Sleep Deprivation Was More Powerful Than Antidepressants for Me
If I'd known a decade ago that staying up at night could help with depression, I'd have been less likely to dismiss my own experience as just a curiosity.
On a Saturday night last year, not long after the death of my grandmother, I went to her house to try a little experiment. I’d been depressed again for more than a week. I felt stodgy and frozen, woozy with lethargy, and at the same time prickling with a static sense of anxiety that became especially charged around other people.
I woke just after 2 am on a sofa bed in her guest room. The house was icy cold and lonely. I switched on the heater in her living room, made myself coffee, and sat down at her heavy dining table with my laptop. Five hours, another coffee, and a couple of thousand words later, the sun was up and I drove to the gym. By the time I met my aunt at a cafe near the beach a couple of hours later, I felt fresh and clear in the sunshine. I could lock eyes and smile with the lovely woman at the table next to us and my conversation with my aunt was fluid and enthusiastic. I was feeling good again.
About a decade ago, I figured out that if I stayed up all or most of the night, I’d usually feel a lot better in the morning. For years, I’d been managing major depressive disorder—I was ill at ease with myself, awkward in conversation, and clumsy and self-conscious in my body. My long-term psychiatrist thought I could be bipolar, and put me on a high dose of the mood stabilizer lithium, to no noticeable effect. I spent the remainder of my early 20s playing the pharmaceutical lottery, to no avail.
It was only recently that I started experimenting with sleep deprivation again, after I learned that others had the same idea. In fact, since the early 1970s, when a young German psychiatrist called Bernhard Pflug noticed that some of his patients felt better after a night without sleep, there has been a tiny but growing school of research studying the potential of sleep deprivation as a fast-acting antidepressant.
In a 2015 study that compared the efficacy of exercise versus sleep deprivation, 75 depressed patients in Copenhagen who were treated with three all-nighters in a week had almost double the remission rate compared to another group who used daily exercise. Seven months after their treatment, 62 percent of the sleep-deprived no longer met the criteria for clinical depression. A 2017 meta-analysis looked at 66 studies of sleep deprivation and its effects on depression published in the past three decades, and found that 50 percent of patients had a clinically significant response to the treatment.
What was remarkable about this research was the speed with which the transformation happened. Where antidepressant meds typically take several weeks to kick in, with these sleep deprivation studies, participants saw an improvement in their mood (at least temporarily) overnight. This represents a significant boon for anyone stuck in the airless swamp of depression, but, according to a small 2014 pilot study in South Carolina, it could be especially potent for those experiencing suicidal thoughts or ideation. That research found that a single night of sleep deprivation led to a 63 percent mean reduction on the Columbia Suicide Severity Rating Scale.
“Even in the ‘70s it was clear—when you've seen a severely melancholic patient turn into somebody who can actually talk to you and even smile just by staying awake all night, you think it's absolutely a miracle,” says Anna Wirz-Justice, professor emeritus at the Centre for Chronobiology in Basel, Switzerland, who first became interested in its therapeutic potential shortly after the first publication of Pflug’s remarkable responses.
It seems almost too good to be true—and in some ways, it is. For the vast majority of patients, as many as 95 percent, the effects wear off as soon as they have a decent sleep. As a psychiatrist once put it to Wirz-Justice, “why offer people paradise just to take it away again?”
Several people with depression I’ve spoken to recently have said that non-clinical, DIY sleep deprivation gives them relief, but with cautious enthusiasm. “It’s notable, but nothing life-changing,” David, a 33-year-old from Quebec, tells me. He usually prefers to “sleep a couple hours and have a decent next day with a slightly less noticeable mood boost,” rather than staying up all night but suffer headaches as a result. “But it doesn't sustain itself for me.”
The cognitive, behavioral, and physical health deficits of sleep deprivation are well-established, and we all recognize them. But the impairments to motor control, memory, and higher cognitive function that the majority report after little or no sleep are also characteristic of depression. Therefore, for depressives, the short-term antidepressant effects of sleep deprivation counter-balance and may outweigh its negative cognitive effects.
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In recent years, most clinical trials have added adjunctive therapies to build on the immediate antidepressant effect of the sleep deprivation. Light therapy, a long-standing treatment for seasonal affective disorder in which patients sit for half an hour in front of a very bright light box, is often used for several mornings after the initial all-nighter. Another method is sleep phase advance (SPA), which begins with early bedtime the night after sleep deprivation and gradually returns the patient’s sleep pattern to normal within a few nights.
It’s also common for patients to be on a longer course of antidepressants like fluoxetine (Prozac), or a mood stabilizer such as lithium, to cement the improvement after the immediate treatment is completed. The combination of sleep deprivation, light therapy, and either SPA or ongoing medication is referred to as ‘triple chronotherapy,’ Wirz-Justice explains. “The idea is you use everything you've got to get out and keep out of depression in four days. Isn't that something to aim for? Why doesn't it catch on?”
I can think of several reasons, and the main one is it’s just really hard. When I’m depressed, I sleep a lot. A lot of depressed people do. I spent much of my 20s lying in bed, staring at the wall with the blinds down. Getting up at all is an effort, let alone staying up all night. Recognizing this, some clinicians use a partial sleep deprivation where patients sleep the first part of the night and are woken at 2 am—it’s an easier sell, and works almost as well.
This is the protocol I’ve adopted. Studies have found little difference between a full all-nighter and grabbing a couple of hours’ rest, says Francesco Benedetti, head of the psychiatry and clinical psychobiology unit at San Raffaele Hospital in Milan and one of the leading researchers in the field. “[Partial sleep deprivation late in the night was followed by response rates similar to those obtained after total sleep deprivation...but the issues of efficacy, timing and stress are yet debated,” he says.
As for doing it at home, as I’ve done recently? “If you’re knowledgeable about it you can find the information and follow the protocol, but to do it on your own I think is very tough,” says David Veale, consultant psychiatrist at the Priory Hospital in North London, where he is running the UK’s first clinical trial of sleep deprivation for depression. He says it’s more difficult than dangerous.“ Perhaps the only potential risk is for people with bipolar disorder who may become manic during the program—so I wouldn’t recommend it if you're on your own...though it’s probably no different from other medications. If you’ve ever met somebody having a manic episode, it isn’t difficult to tell,” Veale adds. Mania is typically characterized by grandiosity, racing thoughts, irritability, sleeplessness and heightened impulsivity.
It’s not only personally counterintuitive to stay up all night when you’re depressed, it also goes against every prevailing cultural norm. The premium importance of sleep is reinforced everywhere, and with good reason. “If you don’t have depression and you stay up all night, you feel pretty crap, don't you?” Veale says. Patients with serious clinical depression may respond differently, though. “Depressed patients will have some tiredness, of course, but if they’re responding then they’re also recovering from their depression.”
Part of the reason for this apparent paradox is the neurotransmitter dopamine. A study in the Journal of Neuroscience suggested that a night of sleep deprivation causes increased dopamine production, which “correlated with increases in fatigue and with deterioration in cognitive performance.” However, dopamine also functions as the brain’s reward mechanism, and its subjective effect is often an increase in mood, short-term energy and feelings of positivity. As Veale explains, patients may be fatigued but they’ll also be feeling better in spite of their tiredness.
Another neurochemical that increases in the sleep-deprived brain, adenosine, has been shown to correlate with resilience to depression and its mind-numbing effects while also mediating the effects of an all-nighter, and it seems to be central to the action of other depression treatments, like ketamine. In fact, according to a paper by Benedetti, sleep deprivation affects “almost all the neurotransmitters targeted by antidepressant drugs."
However, the precise mechanism of how sleep deprivation works for depressed people remains largely mysterious. Both Benedetti and Wirz-Justice note that similar confusion surrounds our understanding of most antidepressant meds. “Maybe you just have to shake up the neurotransmitters,” Wirz-Justice says an old mentor told her. Especially with something as fundamental to our biological and circadian rhythms as sleep, the idea of resetting the clock, so to speak, is a powerful one.
Yet it’s not something that’s caught the popular, or commercial, imagination, Veale says. The fact you can't patent “not sleeping” might have something to do with it. “How do you do double-blind placebo-controlled trials for something like staying awake all night?” Wirz-Justice says. “Who pays for it? How do you calculate the costs? It's so different from a pill.”
If I'd known a decade ago that there was clinical evidence for sleep deprivation, I'd have been less likely to dismiss my own experience as just a curiosity, and kept at it. Instead, for years I largely forgot about it—until my uncle emailed a link about Veale’s study, and I decided there might be something to it after all.
One night last week, around 2am, when my emails finally crossed the incoherency threshold, I flipped my Macbook closed and left the couch for bed. I woke before my 5 am alarm with the birds through the window, to hit the gym and beach as usual. By the time I was happily ensconced in the cafe with free refills of Ethiopian coffee, I felt more alert and in sync than I had all week.
Three days later and I’m still in the clear. I’ve felt consistently lucid, engaged, and energized. Last night, after a long Saturday in the Australian sun, I fell asleep at half past nine still in my tennis clothes. It’s not necessary, or possible, to stay up all night every night. Instead, it can act as a jump-start—after that, it’s over to me to channel and maintain my energy through exercise, people, and things that matter.
Like Veale, Wirz-Justice acknowledges the close link between circadian rhythms and the bipolar. “The switch into mania is nearly always accompanied by a lack of sleep, and with medically prescribed sleep deprivation you can switch someone out of depression. So it’s very deeply rooted with bipolarity.” I explained to her that I experience life itself as a fairly up-and-down affair, to which her response was tart: “Yes, well, I prefer the ups.”
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