Effect of repeated sleep deprivation on clinical symptoms and the TRH test in endogenous depression

Les temps de la dépression

Revue à travers les données de la littérature, la dépression apparaît comme un sujet de recherche très important, qui a déjà suscité de nombreuses théories chronobiologiques, souvent fondées sur des ≪critères diagnostiques objectifs≫. En revanche, l’impact thérapeutique de ces approches reste souvent limité à de rares services ultraspécialisés où les patients déprimés sont adressés en dernier recours.

Dans cet article, les auteurs passent en revue quelques-unes des principales données de la littérature, en particulier celles qui concernent les aspects chronobiologiques de la dépression. Les investigations sophistiquées réalisées dans les unités de recherche peuvent avoir certaines conséquences cliniques et pratiques qui sont également évoquées. En effet, une évaluation clinique soigneuse, orientée sur des bases chronobiologiques suffit bien souvent à proposer des traitements individuels assez simples. Parmi ceux-ci, la privation partielle de sommeil (PPS) représente un moyen utile, permettant une amélioration rapide, mais malheureusement souvent imprévisible et transitoire, des troubles de l’humeur. Il semble possible de rendre plus fiables les PPS grâce à des interventions sur la température, la prise de nourriture et l’exposition à la lumiére.

De plus, les auteurs décrivent un moyen possible de pérenniser les effets antidépresseurs de la PPS par des «microprivations de sommeil» réalisées pendant 15 min, à un moment spécifique de la nuit. Les résultats concernant 11 patients déprimés graves soumis à cette méthode sont exposés, 7 de ces sujets étant maintenus depuis 6 à 20 mois dans un état euthymique.

Effects of Restricted Time in Bed on Antidepressant Treatment Response: A Randomized Controlled Trial

OBJECTIVE

Antidepressant response onset is delayed in individuals with major depressive disorder (MDD). This study compared remission rates and time to remission onset for antidepressant medication delivered adjunctively to nightly time in bed (TIB) restriction of 6 hours or 8 hours for the initial 2 weeks.

METHODS

Sixty-eight adults with DSM-IV-diagnosed MDD (mean ± SD age = 25.4 ± 6.6 years, 34 women) were recruited from September 2009 to December 2012 in an academic medical center. Participants received 8 weeks of open-label fluoxetine 20-40 mg and were randomized to 1 of 3 TIB conditions for the first 2 weeks: 8-hour TIB (n = 19); 6-hour TIB with a 2-hour bedtime delay (late bedtime, n = 24); or 6-hour TIB with a 2-hour rise time advance (early rise time, n = 25). Clinicians blinded to TIB condition rated symptom severity weekly. Symptom severity, remission rates, and remission onset as rated by the 17-item Hamilton Depression Rating Scale were the primary outcomes.

RESULTS

Mixed effects models indicated lower depression severity for the 8-hour TIB compared to the 6-hour TIB group overall (F₈, ₂₂₆.₉ = 2.1, P < .05), with 63.2% of 8-hour TIB compared to 32.6% of 6-hour TIB subjects remitting by week 8 (χ²₁ = 4.9, P < .05). Remission onset occurred earlier for the 8-hour TIB group (hazard ratio = 0.43; 95% CI, 0.20-0.91; P < .03), with no differences between 6-hour TIB conditions.

CONCLUSIONS

Two consecutive weeks of nightly 6-hour TIB does not accelerate or improve antidepressant response. Further research is needed to determine whether adequate sleep opportunity is important to antidepressant treatment response.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01545843.

Chronobiological Therapy for Mood Disorders

Chronobiological therapies for mood disorders include manipulations of the sleep-wake cycle such as sleep deprivation and sleep phase advance and the controlled exposure to light and darkness. Their antidepressant efficacy can overcome drug resistance and targets the core depressive symptoms including suicide, thus making them treatment options to be tried either alone or as adjunctive treatments combined with common psychopharmacological interventions. The specific pattern of mood change observed with chronobiological therapies is characterized by rapid and sustained effects, when used among themselves or combined with drugs. Effects sizes are the same reported for the most effective psychiatric treatments, but side effects are usually marginal or absent. New treatment protocols are developed to adapt them in different clinical settings. This review deals with the general principles of clinical chronobiology and the latest findings in this rapidly developing field.

Chronotherapeutics in a psychiatric ward

Psychiatric chronotherapeutics is the controlled exposure to environmental stimuli that act on biological rhythms in order to achieve therapeutic effects in the treatment of psychiatric conditions. In recent years some techniques (mainly light therapy and sleep deprivation) have passed the experimental developmental phase and reached the status of powerful and affordable clinical interventions for everyday clinical treatment of depressed patients. These techniques target the same brain neurotransmitter systems and the same brain areas as do antidepressant drugs, and should be administered under careful medical supervision. Their effects are rapid and transient, but can be stabilised by combining techniques among themselves or together with common drug treatments. Antidepressant chronotherapeutics target the broadly defined depressive syndrome, with response and relapse rates similar to those obtained with antidepressant drugs, and good results are obtained even in difficult-to-treat conditions such as bipolar depression. Chronotherapeutics offer a benign alternative to more radical treatments of depression for the treatment of severe depression in psychiatric wards, but with the advantage of rapidity of onset.

Relationship between mood and TSH response to TRH stimulation in bipolar affective disorder

Moderate to severe depression and mania are associated with a reduced thyroid stimulating hormone (TSH) response to TSH releasing hormone (TRH). Continued reduction of this response after clinical recovery seems indicative of early relapse. The aim of the present study was to test the relationship between mild changes in mood and the TSH response to TRH stimulation in patients with bipolar affective disorder. Nineteen outpatients with bipolar affective disorder were followed prospectively for three years. Every third month, mood symptoms were rated using the 17-item Hamilton Depression Rating Scale (HAMD-17) and the Bech-Rafaelsen Mania Scale (BRMS). A TRH test was performed in connection with each rating session (IV injection of 200 microg TRH), and serum TSH was measured at 0, 20, and 60 min. The maximum TSH response (D-max TSH) and the temporal change in D-max TSH between succeeding rating sessions (DD-max TSH) were determined. Psychometric rating and TRH data were obtained for a total of 198 examinations. The temporal change in mood symptom rating score was negatively correlated with the temporal change in D-max TSH, thus suggesting that increasing severity of mood symptoms was related to a reduced TSH response to TRH stimulation. The temporal change in TSH response to TRH stimulation correlated with the actual score on an overall index of symptom severity. In conclusion, milder fluctuations in mood in bipolar affective disorder seem to correlate with the TSH response to TRH stimulation: Increasing severity of mood symptoms seems to be associated with reduced TSH response.

Ongoing lithium treatment prevents relapse after total sleep deprivation

Forty bipolar depressed inpatients underwent three consecutive cycles of total sleep deprivation (TSD). At the beginning of the study, 20 patients were free of psychotropic drugs and 20 had been receiving lithium medication for at least 6 months. Mood was rated on the Hamilton Rating Scale for Depression before and after TSD; perceived mood changes during treatment were evaluated with self-administered visual analog scales. Patients undergoing long-term lithium treatment showed a significantly better response to TSD as rated on both scales: 13 of 20 patients (vs. 2 of 20 patients without lithium) showed a sustained response during a follow-up period of 3 months. This preliminary evidence of a positive interaction of TSD and long-term lithium treatment could be explained by a synergistic effect of both treatments on brain serotonergic function, possibly via a desensitization of 5-hydroxytryptamine-1A inhibitory autoreceptors.

The unipolar-bipolar dichotomy and the response to sleep deprivation

Fifty-one inpatients affected by a major depressive episode were divided into four groups according to mood disorder diagnosis and previous clinical history (bipolar disorder type I; bipolar disorder type II; major depressive disorder with at least three previous depressive episodes; and single depressive episode patients) and administered three consecutive total sleep deprivation (TSD) cycles. Mood changes were rated with a reduced version of the Hamilton Depression Rating Scale and with self-administered visual analogue scales. TSD caused better clinical effects in bipolar and single-episode patients; in particular, unipolar patients lacked effects in perceived mood after the first TSD and showed worse Hamilton ratings in respect to the other groups after the three TSD treatments. Discriminant function analysis could correctly classify 80% of bipolar patients, post hoc, based on TSD response. Further researches on the clinical efficacy of TSD must take into account the heterogeneity of depression and of its biological substrate.

Dopamine agonist amineptine prevents the antidepressant effect of sleep deprivation

In a double-blind study, the effects of the interaction between the administration of amineptine versus placebo and repeated cycles of total sleep deprivation (TSD), which is thought to act through an enhancement in dopaminergic transmission, were analyzed. Twenty-two consecutively admitted patients with bipolar depression formed the study group. Repeated administrations of TSD significantly enhanced perceived mood levels in placebo-treated patients, while amineptine administration blocked the antidepressant action of TSD. Hypothesized changes in brain dopaminergic transmission attributable to amineptine pretreatment are discussed.

The relationship between tiredness prior to sleep deprivation and the antidepressant response to sleep deprivation in depression

Recently it was hypothesized that the antidepressant response to total sleep deprivation (SD) results from a disinhibition process induced by the increase of tiredness in the course of SD. In the present study, the role of tiredness in the antidepressant response to SD is further investigated. Seventy-two depressed patients scored subjective tiredness and depressed mood three times daily (in the morning, afternoon, and evening) on the days preceding and following SD. It was found that averaged tiredness on the day prior to SD was related to the SD response, when the severity of depression prior to SD had been held statistically constant. Also, when both severity of depression and diurnal variation of mood prior to SD were partialed out, tiredness showed a positive correlation with the SD response: patients who reported a relatively low degree of tiredness on the day preceding SD improved by SD. This result suggests that tiredness has an influence on SD effects, and that this influence is independent from that of the severity of depression. The findings are in accordance with current ideas on the role of tiredness as a mediating factor in the induction of the therapeutic effects of SD.

Lithium sustains the acute antidepressant effects of sleep deprivation: preliminary findings from a controlled study

Early morning sleep deprivation (patient awake from 0200 to 2200 hours) produces a same-day antidepressant effect in approximately one-half of patients with major depression. Unfortunately, these antidepressant effects are short-lived and patients usually relapse to baseline depression levels within 48 hours. Recent work suggests, however, that the use of lithium with early morning sleep deprivation sustains this rapid antidepressant effect and makes it clinically useful. In a 30-day study, we compared the abilities of four different treatments (lithium plus early morning sleep deprivation, lithium plus a control sleep deprivation procedure, and desipramine with either of the two sleep manipulations) to induce a rapid (next-day) and sustained antidepressant response in 16 depressed patients. Lithium plus early morning sleep deprivation produced a quicker response than lithium with the control sleep deprivation, and the response was sustained for at least 30 days. In this design, however, lithium/early morning sleep deprivation was no faster than either of the two desipramine/sleep deprivation conditions in inducing remission. These results support the results of previous studies and suggest further investigation of this novel sleep/pharmacologic intervention is warranted.

Therapy and prevention of affective illness by total sleep deprivation

The therapeutic effect of total sleep deprivation (SD) given twice a week, for 4 weeks, was investigated in 16 drug-free patients with major affective disorders. The response was excellent in five patients, satisfactory in three and minimal in eight patients. Six of these patients were treated prophylactically once a week, and four had an excellent response. Additionally, out of five normothymic drug-free patients with affective illness treated prophylactically with SD, without prior therapeutic SD treatment, three had an excellent response. The majority of responders were rapid cycling patients. This method is worth applying to patients resistant to classical treatment.

Antidepressant response to sleep deprivation as a function of time into depressive episode in rapidly cycling bipolar patients

Three patients with treatment-resistant rapidly cycling bipolar disorder were studied with multiple sleep deprivations (SD) during several depressive episodes to assess the effect of phase or duration of a depressive episode on SD response. There was little response to SD early in a depressive episode, but responses were often robust late in an episode, sometimes triggering its termination. In 2 subjects, the duration of antidepressant response to SD increased linearly as time into episode increased. Neither the number of SD given in an episode nor the medication status of the patients appeared to account for the observed increases in antidepressant response. These results suggest that the neurobiological substrates underlying depression may change over the course of an episode, resulting in an increased responsivity to sleep deprivation later compared with earlier in the course of an episode in rapidly cycling patients. The generalizability of these findings to unipolar patients remains to be explored.

Effects of partial sleep deprivation on the diurnal variation of mood and motor activity in major depression

Partial sleep deprivation (PSD), keeping a subject awake from 2 AM to 9 PM produces an acute mood improvement in 60% of patients with major depression. We sought to characterize the timing, subcomponent mood, and motor activity changes of this response. Thirty-seven subjects with major depression were rated with the 6-item Hamilton Depression Scale (HAM-6) at 1 PM and completed the Profile of Mood States (POMS) every 2 hr on the day before and day of PSD. Locomotor activity was monitored continuously during the trial with an automated device. Bipolar I patients responded more frequently than other groups. Positive mood responders had greater improvement than nonresponders in POMS subscales of depression, tension, confusion, and anger. The mood improvement increased steadily during the day, peaked in late afternoon, and declined thereafter. Responders showed significantly higher levels of locomotor activity on the baseline pre-PSD day than did nonresponders. All subjects increased motor activity following sleep deprivation, however.

Observed behavior as a predictor of the response to sleep deprivation in depressed patients

Total sleep deprivation (TSD) in depressive patients is known to produce sudden changes in mood, but the factors involved in these mood changes are poorly understood. In this study the role of psychomotor activation was investigated by examining the relationships between baseline measures of activation and subsequent clinical response to TSD. Two methods were used to assess the degree of activation: global judgment (clinical ratings) and direct observation and registration of behavior (ethological methods). Behavioral and global assessments took place 1 day before TSD during a medication-free psychiatric interview. The amount of looking displayed during the interview was negatively correlated with the subsequent clinical response to TSD, while body- and object-touching hand movements showed a positive correlation. During switches from speaking turn and at the start of the patients' speaking turn, responders to TSD showed more hand movements than nonresponders. No relation was found between clinical ratings of the degree of psychomotor activation and the TSD response. Our data suggest that the clinical response to TSD may be predicted and therefore possibly mediated by dimensions of activation. For the detection of these dimensions, behavioral observation appears to be more suitable than global clinical judgment.

Thyroid hormones in the treatment of affective disorders

The experience of using thyroid hormones in affective disorders is summarized. This includes: 1) Using thyroid hormones alone in depression; 2) their combined use with tricyclic antidepressants; 3) addition of thyroid hormones to nontricyclic antidepressants; 4) the use of thyroid stimulating hormone; and 5) thyrotropin releasing hormone in depression. Suggested mechanisms of action are discussed. A special attention is paid to the place of thyroid hormones in the treatment of rapid cycling affective disorder.

Deficient nocturnal surge of TSH secretion during sleep and sleep deprivation in rapid-cycling bipolar illness

Rapid-cycling bipolar patients have a high prevalence of hypothyroidism, and this disturbance in their hypothalamic-pituitary-thyroid (HPT) function may provide a model for understanding the less severe thyroid dysfunction present in other forms of affective disorder. For these reasons, we investigated HPT function in eight rapid-cycling bipolar patients and eight normal controls by measuring plasma levels of thyroid-stimulating hormone (TSH) and cortisol every 30 min during a baseline 24-h period and during an additional night of sleep deprivation. Thyrotropin-releasing hormone (TRH) (500 micrograms) challenge tests were also performed in the patients. Controls exhibited a significant circadian variation in TSH with a nocturnal rise that was augmented by sleep deprivation. In the rapid cyclers, the nocturnal rise in TSH was absent, and sleep deprivation failed to raise their TSH levels significantly compared with baseline. Low nocturnal TSH levels were associated with blunted TSH responses to TRH infusions; due to the relatively brief sampling interval used in the TRH challenge tests, however, these results do not reliably discriminate between hypothalamic and pituitary dysfunction as an etiology for low nocturnal TSH levels. Additional studies are needed to determine the precise nature of the HPT disturbance in rapid-cycling patients.

Response to total sleep deprivation and clomipramine in endogenous depression

In 44 endogenously depressed patients, response to total sleep deprivation (TSD) was investigated as a function of several biographical and clinical variables. All patients were subjected to a schedule of sleep-TSD-sleep-TSD. Antidepressant drug treatment (clomipramine) was started on the day before the first TSD. Sex, age, educational status, number of previous hospitalizations and duration of the current depressive episode were not related to the response to either the first or the second TSD. Likewise, no significant differences were found in the responses of unipolar and bipolar patients. In contrast, diurnal variation appeared to be positively correlated with response to TSD. Depressives with psychotic features reacted more favourably than non-psychotic depressives.

Diagnostic applications of sleep deprivation

Four cases are described in which observation of the response to forty hour sleep deprivation was used in resolving the differential diagnosis between depression and dementia. In each case it was possible to conduct psychometric assessment of cognitive ability during the period of improvement of the clinical state. The utility of this approach and some of the difficulties associated with its use are discussed.

Approaches to the evaluation and treatment of rapid-cycling affective illness

The definition and clinical aspects of rapid cycling affective illness are reviewed and various factors associated with the onset and maintenance of rapid cycling enumerated. On the basis of this information and of reports of the response of rapid cycling patients to various treatment interventions, an approach is suggested to the evaluation and treatment of rapid cycling affective illness.

The sleep therapies of depression

This paper reviews five different types of deliberate sleep-wake manipulations which are reported to have antidepressant effects: total sleep deprivation, partial sleep deprivation, a phase advance of the sleep periods, and REM deprivation. The effects of total sleep deprivation are best documented. Of 852 depressed patients studied, 493 or 57.9% improved following sleep deprivation. The REM deprivation procedure acts more slowly, but is of more lasting clinical value than the other forms. Partial sleep deprivation during the second half of the night may be as good as total sleep deprivation and better tolerated. The findings are reviewed in terms of psychological, neurophysiological, biochemical, and chronobiological perspectives.

Effects of sleep deprivation on depressed patients of different nosological groups

In a study of 80 patients who received 164 treatments with sleep deprivation, the following questions were addressed: Do depressive patients of different subgroups respond differently to sleep deprivation? what complications arise? does the same patient react in the same way to multiple treatments? are there differences between responders and nonresponders? Results indicate that: (1) Endogenous depressions (unipolar, bipolar, and involutional) and psychotic depressions in schizophrenic patients improve significantly the day after sleep deprivation. However, on the second day, after a night's recovery sleep, a significant improvement occurs in neurotic depressives, whereas the endogenous and psychotic depressions worsen again. (2) Schizophrenic patients with a postpsychotic depression respond as well to sleep deprivation as patients with bipolar depression. (3) Complications arise very rarely in sleep deprivation therapy. (4) Patients in all the diagnostic categories studied can respond very differently to multiple treatments with sleep deprivation. (5) Responders and nonresponders do not differ in age, sex, or psychopathological state before sleep deprivation, and psychotropic drugs have no apparent effect on the therapeutic response.