Why depriving people of sleep could help treat depression
It sounds bizarre, but doctors say that staying awake for 36 hours can ‘reset’ the body clock – just don’t try it at home
NOT many of us would willingly have our sleep disrupted for a whole week — but Jaimey Gunton did exactly that in order to tackle her depression. Experiencing it for the second time in 17 years — and after ‘ not getting on with’ antidepressants the first time — Jaimey opted for a most unlikely solution. She volunteered to be part of a pioneering clinical trial where she would be deliberately sleep deprived.
Stopping someone with fragile mental health getting their precious sleep might sound counterintuitive.
In fact, because depression in some people is linked to a disturbance of the circadian rhythm — the body’s internal clock that determines when you feel tired and need to sleep and when to wake up — the thinking is that ‘ resetting’ it into a better pattern can improve mood, potentially by boosting brain chemicals or, as a recent study suggested, by increasing activity in certain areas of the brain.
Using MRI scans, researchers at the University of Pennsylvania in the U.S. looked at the brains of people with and without depression after 36 hours of sleep deprivation: nearly half of those with depression experienced mood improvements — while many of those who weren’t depressed before being sleep- deprived, felt worse afterwards.
Now, long after taking part in the UK clinical trial, Jaimey is convinced she’s still benefiting from this unconventional treatment.
Before joining the study, she had been experiencing what she describes as ‘a few personal issues — perimenopause and life in general was getting on top of me’, says Jaimey, 47, an administration officer who lives in Greenwich, South-East London, with husband Chris, 47, a chief operating officer of a management company.
‘I’d been making mistakes at work, which I never normally did — like getting invoices and stationery orders wrong. At home, I was more snappy and grumpy.
‘Things were getting on top of me and one day I broke down in tears in the office. My manager at the time said I needed professional help, so I contacted my GP.’
Jaimey had been prescribed antidepressants previously, after taking medication for painful periods: a side-effect of the drug was low mood.
She says the antidepressants also made her dizzy, nauseous and despite feeling exhausted, she was unable to sleep. She stopped taking them after about a fortnight.
So when she saw her GP in November 2017, she declined antidepressants and instead went on the waiting list for cognitive behavioural therapy (CBT) — a talking therapy that gives people strategies and coaches them to think differently about their condition.
BUT while she was waiting, she was contacted in early 2018 by South London and Maudsley NHS Trust to see if she’d be interested in joining a trial for a new treatment approach for depression.
‘It involved not sleeping for a whole night, and going to bed earlier than I would normally and getting up earlier for the next four nights, but trying to get eight hours of sleep,’ says Jaimey.
‘I was keen to be involved — not least as I knew it would be at least six months before I had a talking therapy appointment.
‘My sleep pattern had been badly disrupted for years so it seemed ironic that I’d now be giving up a night’s sleep to help treat it.
‘My problem was not falling asleep — I could always get to sleep when I turned in at about 10pm. But I could never stay asleep. And once I was awake, I would not sleep for the rest of that night until I needed to get up at about 6am for work.
‘Often I’d only have about two hours’ sleep at night, which made it hard to function. So I was desperate to sort my sleep and depression.’
The trial was overseen by Professor David Veale, a consultant psychiatrist. It was the first randomised controlled trial in the UK involving out- patients (previously it’s been tested in the Netherlands). Some of the 82 participants were deprived of sleep; others were given advice on getting a better night’s sleep, such as not looking at their phone an hour before bed.
The new sleep approach has three stages — it’s also called triple chronotherapy, or wake and light therapy.
First, the sleep- deprived group had to stay awake for 36 hours in a hospital meeting room, supervised by an occupational therapist.
FOLLOWING this were four nights of a strict eight hours’ sleep — the average for most people when describing a good night’s sleep — but advancing the time of sleep by two hours each evening. (So for example, going to bed at 5pm on the first evening and getting up at 1am and the next evening going to bed at 7pm and waking at 3am, until on the last night going to bed at 11pm and waking up at 7am).
The sleep deprivation, and then advancing bedtimes, is to reset the patient’s body clock, so that it’s in sync with the day/night cycle and as a result their body produces the hormones that control sleep and mood. Two hours before going to bed, participants would wear blue- light blocking glasses to ‘trick’ the brain into thinking it is dark and time to go to bed.
After these first two parts of the trial, participants then had bright light therapy — using a light box every morning for 30 minutes for the next six months.
Meanwhile, the control group — who all got a full night’s rest — were taught about good sleep hygiene (such as consistent bed times, ensuring the bedroom is dark and quiet) and used a light box with a different coloured light, which was actually a placebo, in the mornings for a week.
As Professor Veale explains: ‘ A hormone called melatonin is released at night by the pineal gland in the brain to regulate both your sleep and other hormones.
‘Some people release melatonin at the wrong time of the day.
‘The rationale for this approach is that in some people, depression is associated with disturbance of the circadian rhythm; this therapy can reset your rhythm back in sync with the sun so melatonin is released at the right time.
‘If we can reset this release to the right time of the evening, it can help control sleep but also the symptoms of depression.’ Another effect of sleep deprivation therapy, he says, is a surge in brain chemicals called monoamines (for example, dopamine, which is associated with pleasure and reward), as well as anti-inflammatory chemicals.
Both are thought to be relevant in helping some types of depression. ‘Established treatments such as antidepressants or CBT can sometimes not lead to a response for four to six weeks,’ says Professor Veale.
‘However, experience from triple chronotherapy tells us it can work much more quickly; in some cases within a day or two, but more commonly in four days to a week.
‘We believe that if your circadian rhythm is disrupted by something like the stress caused by sleep deprivation, it leads to an outpouring of chemicals which are important to overcoming depression. Triple chronotherapy can resynchronise the circadian rhythm, possibly by regulating the body’s neurotransmitters [brain chemicals] and hormones.’
In fact, sleep deprivation therapy for depression isn’t new — it was first trialled in the 1970s.
More recently a review of 66 studies involving several hundred patients with depression, published in the Journal of Clinical Psychiatry in 2017, found about 50 per cent of those who underwent sleep deprivation recovered from their depression within 24 hours.
But the relapse rate was high — at 85 per cent — and the benefits didn’t last long.
Nevertheless, there is some evidence that the technique triggers measurable changes in the brain — in a study published last year in the Proceedings of the National Academy of Sciences, researchers at the University of Pennsylvania took MRI scans of 30 people with severe depression before and after 36 hours of sleep deprivation and compared these with scans of 54 people without depression.
The scans were focused on two regions of the brain: the amygdala, which plays a part in processing our emotions; and the anterior cingulate cortex, which is involved in motivation and decision-making, and which has previously been associated with depression.
Results showed increased activity in these two regions in the depressed group after being awake for 36 hours. Furthermore, 43 per cent of them experienced an improvement in mood — and this lasted at least five days.
Philip Gehrman, an associate professor of psychology, who led the study, told Good Health that while the results were positive, it’s possible they were affected by the design of the study.
‘Removing people with depression from their usual environments and giving them lots of attention ended up leading to improvements in mood prior to starting sleep
‘It felt as if something clicked inside me and a weight had been lifted’
Jaimey Gunton
deprivation in many subjects,’ he explains. ‘And by the fifth day in hospital, subjects were excited to go home, so almost everyone felt great.’
The Maudsley trial, published in the British Journal of Psychiatry Open in 2021, found there was more than a 50 per cent reduction in symptoms of depression for a third of patients in the triple chronotherapy group, compared to only 16 per cent in the control group after one week.
These figures remained steady until the trial ended after 26 weeks of observation. And there were no reported side-effects. The researchers concluded it led to ‘a significant and rapid benefit’ for patients.
But it’s not suitable for all patients, says Professor Veale, and may be difficult to implement outside of a hospital setting. In other words, do not try this yourself at home.
‘The problem with depression is that there are many different types, so we do not yet know which type responds best to a treatment like this,’ says Professor Veale.
‘But it will clearly not work for everyone. And while we know this treatment can be successfully used in a hospital setting where staff can monitor patients, it’s more difficult to organise for out-patients.’
Neil Stanley, an independent sleep expert and former chairman of the British Sleep Society, told Good Health: ‘The established way to measure depression is with the Hamilton Depression Rating Scale.
‘We already know sleep deprivation can reduce depression by up to 50 per cent in one night using this scale. That’s quicker and more effective than any antidepressant drugs. But trials show these effects are fairly short term; once the person goes back to the type of sleep they had before, the benefits can wear off very fast.’
Stuart Peirson, a professor of circadian neuroscience at Oxford University, adds: ‘Sleep and circadian rhythm disruption is very common in depression and improving sleep has been shown to help improve symptoms.
‘However, why this occurs is poorly understood. We are just starting a new project to investigate possible pathways in the brain that may underlie this relationship,’ he says.
ANOTHER possible link may be the role of light. A new receptor system was discovered in the eye around 20 years ago, consisting of a subset of photosensitive retinal ganglion cells that play a key role in setting our circadian clock according to the light environment.
‘More recently, studies in mice have shown that these cells regulate mood, providing an interesting new angle to understand the relationship between circadian rhythms and depression.
‘ In humans, clinical trials have shown that light can be effective in treating depression, although this is not currently approved by NICE in the UK,’ he explains.
‘We certainly need more research in this area as light therapy is well-tolerated and has few side effects.’
And the experts agree: although sleep deprivation may help with depression, it needs to be done in a supervised way, as a lack of sleep can have severe consequences.
‘For instance, it would be dangerous to drive or operate machinery if you were severely lacking in sleep and feeling very tired,’ says Neil Stanley.
On the day the trial began, Jaimey travelled to the Bethlem Royal Hospital in South-east London for the 9pm start. She stayed all night with others, then went home at 8am with strict instructions not to nod off before 5pm; a total of 36 hours from the time she woke up before coming to hospital.
She recalls: ‘We had an occupational therapist with us helping to keep us awake. We did lots of things to stop us falling asleep, such as eating noisy, crunchy snacks; drawing; reading; and we went for a couple of walks.
‘In the early hours I began feeling very emotional and tearful for no reason but managed to stay awake.
‘even without sleep I felt somehow different, as if something had clicked inside me and a weight had been lifted. I thought I might be imagining it, but Professor Veale reassured me it happens in other people, too.’
She adds: ‘I got the train home from the hospital and stood up on the journey so I wouldn’t go to sleep.
‘It was difficult to stay awake and I nearly dozed off when I went to the hairdressers. But I tried to fill my day with enough distractions.’
Over the following few nights, she staggered her bedtimes; 7pm to 3am, then 9pm to 5am. She also had a light box ‘and would sit facing it for half an hour every morning while eating my breakfast or reading a book’.
Jaimey says: ‘I started feeling better and more like myself in those first few days. Almost straight after going on the trial I was sleeping better but also able to cope better with day-to-day and family-related stress.
‘I now get about six or so hours of good-quality sleep each night, so lots better than it was. I feel fortunate the trial came along, and I was able to be involved with it.’