Sleep deprivation with consecutive sleep-phase advance therapy in patients with major depression: A pilot study

Abstract

Since the early 1970s sleep deprivation has been regarded as a beneficial treatment morality for about 60% of patients with major depressive disorder. Unfortunately, however, more than 80% of the improved patients relapse into depression after the next night of sleep (Wu and Bunney 1990). Even short periods of daytime sleep (naps) after successful sleep deprivation can provoke a mood setback. This could be demonstrated not only by single case studies but also by systematic investigations (Riemann et al 1990; Wiegand et al !992): About 50% of patients exhibit a relapse into depression when the nap takes place in the first part of the day (5 AM, 9 AM, and 1 PM) after successful sleep deprivation, whereas naps in the afternoon do not provoke depressive relapse. These observations support the assumption not only that wakefulness is antidepressive but also that sleep is depressiogenic, especially sleep in the first half of the day. Wehr and Wirz-Justice, who first proposed sleep-phase advance therapy, called this period of sleep the critical (Wehr et al 1979). These circadian alterations in the detrimental effect of sleep are also indicated by the fact that partial sleep deprivation is more effective in the second than in the first part of the night (Sack et al 1988). In accordance with these data we tried in this study to prevent rapid relapse into depression after successful total sleep deprivation (TSD) by treating patients with consecutive sleep phase advance for ! week. The aim of this intervention was to initially avoid and then to limit sleep at the vulnerable times of the day. That means sleep was allowed in the evening and first part of the night and was prevented during the second half of the night. The sleep period was shifted back step by step to a normal time of night sleep, a procedure that provided the patients a sleeping time of about 7-hr in order to prevent cumulative sleep deprivation and exhaustion.