Vol 5 n° 4 - Chronobiology and Mood Disorders
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3 6 6 Posters & images in neuroscience Sleep deprivation and antidepressant treatment The main limitation is the transient nature of the effect, since the majority—but not all—of the improved patients experience a relapse after the next night of sleep.2 Despite the rapid effects and low risk of relevant side effects (Table I),2-9 the method has remained an “orphan drug” or “orphan method.” This may be explained not only by the effort and motivation needed by the patient and by the frequent relapses after the next night of sleep, but also by the lack of funding for nonpharmacological and  nonneurochemical  research.  Nevertheless,  some progress has been made within the last few years.A vari- ety of studies have focused on the problem of how to avoid relapses occurring after the next night of sleep and additionally  treated  the  patients  with  light  therapy, lithium, or other drugs. Lower relapse rates after SD were found when SD was combined with one of these therapeutic options (Table II).10-20 A further strategy has been to advance the sleep period to an “unphysiological” time. Several uncontrolled stud- ies in small numbers of patients have indicated that this phase advance procedure per se acts as an antidepres- sant. More recent studies have combined SD with a sub- sequent  phase  advance  of  the  sleep  period, over  the course of either six or three nights and consistently found that a phase advance of the sleep period stabilizes the antidepressant  effect  of  SD  in  about  60%  of  those patients who responded positively to SD.17-20 Only one study also included a control group which participated in a  phase-delay  protocol  after  SD  instead  of  a  phase- advance protocol.18 Significantly more patients relapsed in the phase-delay protocol compared with the phase advance protocol (Figure 1). This indicates that the high Copyright © 2003 LLS SAS. All rights reserved The mood-improving effect of sleep deprivation (SD) in depression is even today still not fully understood. Despite the fact that mood and cognitive functions are lowered by prolonged sleep loss and despite convincing data that insomnia is a strong risk factor for subsequent depression,1 acute SD for one night or even partial SD in the second half of the night improves mood in about 60% of depressed patients the day after.2,3 In this respect, among all types of antidepressant treatments, SD elicits the fastest results, faster even than electroconvulsive therapy. Many authors correlate the likelihood of responding to SD with clinical variables. A summary of predictors is listed in Table I. Table I. Clinical predictors of an antidepressant response to sleep deprivation (SD) in depressed subjects and side effects. *Not based on systematic documentation. Predictive • High level of arousal4 • High variability of mood swings5 • Diurnal and day-to-day mood variations6 • “Endogenous” and melancholic subtype2,3 • Bipolar subtype7 Not predictive2,3 • Age • Sex • Severity of depression • Duration of depressive episode • Duration of illness • Earlier treatments • Expectation of patients Side effects of SD in depression* • Tiredness, fatigue • Switch to hypomania or mania in bipolar patients8 • Exacerbation of psychotic symptoms in psychotically depressed patients9 • Lowering of seizure threshold Table II. Therapeutic strategies to avoid relapses after successful sleep deprivation in depression (selected papers). • Antidepressants (clomipramine)10 • Lithium11-13 • Pindolol14 • Light therapy15,16 • Sleep phase advance over 3 to 6 nights17-20