The influence of physical activity and posture on the antidepressant effect of sleep deprivation in depressed patients

Effect of sleep deprivation plus existing therapies on depression: A systematic review and meta-analysis of randomized controlled trials

BACKGROUNDS

Depression is the most common mental disorder in the world. Sleep deprivation (SD) is a well-known antidepressant. Several recombination protocols (including medications, bright light treatment [BLT], cognitive-behavioral therapy, sleep phrase advance/sleep phrase delay [SPA/SPD], and repetitive transcranial magnetic stimulation [rTMS]) have been developed to improve and maintain the effect of SD. However, relapse after recovery sleep has been reported, and different recombination protocols result in different outcomes.

METHODS

The Embase, Cochrane, PubMed, CBM, Web of Science, and CINAHL databases were searched for clinical trials assessing depression and SD. Three independent reviewers classified forty-three abstracts. The Hamilton Depression Rating Scale was used to assess the outcomes.

RESULTS

Compared with existing therapy, patients receiving SD displayed a significant improvement in clinician-rated depressive symptoms (MD -1.48 [95 % CI -2.60, -0.37], p < 0.05). A significant decrease was found in the subgroups of SD plus SPA/SPD (odds ratio 3.90 [95 % CI 1.66, 9.17], p < 0.05), total sleep deprivation[TSD] plus BLT (MD -3.28 [95 % CI -5.06, -1.50], p < 0.05), and partial sleep deprivation[PSD] plus rTMS (MD -7.94 [95 % CI -11.44, -4.45], p < 0.05). No significant differences were observed in the other subgroups.

CONCLUSIONS

Adding SD to existing therapies showed a positive outcome in improving depression treatment, which provides evidence for the use of SD in treating depression. Further studies are needed to determine the precise effects of SD plus other interventions.

Motor activity in depressed patients during therapeutic sleep deprivation

PROBLEM

Both sleep and motor activity have a bidirectional relationship with depression. The existing literature on motor activity during therapeutic sleep deprivation in depressed patients is inconsistent and fragmentary. In the present study we measured motor activity continuously during 40 hours of sleep deprivation in depressed patients.

METHOD

Thirty-four inpatients suffering from a major depression (DSM-IV) underwent sleep deprivation with a continuous waking period of 40 hours. Motor activity of the patients was continuously recorded using an actigraph on the non-dominant wrist. The effect of sleep deprivation was assessed by the Hamilton Depression Scale (six-item version), thus separating the group into responders and non-responders to sleep deprivation.

RESULTS

We found no significant differences in motor activity between responders and non-responders on the day before sleep deprivation. During the night, responders to sleep deprivation exhibited a higher motor activity and less periods of rest. On the day after sleep deprivation, responders exhibited a higher activity, too.

CONCLUSIONS

Motor activity levels differ between the two groups, thus giving more insight into possible mechanisms of action of the therapeutic sleep deprivation. We suggest that higher motor activity during the night prevents naps and leads to better response to sleep deprivation.

Clinical applicability of therapeutic sleep deprivation

The short-term antidepressive effect of single sleep deprivation (SD) treatment has been unanimously confirmed in a large number of studies. SD is most effective in patients with a major depressive episode (with melancholic features) but is also promising in other depressed patients suffering from vital symptoms and exhibiting a typical diurnal variation in mood (with morning low) irrespective of the type of depression. The SD modification of choice is partial SD in the second half of the night. SD is an easily applied treatment measure that is free from serious side effects. The tolerability can be improved further by performing SD in groups. SD is to be administered repeatedly rather than once and combined with pharmacotherapy. The mechanism of action underlying therapeutic SD has not yet been discovered. However, for its favorable influence on the overall antidepressive treatment outcome, SD should not only be applied in therapy-resistant depression but is to be looked upon as part of the standard antidepressive somatotherapy.

Sleep deprivation therapy

This review reports, with as much detail as possible, on the literature relating to therapeutic sleep deprivation (or induced-wakefulness therapy) since it was first described in 1971. The antidepressive effect of sleep deprivation has been substantiated by numerous studies. A series of clinical predictors of response to sleep deprivation are also described. Partial sleep deprivation late in the night is equivalent to total sleep deprivation in terms of therapeutic value and--because of its simpler application--can be regarded today as the sleep deprivation method of choice. The status of sleep deprivation in the overall treatment schedule for depressive disorders is discussed in detail. Numerous findings, some of them contradictory, have been published on the effect of sleep deprivation on biological variables. To date, no unequivocal explanation has been found for the mechanism of action of sleep deprivation.