Wake Therapy

Dear Editor:

As an inpatient psychiatrist, I was intrigued to read in the September issue of Psychiatry 2008 Feifel's article on wake therapy as a viable intervention in the management of patients hospitalized with treatment-resistant depression (“Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting”).¹ Dr Feifel correctly reiterates that wake therapy is the most rapidly acting antidepressant strategy.² Yet it is sadly underutilized. Sixty percent of depressed patients experience substantial improvement after a total night of sleep deprivation. However, the antidepressant effect is lost the following day. Berger et al³ described a procedure wherein the antidepressant benefits derived from a single night of sleep deprivation were sustained with a simple sleep phase advance intervention. In their wake therapy protocol, conducted on an inpatient psychiatric unit in Freiburg, Germany, patients diagnosed with major depressive disorder were kept up on Day 1. On Day 2, they went to bed from 5:00 pm to 12:00 midnight, and gradually postponed their bedtime by an hour each subsequent night, till they arrived at a bedtime of 11:00 pm to 6:00 am. The process was completed in eight consecutive days. This is a longer interval than the average length of stay for patients hospitalized with depression in the US. On the inpatient psychiatry unit at St Lawrence/Sparrow Hospital in Lansing, Michigan, we abbreviated the sleep phase advance procedure to four days, by postponing sleep time by two hours rather than one hour each day. Following a night of total sleep deprivation, the patients were asked to go to bed at 5:00 pm, 7:00 pm, and 9:00pm on Days 2, 3, and 4, respectively, seeking to sustain the antidepressant benefit. We permitted the use of caffeine and hypnotics to facilitate the procedure. We encountered obstacles: Patients hospitalized on inpatient psychiatric units are required to adhere to a highly regimented sleep-wake schedule. The necessary 15-minute visual patient safety checks and environmental noise often disrupted sleep continuity. The introduction of a wake-therapy intervention required a change of mindset. Nevertheless, considering the limited efficacy of antidepressant medications⁴ in treatment-resistant depression, wake therapy needs to be more widely employed as a viable therapeutic option.

With regards, Dale A. D'Mello, MD
Associate Professor, Department of Psychiatry, Michigan State University, East Lansing, Michigan; MSU, Inpatient Psychiatry Service St. Lawrence/Sparrow Hospital, Lansing, Michigan