What natural treatment produces the most rapid relief of depression of any known treatment (other than the intravenous administration of drugs)? About 60 percent of people who do this can feel substantially less depressed within twelve hours, often much sooner. I have seen its effects coax patients back from serious suicidal thoughts. This improvement requires neither a drug nor any high-tech electromagnetic apparatus. It does not require your calling an infomercial’s 800 number within the next five minutes to receive a special discount. Nor does it involve a trip to Lourdes. And it does not cost you a penny.
If you are old enough, you may recall the 1950s TV quiz show You Bet Your Life that Groucho Marx hosted. At a point in each show a duck descended from the ceiling, its bill bearing a slip of paper that contained the secret word for the day. Any contestant who accidentally said the word automatically won a prize. The word was never esoteric, never miscegenation or craniotomy. Rather, in Groucho’s words, it was something you say around your house every day.
In our case, the secret word, one which most physicians and many psychiatrists still don’t utilize for depression, is sleep. But I don’t mean getting a good night’s sleep, which indeed is an important contributor to good health. Everyone knows that. Rather, as strange as it may seem, I refer to the opposite, sleep deprivation.
Considerable scientific research has documented the often dramatic and usually rapid alleviation of depression when sufferers from it stay up all night. But here is one catch. They must literally stay up the entire night without even a moment’s sleep. And then they must not return to sleep till early the following evening, say five or six PM. If you fall asleep during this interval for even the briefest period, all benefits are lost. This is the Invasion of the Body Snatchers principle, as in that horror film alien pods erased the identity of those who fell asleep. In sleep deprivation treatment (or wake therapy, as its practitioners prefer to term it since no one likes to be deprived of anything), an alien villain of another sort, depression, takes you over once again if you nod off.
When you are depressed, you are likely to sleep worse than usual. Depressed patients who see me are often most concerned about their insomnia, which does indeed aggravate their distress by producing exhaustion, impaired thinking, and thus even worse depression or associated anxiety. When I propose sleep deprivation to them, they usually recoil with horror, as if I had tossed a live scorpion into their laps. Sleep deprivation is just about the last thing they want to do. And yet it works.
Few Americans, in fact few mental health professionals in the U.S., know about the benefits of this treatment. That is probably because no mega-corporations want us to know. After all, they cannot garner large profits from our depriving ourselves of sleep. So there are no sales reps chasing shrinks like hectoring hallucinations down the corridors of clinics in order to promote wake therapy and associated tactics. There are no ads touting such treatment. And no pharmaceutical companies are sponsoring talks on the subject. Consequently we find such therapy to be more popular in Europe, where drugs are not the first answer to every problem.
But why bother staying up all night if depression returns during the inevitable sleep that follows sooner or later? Such an endeavor seems as pointless an ordeal as starving yourself for one day in order to lose weight, right? Well, I am happy to report that there is good news indeed: Patients undergoing this procedure need not be doomed to never-ending sleeplessness, eyelids mechanically propped open 24/7 a la Clockwork Orange. Because researchers and clinicians eventually figured out how to sustain the benefits of wake therapy so that it can remain a highly effective treatment for depression.
Sleep deprivation combined with daily light box therapy (see http://www.greenpsychiatrist.com/light-therapy-depression/) more frequently and lastingly alleviates depression than does either treatment alone. The sleep deprivation may consist of wakefulness for an entire night with return to sleep early the following evening. Or it may involve deprivation of sleep only during the latter half of the night, which studies show is more effective than deprivation during the first half. The deprivation may occur once weekly, thrice weekly, or some other frequency, depending upon both feasibility and clinical urgency. A patient may continue a regular schedule of deprivation or do it in pulses with periods of normal sleep in between. Increasing numbers of inpatient mental health units have been employing such treatment, again mostly in Europe.
There is another tactic that extends the benefits of sleep deprivation, with or without light therapy. That is what is known as sleep phase advance therapy.
Forty-one years old, divorced, and unemployed following many productive years as a draftsman, Gabe remains severely depressed, even after his discharge from an inpatient psychiatric unit. Virtually every known drug in the pharmacopeia of Western medicine has failed to help his recurring depressive disorder, with the exception of duloxetine (brand name Cymbalta), which he currently takes because it slightly, but only slightly, alleviates his distress. But even with the medication he continues to ruminate about suicide. And over the passage of several weeks he inches toward the precipice, with a growing conviction that death can afford him his only real relief.
Given his desperation and mine, I prescribe for him a seemingly bizarre ritual. He is to stay up all night and remain awake till 5 PM the next day, at which time he will go to bed until midnight, whereupon he will arise and remain awake until 6 PM the following evening. Again he will go to sleep, but this time will awaken at 1 AM and remain awake till 7 PM the following evening, then sleep till 2 AM. In this manner he will continue to delay his bedtime by one hour each succeeding evening and will arise each morning one hour later than the previous morning. But once he attains his normal bedtime of 10 PM he will continue to go to bed at that time.
Gabe carries out my instructions to the letter. And beginning in the morning following the first night of wakefulness he finds that he is much less depressed. His suicidal wishes have vanished into that night’s air and he remains free of them. Though still somewhat depressed over the ensuing days he is able to function more effectively, and gradually the remainder of his depression abates.
Why such sleep phase advance therapy works is a matter of debate. One explanation is that it resynchronizes the neuro-endocrine physiological axis responsible for governing the biological clock within each of us. But whether it works is not debatable. In large-scale research trials in Europe, combined wake and light therapy improved the response of 44 – 70 percent of medicated bipolar patients. After nine months, up to 57 percent of these responders remained free of depression.
One study reported the effects of the chronotherapeutic blue plate special–wake therapy with sleep phase advance plus light therapy. Clinicians administered this treatment to twelve unmedicated patients with major depression during a hospital stay of only four days. All patients responded rapidly, and four weeks later all remained well.
Potentially anyone suffering from depression can benefit from these approaches. Exceptions include those with a mixed bipolar state, meaning a simultaneous combination of depression and hypomania. Both wake therapy and light therapy can trigger serious decompensation in such instances. If you are considering light therapy but suffer from eye disease or take medications that enhance light sensitivity (St. John’s wort, for example), confer with your physician. Unfortunately, sleep deprivation is unlikely to work if you take sedating bedtime medications or antipsychotics on a regular basis.
By the way, wake therapy need not constitute as much of an ordeal as my descriptions depict. Many effective variations in treatment protocols exist, some less stringent than others. Those interested in learning more may wish to consult Chronotherapeutics for Affective Disorders by Wirz-Justice, Benedetti, and Terman. Dense with research and clinical detail, it is written primarily for researchers and clinicians. However, given Pharma’s stranglehold on psychiatry and our popular media, this publication may be the only entree you have to information about this growing field. Come to think of it, tell your psychiatrist to read it.
If you would like to use these approaches, it is best that you do so under psychiatric supervision. Do not treat yourself if your depression may be part of a bipolar disorder. If it is, the above “chronotherapy” (the therapeutic manipulation of environmental stimuli and sleep-wake cycles to improve functioning and resolve psychiatric problems) may still help you enormously, as it has many with BPD, but there is a small risk that these techniques will trigger a hypomanic or manic episode or a worsening of your mood swings. So if you think you may have BPD, it is imperative that you collaborate with a knowledgeable psychiatrist.
How can you tell if you may have BPD?
(a) You have experienced periods of lessened need for sleep accompanied by an excess of energy that has prompted you to act in ways that are normally uncharacteristic of you; these atypical behaviors—e.g. overspending, overcleaning, excessive or inappropriate talking; unusually uninhibited or inappropriately belligerent behavior toward others; excessive exercising; excess drinking or interest in sex. These behaviors have caused problems for you or others, or else you have realized later that you went overboard or to too much of an extreme in these behaviors.
(b) You have experienced periods of feeling naturally (i.e. not because of the effect of drugs or alcohol) great emotionally for no clear reason (i.e. not because you just received a promotion or are in love), accompanied by greater energy than usual so that you engage in the sort of excessive activities described under (a).
(c) You have experienced recurring periods of depression, during which you are not only depressed but also excessively angry or irritable in ways that are not characteristic of you ordinarily. If this description applies to you, you may be suffering from bipolar mixed states, and therefore run a particularly high risk that chronotherapy may aggravate your condition, at least without proper supervision of your treatment.
If you are going to use wake therapy, you should combine it with sleep phase advance therapy, as described above in the case of Gabe, in order to sustain and maximize benefits.
In order to remain awake during the sleep deprivation, you may consume a moderate amount of caffeine during the waking part of the night and during the morning of the succeeding day. However, it is best that you avoid caffeine after noon so it doesn’t interfere with your going to sleep at your early bedtime. If you are especially sensitive to caffeine, you may need to avoid it altogether in the morning.
In order to remain awake during the prescribed period, engage in physical activity, if possible. If you are engaged in mental activity, keep it as stimulating as possible; if feasible, stand up while you are engaging in such activity to avoid inadvertently falling asleep.
Be well, and when you finally sleep, may your dreams be pleasant ones.