Wake therapy is a promising, new technique for treating depression that harnesses the surprising benefits of sleep deprivation. Psychiatrist Professor David Veale explains how staying awake for 36 hours, under carefully controlled conditions, can result in a rapid recovery.
How did the idea for wake therapy come about?
It started in about 1967, when a patient in Germany reported to her psychiatrist that she could treat her depression by going cycling through the night. It was later recognised that it wasn’t the exercise that was important, it was the sleep deprivation. Sleep deprivation was then tested: around 50 per cent recovered, but of those about 80 to 90 per cent relapsed. So it didn’t really seem to be worth it.
There were quite a few studies and trials that went on in the 1980s and 1990s on sleep deprivation alone, but it became a little sort of footnote in textbooks – ‘this is what happens if we do sleep deprivation’. It got forgotten about. It was only in the late 1990s and 2000s that people started to try to work out what can stabilise this response.
Since then, there have been about 12 case series where people have reported on what they’d been doing with their patients, and three randomised control trials where they’ve compared against a control treatment. And they look very promising: they report that around 50 per cent of people recover, and that’s what we’ve been finding in our research and in our patients so far, too.
Who is wake therapy for?
It’s for people suffering from depression. It can be either unipolar depression, which means people who have only depression, or bipolar, which fluctuates between mania and depression.
How does wake therapy work?
You’re supported to stay up all night, usually in a small group of about four people with an occupational therapist. You come in early Friday morning and don’t go to bed until 5pm on Saturday, so you’re awake for 36 hours.
With sleep deprivation, about 50 per cent of patients will recover within a couple of days. But the problem is that about 80 to 90 per cent of those that do recover will relapse very quickly, if we can’t stabilise it.
So how do you stabilise that mood improvement?
We go to what’s called ‘phase-advance’ of one’s sleep and bright light therapy. So you’ve now gone to sleep on Saturday, hopefully, at 5pm. You get eight good hours’ sleep, and you get up at 1am on Sunday. That’s a tricky time, because it’s just very odd. You may feel refreshed, because you’ve just had eight hours’ sleep, but it doesn’t feel right because it’s still dark and it’s the wrong time. So it’s very important that you keep yourself active and don’t go back to bed, and you stay awake now until 7pm on the Sunday.
Then you’re in bed for eight hours, and you get up at 3am on the Monday. You then go to bed the next night at 9pm, and get up on Tuesday at 5am. Then you’re back to going to bed at, say, 11pm, and getting up at the normal 7am. And you can’t nap throughout treatment: if you nap or fall asleep or whatever during that time, it ruins the effects.
Now we’re also going to combine it with bright white light in the mornings. It’s something you can have in the kitchen while you’re sitting down having breakfast, or reading the paper or using the computer, and it switches off melatonin in the morning.
You’re essentially creating sunlight – it’s the same bright-white light that’s used for seasonal affective disorder, but it can also be quite helpful for non-seasonal depression. And you carry on using that for at least another six months or a year, to help stabilise your resetting of the circadian rhythm.
How do you define ‘recover’?
Usually it’s defined by at least a 50 per cent reduction in your symptoms.
Is there any way to know who will respond to this kind of treatment?
We don’t really know what predicts who’s going to respond well. The problem with the term ‘depression’ is that it’s very heterogeneous. There are many different types of depression, and lots of different symptoms. So, for example, you can have two different patients who score exactly the same on the severity rating scale, but one of them may just get better by themselves within a few weeks, and the other one you know is going to have chronic depression and be very difficult to treat.
Let’s say the first one, the easy one, may be a person who has got very good family and social support. Their boyfriend or girlfriend has just left them, perhaps, but they have other things going for them and there’s no particular family history of depression.
Whereas the other person may have been, I don’t know, emotionally or sexually abused as a child, there’s a strong family history of depression, and they’re now a single parent. You know, they’ve got lots of other social stressors. These two people may both have the same symptoms of depression, and yet the first one is probably going to get better by herself, and the second one is going to take a lot of help.
The problem in psychiatry and psychology at the moment is, although we can use terms like ‘depression’ for communication, they don’t really tell us much about what is actually going on, because depression is an end pathway for different types of problems.
But for the large majority of people who have depression, where there is some disruption to their circadian rhythm – they’re waking early in the morning, or going to sleep late, or feeling worse in the mornings – wake therapy seems to be particularly helpful. It’s especially useful because bipolar depression is quite difficult to treat – antidepressant medication doesn’t work that well.
You talked about resetting circadian rhythms – is that, essentially, how this treatment works?
Yes, some people with depression seem to have disrupted circadian rhythms. That’s why their depression’s often worse in the mornings.
Melatonin is released at night by the pineal gland, which regulates both your sleep and other hormones. Some people with depression have a disrupted circadian rhythm, and might release melatonin at the wrong time of the day. The idea is that if we can reset the circadian rhythm and melatonin to be released at the right time of the evening, then this can help control symptoms
How much do we know about the causes of depression?
What presents as depression is probably caused by many things – it’s a common final pathway. It’s a bit like saying, ‘What’s the cause of fever?’ Fever is caused by many different things. Or what’s the cause of headache – that’s caused by many different things, too. So we don’t know yet, it’s very difficult.
We can talk at a psychological level in terms of the way people get caught up with ruminating, or self-attacking or constantly subjugating themselves in a rather submissive way. You could talk at a sociological level, you can talk at a biological level. Another idea that’s doing the rounds at the moment is that it’s all about inflammation. Again, you’ll find that this is probably another sub-type of depression, that not everybody with depression has increased inflammation, and so on.
Of course, we must try and understand what mediates wake therapy and what makes it work. But at this stage, our understanding of things like depression just isn’t good enough.
You’d think that depriving people of sleep would make everything worse…
It does, if it’s done intermittently. Across the world, certainly in the UK, if you’re an inpatient on the psychiatric ward, and you’ve been admitted because you’re suicidal, you get a nurse observing you every hour or so. And when they do this, they open the door and they come in with a bright torch, and they shine it at you to check you’re still alive.
Now, we know from our own research that this causes a great deal of sleep deprivation. And when you’ve got a psychiatric disorder like that, we know that being constantly disturbed actually increases your suicide risk. It makes it harder to tolerate difficult emotions, so it’s more likely to lead to increased self-harm. The very things you were admitted onto the ward to keep you safe from!
At the moment, sleep deprivation is a major problem on psychiatric wards because of the noise, nursing staff checking on you and so on. And obviously, sleep deprivation is also just a very common experience, isn’t it? You can’t get to sleep, and it makes you feel worse the next day.
But in somebody suffering from depression, you can do total sleep deprivation on a ward and be supported by staff to stay awake for 36 hours, and then phase-advance the time of your sleep with the light therapy. That’s when you see benefits.
Can wake therapy go wrong?
There are no significant side effects apart from, obviously, some tiredness. There is a slight risk – about 1 per cent – that if you suffer from bipolar disorder, you may become manic if deprived of sleep. But that can be reduced if you’re taking a mood stabiliser such as lithium.
Once we get to know who best responds, then hopefully we can target it more, but at the moment, if you don’t respond, the worst that’s happened is you get tired. It’s not a good idea to drive or operate heavy machinery the next day.
How do you choose what treatment to use for people with depression?
If you are suitable, then I would offer wake therapy first as you’ll know whether you are going to get better straight away. Not everyone is suitable for this treatment, and it needs a careful assessment. There are many treatments that have been shown to be helpful: cognitive behaviour therapy, anti-depressant medication, exercise, eating a Mediterranean diet, improving social connections and so on. Some of these approaches overlap, but the trick is knowing which patients will respond to which form of therapy.
It’s UK Mental Health Awareness week. What should the public know about depression and bipolar disorder?
These are treatable conditions. Don’t suffer in silence – seek help.
WARNING: Please do not try this at home. If you are suffering with depression, or you’re worried about someone who is, visit your GP. For more information about mental health, visit mind.org.uk
- This article was first published in BBC Science Focus in May 2019 – subscribe here
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