metabolite showed barely detectable levels.
The patient was started on melatonin (a controlled release formulation), his sleep cycle stabilized, and his psychiatric medication was slowly withdrawn over the next several months. Repeat sleep studies showed normalized sleep. Since rapid release melatonin lasts 60-90 minutes, it was felt it was not a suitable replacement for the absent pineal gland - thus the controlled release formulation.
Interestingly enough, the patient discontinued his melatonin in 2009 and remained symptom free, with a stable sleep-wake cycle. The authors of the letter speculated that his bipolar symptoms arose from lack of restorative sleep, and with the help of exogenous melatonin, the patient was able to somehow use other signals to synchronize his sleep wake times, preventing relapse.
Lesson - sleep is exceedingly important (more on this fact in future posts). Also, all my first episode psychotic patients get an MRI and a full medical work-up.