Depression is a common problem without a silver bullet. I’m excited to offer our Wake and Light Therapy (*Also called “Triple Chronotherapy”) for the RAPID treatment of depression at the Priory Hospital North London. As far as I am aware, it is not available at any other hospital in the UK.
I have read most of the literature on Light Therapy and talked to some of the leading scientists in this area. I also headed a pilot controlled trial in out-patients at the Maudsley with results similar to those of previous studies around the world in inpatients. This study is currently being reviewed by a high impact journal. What appeals to me is its simplicity and the lack of any significant side effects. This promising area is strangely neglected by psychiatrists and psychologists.
Rapid response within 1 week
It commonly takes 3 to 6 weeks to see any benefit from standard anti-depressant medication or a psychological therapy. In contrast, Wake Therapy combined with Light Therapy can result in a rapid response within 4-7 days.
How many people respond?
About 50% of patients appear to get better with Wake and Light therapy, but we cannot predict who will benefit. We have therefore developed the RAPID (“Rapid Acting Programme In Depression”) at our hospital to work alongside standard treatments, which we recommend patients to continue. Of course, we need more research in this area.
What does it consist of?
Rapid treatment of depression combines Wake Therapy and Bright Light Therapy. Wake Therapy is designed to reset your internal clock. We keep you awake for the first night (with lots of help) and advance the time you go to bed each day for 5 days. Once this phase is completed, the focus of treatment is on Behavioural Activation or Cognitive Behaviour Therapy, sleep hygiene and changes in your lifestyle (for example diet and use of alcohol). Once there is some improvement in your mood over the first week, you will find you can tackle longer standing problems such as conflicts or losses in your life that may be contributing to your depressed mood.
Wake and Light Therapy is a promising treatment for the rapid treatment of depression and has been shown to be effective in 3 controlled studies and several case series around the world. It was first described in a PhD by Dr Burkhard Pflug in Germany in 1973 which recognised that there was a high rate of relapse after the night of sleep deprivation. A couple of decades later, researchers found ways of preventing the relapse with advancing the phase of sleep and using Light Therapy.
Does Light Therapy “work”?
You can have Bright Light Therapy with Behavioural Activation and medication on their own. You are more likely to get good results by combining these components with Wake Therapy. There are no known major side effects from these therapies, and they can be used with anti-depressant medication and other psychological therapies. You’ll know whether it’s working or not after the first 5 days.
These therapies do not appear in the NICE Guidelines for depression, because there is not yet enough evidence and because no-one on the expert guideline committee picked up on it.
Who improves with Wake and Light Therapy?
We do not yet know who may get better with Wake and Light Therapy. It seems to work with all types of depression, both unipolar and bipolar. It may work best when you have the core symptoms of depression such as melancholia, waking early in the morning, poor appetite or weight loss, retardation and guilt. Some people find they are more prone to depression in the winter. Hospitals generally admit more patients with depression in the winter months when there is less sunlight. However Light Therapy can also work whether you experience a seasonal onset or not.
Why might the Wake and Light therapy be of help?
A hormone, called melatonin, is released at night by the pineal gland in the brain to regulate both your sleep and other hormones. Some people release melatonin at the wrong time of the day. If we can reset this release to the right time of the evening, it can help control symptoms of depression. Another effect of sleep deprivation is a surge of mono-amines (for example serotonin, dopamine). The positive effects of Wake and Light Therapy can be enhanced by ensuring routine in your activity, sleep and eating. I see the Wake Therapy as turbo-charged version of Behavioural Activation.
The following is a typical one week program for depression for our inpatients.
Day 1 (we usually start on a Monday)
Before you begin, we assess the severity and type of your depression and the pattern of your sleep.
On the first night, you stay awake with no naps. This is usually done with the support of a nurse and fellow patients in a small group. We plan activities for the night on the ward e.g. watching a film; a short walk in the grounds or perhaps an excursion to an all-night venue. You will have access to coffee/tea and snacks on the ward.
Day 2 (Tuesday)
You may get an immediate improvement in your mood. Unless you continue with the program in the way we describe, you are very likely to relapse. You receive Bright Light Therapy for 30 minutes in your room sometime between 6.45am and 9am. The exact timing will depend on the results of a questionnaire. You sit about a foot (30cm) from the light with your eyes open. Ideally, the light screen should be tilted at a 15° angle toward you so that the light is projected over as you receive treatment. You should not stare at the light but you may read, work, eat, etc. while receiving the light therapy. A nurse on the ward will provide guidance on its use. An alternative to Bright Light Therapy is to go outdoors first thing in the morning for natural sunlight especially in the Summer months.
You stay awake during the day and structure your activities as planned with your therapist. You should try not to have any naps. If you cannot resist a nap it should last no more than 10-15 mins. You should go to bed at 5pm (17.00) and wake by 1am (i.e. about 8 hours sleep).
Day 3 (Wednesday)
You stay awake during the day, go to bed at 7pm and wake by 3am. After a light snack, the nursing staff on the ward provide some activity. Bright Light Therapy is provided as described with the same timing as on Day 2. There is a planned activity schedule and treatment as usual on the ward.
Day 4 (Thursday)
You stay awake during the day, go to bed at 9pm and wake by 5am.
You have Bright Light Therapy at the same time as you did on Day 2 with similar activities and treatment on the ward.
Day 5 (Friday onwards)
Life is getting back to normal. You go to bed by 11pm and wake by 7am.
Bright Light Therapy is provided at the same time as on Day 2, and there are activities and treatment on the ward.
How will we know if there is any benefit?
Naturally, you will want to judge how effective the therapy is and whether there is a downside. One of the staff will rate your symptoms on a scale and we will ask you to complete some questionnaires at the beginning of the treatment and again at the start of the following week to assess progress.
Are there any reported side effects of Bright Light Therapy?
Side effects are generally uncommon but include decreased sleep, dry mouth, nausea, headache, weakness and fatigue. These symptoms are transitory and can usually be managed by reducing the duration of the light therapy to 15-20 minutes or adjusting the distance from the light box. In rare cases, if you have bipolar disorder, you might switch from depression to mania.
Is Wake Therapy (Sleep deprivation) suitable for everyone?
If you have a history of epilepsy, then wake therapy may induce a seizure. This will need further discussion: it may be better for you to have Bright Light Therapy without sleep deprivation.
Is Bright Light Therapy suitable for everyone?
- bright light therapy is not for you if you have severe eye disease or traumatic injury affecting both eyes or if you are taking photo-sensitising medication that commonly causes burns with bright light
- if you are currently on night-shift work – you need to return to a normal sleep pattern before starting the program
- if you are suffering from mania or have rapid cycling which is occurring daily – this can still be helped by a modified version of the programme.
Please contact me if you’d like an assessment for Wake and Light Therapy.
Who else provides Wake and Light Therapy?
I’d like to know so that we can network and share our experience! I am aware of an outpatient service in USA and one or two across Europe and Japan. So, it very exciting to be pioneering this treatment in our hospital for private patients. I hope to conduct research for a much bigger controlled trial in the NHS so it can be introduced more widely.
We really need a research centre for chronotherapy. If you are interested in funding a PhD student or research at my department at King’s College London or know anyone who would be happy to be approached for a contribution, please contact me.