If you missed a few hours of sleep, you’re definitely going to feel tired the next day. And with that fatigue will likely come all sorts of ideas for staying awake, such as guzzling caffeine, taking a long nap, or going to bed super early. But even though it all seems like a good idea when you’re tired, these are things you should avoid at all costs.
The only real cure for fatigue is getting a good night’s sleep, every single day. And that means creating a healthy sleep schedule, one night at a time. “Resetting your sleep schedule or establishing good sleep hygiene is a process and takes more than a few days,” licensed psychologist Nicole Issa, PsyD, tells Bustle.
And yet, the sooner you can start, the better. “It will begin with having a consistent wake up time and sticking to it,” she says. “Your bedtime willgradually shift to an earlier time to allow you to get enough rest.”
Creating a relaxing evening routine can come in handy, too, such as slowing down, putting away your phone, reading a book, and even getting ready for bed beforeyou’re tired. As Dr. Issa says, “That way you can just go to bed when you are ready and not get woken up by washing your face, brushing your teeth, etc.”
These are things you should do for good sleep, as opposed to the things listed below, which experts say you should try to avoid if you’re tired.
1. Drinking Tons Of Energy Drinks
Even though they can give you a quick boost of energy, it’s not a good idea to load up on these drinks as a way to stay awake.
“[They] often have a lot of B vitamins, which can be stimulating, and then cause insomnia, which perpetuates the cycle of being tired and reaching for more energy drinks,” Catherine Darley, ND, from the The Institute of Naturopathic Sleep Medicine, tells Bustle.
Instead, stick to one caffeinated drink in the morning, so it has plenty of time to wear off before bed, when you can officially catch up on your rest.
2. Taking A Nap
If you can, try to resist the urge to take a nap. Or at least try to time it right.
“Avoid taking a nap longer than 30 minutes to ‘catch up,'” Doug Hale, a sleep expert from Brooklyn Bedding, tells Bustle. “Just as important, don’t take a nap late in the day as that will disrupt your normal sleep cycle, leading to insomnia at night.”
3. Going To Bed Super Early
While it might be tempting to pass out the moment the sun goes down, try to stay awake as long as possible, or until your usual bedtime.
“Going to bed too early […] can result in what is essentially a long nap late in the evening,” Dr. Darley says, “which then causes the inability to sleep through the night.”
Do this, and you’ll likely wake up at 3 a.m., and be just as tired the next day.
4. Staying Inside
When you’re tired, you might want to hide away from the blinding light of the sun. But stepping out can actually be a good thing.
“Get outside in bright sunlight for 20 minutes soon after getting up, then continue with light bursts of 10 minutes every couple hours,” Dr. Darley says. “Full spectrum light naturally increases alertness.” And that can help get you through the day.
5. Doing A Strenuous Workout
“It might seem like a good idea to burn off energy in order to get a restful sleep, but working out later in the day can cause cortisol to spike which can prevent some people from being able to fall asleep,” health coach Rachel MacPherson tells Bustle. Instead, do your workout in the morning. Or skip it entirely until you’ve caught up on sleep.
6. Snacking To Stay Awake
Fatigue can make you feel hungrier than normal, and lead to cravings for simple carbohydrates. And while that’s fine, keep in mind that eating sugary snacks can crash your blood sugar, and make you feel even worse. Instead, “eat a healthy balanced diet so your blood sugar levels remain steady,” Dr. Darley says.
7. Drinking A Night Cap
A night cap may seem like a good idea, if you want to fall asleep faster. But if you want that deep sleep, you may want to stick with water.
“Alcohol interferes with your deep sleep cycles and REM cycles,” Jason Piper, a sleep and nutrition coach, tells Bustle. “These are the restorative phases we go through at night. Alcohol keeps you mainly in a light sleep phase.”
8. Cramming For A Test
If you have a big test tomorrow, and plan to stay up all night studying, it may be smarter to just go to bed. “You may feel like you are making progress, but when you finally go to sleep and it is a short duration, you will miss out on a lot of your REM sleep,” Piper says. “REM sleep is when the brain moves short-term memories into long-term memory, so a lot of what you were studying becomes lost.”
9. Sleeping In
Just like going to bed early, sleeping in always seems like a good idea in the moment. And yet, “it can shift [your] circadian rhythm for the day, making it harder to fall asleep at night,” Piper says.
Basically, sleeping in — even for just one hour past your usual wake time — throws off the timing of the sleep hormone, melatonin. It’s best to stick to your normal sleep and wake times, to help your body get back on track.
10. Eating Right Before Bed
While it’s OK to have a light snack before bed, keep in mind that eating a big meal can make for a rough night.
“Your body needs to digest the food,” Piper says. “So it will raise your internal core [temperature] as it metabolizes the food and also will divert energy away from sleep to digesting the food.”
With all that going on, it’ll be hard for the body to slip into a deeper, more restorative sleep cycle, Piper says, and you’ll feel even more tired come morning.
11. Checking The Clock
If you ever find yourself in bed, tired, and yet unable to fall asleep, do yourself a favor and avoid staring at the clock. Or worse, wondering when (or if) you’ll ever fall asleep.
“Doing this isn’t going to change anything,” Dr. Issa says. “In fact, it will only make you feel more anxious which will increase your physiological arousal and make it harder to fall asleep.”
12. Relaxing With Your Phone
However tempting it may be, don’t lay in bed and scroll through you phone, as the “blue light from it will interfere with your ability to fall asleep,” Dr. Issa says. If you want to fall asleep easily, and wake feeling rested, avoiding electronics before bed will be key.
13. Willing Yourself To Sleep
Have you ever had that moment where, despite how tired you feel, you just can’t fall asleep? When that happens, it’s actually best to get out of bed, instead of lying there wishing for sleep.
“Doing that will probably come with a lot of other thoughts about your lack of sleep,” Dr. Issa says, including anxiety about how tired you’ll feel the next day.
“Instead, get out of bed and take a break,” she says. “Get up and go in a different room until you start to naturally feel tired. Then go back into your bed.”
14. Making Important Decisions
If a big decision can wait, do yourself a favor and wait. “Whether financial, relationship, or anything important, you would be much better off making that decision in the morning when your mind and body are fully rested,” Bill Fish, certified sleep science coach and co-founder of Tuck, tells Bustle. When you’re fatigued, you just won’t have the capacity to think clearly.
15. Soaking In A Hot Bath
In order to fall asleep quickly, it may be a good idea to avoid warm showers and baths right before bed, and instead opt for a quick (and cool) rinse.
According to MacPherson, since your core body temperature drops at night in preparation for sleep, taking a hot bath can disrupt that cycle, increase your heart rate, and make it difficult to sleep.
Even though it often seems like a good idea, doing these things when you’re tired tends to be anything but helpful. The best and only way to feel less fatigued is to get a good night’s sleep, which includes sticking to a bedtime routine, and getting the right amount of rest every day.
The next time you tell yourself that you’ll sleep when you’re dead, realize that you’re making a decision that can make that day come much sooner. Pushing late into the night is a health and productivity killer.According to the Division of Sleep Medicine at the Harvard Medical School, the short-term productivity gains from skipping sleep to work are quickly washed away by the detrimental effects of sleep deprivation on your mood, ability to focus, and access to higher-level brain functions for days to come. The negative effects of sleep deprivation are so great that people who are drunk outperform those lacking sleep.
Why You Need Adequate Sleep to Perform
We’ve always known that sleep is good for your brain, but research from the University of Rochester provides the first direct evidence for why your brain cells need you to sleep (and sleep the right way—more on that later). The study found that when you sleep your brain removes toxic proteins from its neurons that are by-products of neural activity when you’re awake. Unfortunately, your brain can remove them adequately only while you’re asleep. So when you don’t get enough sleep, the toxic proteins remain in your brain cells, wreaking havoc by impairing your ability to think—something no amount of caffeine can fix.
Skipping sleep impairs your brain function across the board. It slows your ability to process information and problem solve, kills your creativity, and catapults your stress levels and emotional reactivity.
What Sleep Deprivation Does to Your Health
Sleep deprivation is linked to a variety of serious health problems, including heart attack, stroke, type 2 diabetes, and obesity. It stresses you out because your body overproduces the stress hormone cortisol when it’s sleep deprived. While excess cortisol has a host of negative health effects that come from the havoc it wreaks on your immune system, it also makes you look older, because cortisol breaks down skin collagen, the protein that keeps skin smooth and elastic. In men specifically, not sleeping enough reduces testosterone levels and lowers sperm count.
Too many studies to list have shown that people who get enough sleep live longer, healthier lives, but I understand that sometimes this isn’t motivation enough. So consider this—not sleeping enough makes you fat. Sleep deprivation compromises your body’s ability to metabolize carbohydrates and control food intake. When you sleep less you eat more and have more difficulty burning the calories you consume. Sleep deprivation makes you hungrier by increasing the appetite-stimulating hormone ghrelin and makes it harder for you to get full by reducing levels of the satiety-inducing hormone leptin. People who sleep less than 6 hours a night are 30% more likely to become obese than those who sleep 7 to 9 hours a night.
How Much Sleep Is Enough?
Most people need 7 to 9 hours of sleep a night to feel sufficiently rested. Few people are at their best with less than 7 hours, and few require more than 9 without an underlying health condition. And that’s a major problem, since more than half of Americans get less than the necessary 7 hours of sleep each night, according to the National Sleep Foundation.
For go-getters, it’s even worse.
A recent survey of Inc. 500 CEOs found that half of them are sleeping less than 6 hours a night. And the problem doesn’t stop at the top. According to the Centers for Disease Control and Prevention, a third of U.S. workers get less than 6 hours of sleep each night, and sleep deprivation costs U.S. businesses more than $63 billion annually in lost productivity.
Doing something about it
Beyond the obvious sleep benefits of thinking clearly and staying healthy, the ability to manage your emotions and remain calm under pressure has a direct link to your performance. TalentSmart has conducted research with more than a million people, and we’ve found that 90% of top performers are high in emotional intelligence (EQ). These individuals are skilled at understanding and using emotions to their benefit, and good sleep hygiene is one of the greatest tools at their disposal.
High-EQ individuals know it’s not just how much you sleep that matters, but also how you sleep. When life gets in the way of getting the amount of sleep you need, it’s absolutely essential that you increase the quality of your sleep through good sleep hygiene. There are many hidden killers of quality sleep. The 10 strategies that follow will help you identify these killers and clean up your sleep hygiene. Follow them, and you’ll reap the performance and health benefits that come with getting the right quantity and quality of sleep.
1. Stay Away from Sleeping Pills
When I say sleeping pills, I mean anything you take that sedates you so that you can sleep. Whether it’s alcohol, Nyquil, Benadryl, Valium, Ambien, or what have you, these substances greatly disrupt your brain’s natural sleep process. Have you ever noticed that sedatives can give you some really strange dreams? As you sleep and your brain removes harmful toxins, it cycles through an elaborate series of stages, at times shuffling through the day’s memories and storing or discarding them (which causes dreams). Sedation interferes with these cycles, altering the brain’s natural process.
Anything that interferes with the brain’s natural sleep process has dire consequences for the quality of your sleep. Many of the strategies that follow eliminate factors that disrupt this recovery process. If getting off sleeping pills proves difficult, make certain you try some of the other strategies (such as cutting down on caffeine) that will make it easier for you to fall asleep naturally and reduce your dependence upon sedatives.
2. Stop Drinking Caffeine (at Least after Lunch)
You can sleep more and vastly improve the quality of the sleep you get by reducing your caffeine intake. Caffeine is a powerful stimulant that interferes with sleep by increasing adrenaline production and blocking sleep-inducing chemicals in the brain. Caffeine has a 6-hour half-life, which means it takes a full 24 hours to work its way out of your system. Have a cup of joe at 8 a.m., and you’ll still have 25% of the caffeine in your body at 8 p.m. Anything you drink after noon will still be near 50% strength at bedtime. Any caffeine in your bloodstream—the negative effects increasing with the dose—makes it harder to fall and stay asleep.
When you do finally fall asleep, the worst is yet to come. Caffeine disrupts the quality of your sleep by reducing rapid eye movement (REM) sleep, the deep sleep when your body recuperates most. When caffeine disrupts your sleep, you wake up the next day with a cognitive and emotional handicap. You’ll be naturally inclined to grab a cup of coffee or an energy drink to try to make yourself feel more alert, which very quickly creates a vicious cycle.
3. Avoid Blue Light at Night
This is a big one—most people don’t even realize it impacts their sleep. Short-wavelength blue light plays an important role in your mood, energy level, and sleep quality. In the morning, sunlight contains high concentrations of this “blue” light. When your eyes are exposed to it directly (not through a window or while wearing sunglasses), the blue light halts production of the sleep-inducing hormone melatonin and makes you feel more alert. This is great, and exposure to a.m. sunlight can improve your mood and energy levels. If the sun isn’t an option for you, try a blue light device.
In the afternoon, the sun’s rays lose their blue light, which allows your body to produce melatonin and start making you sleepy. By the evening, your brain does not expect any blue light exposure and is very sensitive to it. The problem this creates for sleep is that most of our favorite evening devices—laptops, tablets, televisions, and mobile phones—emit short-wavelength blue light. And in the case of your laptop, tablet, and phone, they do so brightly and right in your face. This exposure impairs melatonin production and interferes with your ability to fall asleep as well as with the quality of your sleep once you do nod off. Remember, the sleep cycle is a daylong process for your brain. When you confuse your brain by exposing it in the evening to what it thinks is a.m. sunlight, this derails the entire process with effects that linger long after you power down. The best thing you can do is avoid these devices after dinner (television is okay for most people as long as they sit far enough away from the set). If you must use one of these devices in the evening, you can limit your exposure with a filter or protective eyewear.
4. Wake Up at the Same Time Every Day
Consistency is key to a good night’s sleep, especially when it comes to waking up. Waking up at the same time every day improves your mood and sleep quality by regulating your circadian rhythm. When you have a consistent wake-up time, your brain acclimates to this and moves through the sleep cycle in preparation for you to feel rested and alert at your wake-up time. Roughly an hour before you wake, hormone levels increase gradually (along with your body temperature and blood pressure), causing you to become more alert. This is why you’ll often find yourself waking up right before your alarm goes off.
When you don’t wake up at the same time every day, your brain doesn’t know when to complete the sleep process and when it should prepare you to be awake. Long ago, sunlight ensured a consistent wake-up time. These days, an alarm is the only way most people can pull this off, and doing this successfully requires resisting the temptation to sleep in when you’re feeling tired because you know you’ll actually feel better by keeping your wake-up time intact.
5. No Binge Sleeping (In) on the Weekend
Sleeping in on the weekend is a counterproductive way to catch up on your sleep. It messes with your circadian rhythm by giving you an inconsistent wake-up time. When you wake up at the same time during the work week but sleep past this time on the weekend, you end up feeling groggy and tired because your brain hasn’t prepared your body to be awake. This isn’t a big deal on your day off, but it makes you less productive on Monday because it throws your cycle off and makes it hard to get going again on your regular schedule.
6. Learn How Much Sleep You Really Need
The amount of sleep you need is something that you can’t control, and scientists are beginning to discover the genes that dictate it. The problem is, most people sleep much less than they really need and are under-performing because they think they’re getting enough. Some discover this the hard way. Ariana Huffington was one of those frantic types who underslept and overworked, until she collapsed unexpectedly from exhaustion one afternoon. She credits her success and well-being since then to the changes she’s made to her sleep habits. “I began getting 30 minutes more sleep a night, until gradually I got to 7 to 8 hours. The result has been transformational,” Huffington says, adding that, “all the science now demonstrates unequivocally that when we get enough sleep, everything is better: our health; our mental capacity and clarity; our joy at life; and our ability to live life without reacting to every bad thing that happens.”
Huffington isn’t the only one. Jeff Bezos, Warren Buffet, and Sheryl Sandberg have all touted the virtues of getting enough sleep. Even Bill Gates, an infamous night owl, has affirmed the benefits of figuring out how much sleep you really need: “I like to get 7 hours of sleep a night because that’s what I need to stay sharp and creative and upbeat.” It’s time to bite the bullet and start going to bed earlier until you find the magic number that enables you to perform at your best.
7. Stop Working
When you work in the evening, it puts you into a stimulated, alert state when you should be winding down and relaxing in preparation for sleep. Recent surveys show that roughly 60% of people monitor their smartphones for work emails until they go to sleep. Staying off blue light-emitting devices (discussed above) after a certain time each evening is also a great way to avoid working so you can relax and prepare for sleep, but any type of work before bed should be avoided if you want quality sleep.
8. Eliminate Interruptions
Unfortunately for those with small children, the quality of your sleep does suffer when it is interrupted. The key here is to eliminate all the interruptions that are under your control. If you have loud neighbors, wear earplugs to bed. If your mother likes to call at all hours of the night, make certain you silence your ringer before you go to bed. If you had to wake up extra early in the morning, make sure your alarm clock is back on its regular time when you go to bed. Don’t drink too much water in the evening to avoid a bathroom trip in the middle of the night. If your partner snores . . . well, you get the idea. If you think hard enough, there are lots of little things you can do to eliminate unnecessary interruptions to your sleep.
9. Learn to Meditate
Many people who learn to meditate report that it improves the quality of their sleep and that they can get the rest they need even if they aren’t able to significantly increase the number of hours they sleep. At the Stanford Medical Center, insomniacs participated in a 6-week mindfulness meditation and cognitive-behavioral therapy course. At the end of the study, participants’ average time to fall asleep was cut in half (from 40 to 20 minutes), and 60% of subjects no longer qualified as insomniacs. The subjects retained these gains upon follow-up a full year later. A similar study at the University of Massachusetts Medical School found that 91% of participants either reduced the amount of medication they needed to sleep or stopped taking medication entirely after a mindfulness and sleep therapy course. Give mindfulness a try. At minimum, you’ll fall asleep faster, as it will teach you how to relax and quiet your mind once you hit the pillow.
10. When All Else Fails: Take Naps
One of the biggest peaks in melatonin production happens during the 1:00 to 3:00 p.m. time frame, which explains why most people feel sleepy in the afternoon. Companies like Google and Zappos are capitalizing on this need by giving employees the opportunity to take short afternoon naps. If you aren’t getting enough sleep at night, you’re likely going to feel an overwhelming desire to sleep in the afternoon. When this happens, you’re better off taking a short nap (even as short as 15 minutes) than resorting to caffeine to keep you awake. A short nap will give you the rest you need to get through the rest of the afternoon, and you’ll sleep much better in the evening than if you drink caffeine or take a long afternoon nap.
Bringing it all together
I know many of you reading this piece are thinking something along the lines of “but I know a guy (or gal) who is always up at all hours of the night working or socializing, and he’s the number one performer at our branch.” My answer for you is simple: This guy is underperforming.
We all have innate abilities that we must maximize to reach our full potential. My job is to help people do that—to help the good become great by removing unseen performance barriers. Being number one in your branch is an accomplishment, but I guarantee that this guy has his sights set on bigger things that he isn’t achieving because sleep deprivation has him performing at a fraction of his full potential. You should send him this article. It just might shake something loose.
After all, the only thing worth catching up on at night is your sleep.
The first sign that something is happening is Angelina’s hands. As she chats to the nurse in Italian, she begins to gesticulate, jabbing, moulding and circling the air with her fingers. As the minutes pass and Angelina becomes increasingly animated, I notice a musicality to her voice that I’m sure wasn’t there earlier. The lines in her forehead seem to be softening, and the pursing and stretching of her lips and the crinkling of her eyes tell me as much about her mental state as any interpreter could.Angelina is coming to life, precisely as my body is beginning to shut down. It’s 2am, and we’re sat in the brightly lit kitchen of a Milanese psychiatric ward, eating spaghetti. There’s a dull ache behind my eyes, and I keep on zoning out, but Angelina won’t be going to bed for at least another 17 hours, so I’m steeling myself for a long night. In case I doubted her resolve, Angelina removes her glasses, looks directly at me, and uses her thumbs and forefingers to pull open the wrinkled, grey-tinged skin around her eyes. “Occhi aperti,” she says. Eyes open.This is the second night in three that Angelina has been deliberately deprived of sleep. For a person with bipolar disorder who has spent the past two years in a deep and crippling depression, it may sound like the last thing she needs, but Angelina – and the doctors treating her – hope it will be her salvation. For two decades, Francesco Benedetti, who heads the psychiatry and clinical psychobiology unit at San Raffaele Hospital in Milan, has been investigating so-called wake therapy, in combination with bright light exposure and lithium, as a means of treating depression where drugs have often failed. As a result, psychiatrists in the USA, the UK and other European countries are starting to take notice, launching variations of it in their own clinics. These ‘chronotherapies’ seem to work by kick-starting a sluggish biological clock; in doing so, they’re also shedding new light on the underlying pathology of depression, and on the function of sleep more generally.“Sleep deprivation really has opposite effects in healthy people and those with depression,” says Benedetti. If you’re healthy and you don’t sleep, you’ll feel in a bad mood. But if you’re depressed, it can prompt an immediate improvement in mood, and in cognitive abilities. But, Benedetti adds, there’s a catch: once you go to sleep and catch up on those missed hours of sleep, you’ll have a 95 per cent chance of relapse.The antidepressant effect of sleep deprivation was first published in a report in Germany in 1959. This captured the imagination of a young researcher from Tübingen in Germany, Burkhard Pflug, who investigated the effect in his doctoral thesis and in subsequent studies during the 1970s. By systematically depriving depressed people of sleep, he confirmed that spending a single night awake could jolt them out of depression.
Benedetti became interested in this idea as a young psychiatrist in the early 1990s. Prozac had been launched just a few years earlier, hailing a revolution in the treatment of depression. But such drugs were rarely tested on people with bipolar disorder. Bitter experience has since taught Benedetti that antidepressants are largely ineffective for people with bipolar depression anyway.
His patients were in desperate need of an alternative, and his supervisor, Enrico Smeraldi, had an idea up his sleeve. Having read some of the early papers on wake therapy, he tested their theories on his own patients, with positive results. “We knew it worked,” says Benedetti. “Patients with these terrible histories were getting well immediately. My task was finding a way of making them stay well.”
So he and his colleagues turned to the scientific literature for ideas. A handful of American studies had suggested that lithium might prolong the effect of sleep deprivation, so they investigated that. They found that 65 per cent of patients taking lithium showed a sustained response to sleep deprivation when assessed after three months, compared to just 10 per cent of those not taking the drug.
Since even a short nap could undermine the efficacy of the treatment, they also started searching for new ways of keeping patients awake at night, and drew inspiration from aviation medicine, where bright light was being used to keep pilots alert. This too extended the effects of sleep deprivation, to a similar extent as lithium.
“We decided to give them the whole package, and the effect was brilliant,” says Benedetti. By the late 1990s, they were routinely treating patients with triple chronotherapy: sleep deprivation, lithium and light. The sleep deprivations would occur every other night for a week, and bright light exposure for 30 minutes each morning would be continued for a further two weeks – a protocol they continue to use to this day. “We can think of it not as sleep-depriving people, but as modifying or enlarging the period of the sleep–wake cycle from 24 to 48 hours,” says Benedetti. “People go to bed every two nights, but when they go to bed, they can sleep for as long as they want.”
San Raffaele Hospital first introduced triple chronotherapy in 1996. Since then, it has treated close to a thousand patients with bipolar depression – many of whom had failed to respond to antidepressant drugs. The results speak for themselves: according to the most recent data, 70 per cent of people with drug-resistant bipolar depression responded to triple chronotherapy within the first week, and 55 per cent had a sustained improvement in their depression one month later.
And whereas antidepressants – if they work – can take over a month to have an effect, and can increase the risk of suicide in the meantime, chronotherapy usually produces an immediate and persistent decrease in suicidal thoughts, even after just one night of sleep deprivation.
Angelina was first diagnosed with bipolar disorder 30 years ago, when she was in her late 30s. The diagnosis followed a period of intense stress: her husband was facing a tribunal at work, and they were worried about having enough money to support themselves and the kids. Angelina fell into a depression that lasted nearly three years. Since then, her mood has oscillated, but she’s down more often than not. She takes an arsenal of drugs – antidepressants, mood stabilisers, anti-anxiety drugs and sleeping tablets – which she dislikes because they make her feel like a patient, even though she acknowledges this is what she is.
If I’d met her three days ago, she says, it’s unlikely I would have recognised her. She didn’t want to do anything, she’d stopped washing her hair or wearing make-up, and she stank. She also felt very pessimistic about the future. After her first night of sleep deprivation, she’d felt more energetic, but this largely subsided after her recovery sleep. Even so, today she felt motivated enough to visit a hairdresser in anticipation of my visit. I compliment her appearance, and she pats her dyed, golden waves, thanking me for noticing.
At 3am, we move to the light room, and entering is like being transported forward to midday. Bright sunlight streams in through the skylights overhead, falling on five armchairs, which are lined up against the wall. This is an illusion, of course – the blue sky and brilliant sun are nothing more than coloured plastic and a very bright light – but the effect is exhilarating nonetheless. I could be sitting on a sun lounger at midday; the only thing missing is the heat.
When I’d interviewed her seven hours earlier, with the help of an interpreter, Angelina’s face had remained expressionless as she’d replied. Now, at 3.20am, she is smiling, and even beginning to initiate a conversation with me in English, which she’d claimed not to speak. By dawn, Angelina’s telling me about the family history she’s started writing, which she’d like to pick up again, and inviting me to stay with her in Sicily.
How could something as simple as staying awake overnight bring about such a transformation? Unpicking the mechanism isn’t straightforward: we still don’t fully understand the nature of depression or the function of sleep, both of which involve multiple areas of the brain. But recent studies have started to yield some insights.
The brain activity of people with depression looks different during sleep and wakefulness than that of healthy people. During the day, wake-promoting signals coming from the circadian system – our internal 24-hour biological clock – are thought to help us resist sleep, with these signals being replaced by sleep-promoting ones at night. Our brain cells work in cycles too, becoming increasingly excitable in response to stimuli during wakefulness, with this excitability dissipating when we sleep. But in people with depression and bipolar disorder, these fluctuations appear dampened or absent.
Depression is also associated with altered daily rhythms of hormone secretion and body temperature, and the more severe the illness, the greater the degree of disruption. Like the sleep signals, these rhythms are also driven by the body’s circadian system, which itself is driven by a set of interacting proteins, encoded by ‘clock genes’ that are expressed in a rhythmic pattern throughout the day. They drive hundreds of different cellular processes, enabling them to keep time with one another and turn on and off. A circadian clock ticks in every cell of your body, including your brain cells, and they are coordinated by an area of the brain called the suprachiasmatic nucleus, which responds to light.
“When people are seriously depressed, their circadian rhythms tend to be very flat; they don’t get the usual response of melatonin rising in the evening, and the cortisol levels are consistently high rather than falling in the evening and the night,” says Steinn Steingrimsson, a psychiatrist at Sahlgrenska University Hospital in Gothenburg, Sweden, who is currently running a trial of wake therapy.
Recovery from depression is associated with a normalisation of these cycles. “I think depression may be one of the consequences of this basic flattening of circadian rhythms and homeostasis in the brain,” says Benedetti. “When we sleep-deprive depressed people, we restore this cyclical process.”
But how does this restoration come about? One possibility is that depressed people simply need added sleep pressure to jump-start a sluggish system. Sleep pressure – our urge to sleep – is thought to arise because of the gradual release of adenosine in the brain. It builds up throughout the day and attaches to adenosine receptors on neurons, making us feel drowsy. Drugs that trigger these receptors have the same effect, whereas drugs that block them – such as caffeine – make us feel more awake.
To investigate whether this process might underpin the antidepressant effects of prolonged wakefulness, researchers at Tufts University in Massachusetts took mice with depression-like symptoms and administered high doses of a compound that triggers adenosine receptors, mimicking what happens during sleep deprivation. After 12 hours, the mice had improved, measured by how long they spent trying to escape when forced to swim or when suspended by their tails.
We also know sleep deprivation does other things to the depressed brain. It prompts changes in the balance of neurotransmitters in areas that help to regulate mood, and it restores normal activity in emotion-processing areas of the brain, strengthening connections between them.
And as Benedetti and his team discovered, if wake therapy kick-starts a sluggish circadian rhythm, lithium and light therapy seem to help maintain it. Lithium has been used as a mood stabiliser for years without anyone really understanding how it works, but we know it boosts the expression of a protein, called Per2, that drives the molecular clock in cells.
Bright light, meanwhile, is known to alter the rhythms of the suprachiasmatic nucleus, as well as boosting activity in emotion-processing areas of the brain more directly. Indeed, the American Psychiatric Association states that light therapy is as effective as most antidepressants in treating non-seasonal depression.
In spite of its promising results against bipolar disorder, wake therapy has been slow to catch on in other countries. “You could be cynical and say it’s because you can’t patent it,” says David Veale, a consultant psychiatrist at the South London and Maudsley NHS Foundation Trust.
Certainly, Benedetti has never been offered pharmaceutical funding to carry out his trials of chronotherapy. Instead, he has – until recently – been reliant on government funding, which is often in short supply. His current research is being funded by the EU. Had he followed the conventional route of accepting industry money to run drug trials with his patients, he quips, he probably wouldn’t be living in a two-bedroom apartment and driving a 1998 Honda Civic.
The bias towards pharmaceutical solutions has kept chronotherapy below the radar for many psychiatrists. “A lot of people just don’t know about it,” says Veale.
It’s also difficult to find a suitable placebo for sleep deprivation or bright light exposure, which means that large, randomised placebo-controlled trials of chronotherapy haven’t been done. Because of this, there’s some scepticism about how well it really works. “While there is increasing interest, I don’t think many treatments based on this approach are yet routinely used – the evidence needs to be better and there are some practical difficulties in implementing things like sleep deprivation,” says John Geddes, a professor of epidemiological psychiatry at the University of Oxford.
Even so, interest in the processes underpinning chronotherapy is beginning to spread. “Insights into the biology of sleep and circadian systems are now providing promising targets for treatment development,” says Geddes. “It goes beyond pharmaceuticals – targeting sleep with psychological treatments might also help or even prevent mental disorders.”
In the UK, the USA, Denmark and Sweden, psychiatrists are investigating chronotherapy as a treatment for general depression. “A lot of the studies that have been done so far have been very small,” says Veale, who is currently planning a feasibility study at Maudsley Hospital in London. “We need to demonstrate that it is feasible and that people can adhere to it.”
So far, what studies there have been have produced mixed results. Klaus Martiny, who researches non-drug methods for treating depression at the University of Copenhagen in Denmark, has published two trials looking at the effects of sleep deprivation, together with daily morning bright light and regular bedtimes, on general depression. In the first study, 75 patients were given the antidepressant duloxetine, in combination with either chronotherapy or daily exercise. After the first week, 41 per cent of the chronotherapy group had experienced a halving of their symptoms, compared to 13 per cent of the exercise group. And at 29 weeks, 62 per cent of the wake therapy patients were symptom-free, compared to 38 per cent of those in the exercise group.
In Martiny’s second study, severely depressed hospital inpatients who had failed to respond to antidepressant drugs were offered the same chronotherapy package as an add-on to the drugs and psychotherapy they were undergoing. After one week, those in the chronotherapy group improved significantly more than the group receiving standard treatment, although in subsequent weeks the control group caught up.
No one has yet compared wake therapy head-to-head with antidepressants; neither has it been tested against bright light therapy and lithium alone. But even if it’s only effective for a minority, many people with depression – and indeed psychiatrists – may find the idea of a drug-free treatment attractive.
“I’m a pill pusher for a living, and it still appeals to me to do something that doesn’t involve pills,” says Jonathan Stewart, a professor of clinical psychiatry at Columbia University in New York, who is currently running a wake therapy trial at New York State Psychiatric Institute.
Unlike Benedetti, Stewart only keeps patients awake for one night: “I couldn’t see a lot of people agreeing to stay in hospital for three nights, and it also requires a lot of nursing and resources,” he says. Instead, he uses something called sleep phase advance, where on the days after a night of sleep deprivation, the time the patient goes to sleep and wakes up is systematically brought forward. So far, Stewart has treated around 20 patients with this protocol, and 12 have shown a response – most of them during the first week.
It may also work as a prophylactic: recent studies suggest that teenagers whose parents set – and manage to enforce – earlier bedtimes are less at risk of depression and suicidal thinking. Like light therapy and sleep deprivation, the precise mechanism is unclear, but researchers suspect a closer fit between sleep time and the natural light–dark cycle is important.
But sleep phase advance has so far failed to hit the mainstream. And, Stewart accepts, it’s not for everybody. “For those for whom it works, it’s a miracle cure. But just as Prozac doesn’t get everyone better who takes it, neither does this,” he says. “My problem is that I have no idea ahead of time who it’s going to help.”
Depression can strike anyone, but there’s mounting evidence that genetic variations can disrupt the circadian system to make certain people more vulnerable. Several clock gene variations have been associated with an elevated risk of developing mood disorders.
Stress can then compound the problem. Our response to it is largely mediated through the hormone cortisol, which is under strong circadian control, but cortisol itself also directly influences the timing of our circadian clocks. So if you have a weak clock, the added burden of stress could be enough to tip your system over the edge.
Indeed, you can trigger depressive symptoms in mice by repeatedly exposing them to a noxious stimulus, such as an electric shock, from which they can’t escape – a phenomenon called learned helplessness. In the face of this ongoing stress, the animals eventually just give up and exhibit depression-like behaviours. When David Welsh, a psychiatrist at the University of California, San Diego, analysed the brains of mice that had depressive symptoms, he found disrupted circadian rhythms in two critical areas of the brain’s reward circuit – a system that’s strongly implicated in depression.
But Welsh has also shown that a disturbed circadian system itself can cause depression-like symptoms. When he took healthy mice and knocked out a key clock gene in the brain’s master clock, they looked just like the depressed mice he’d been studying earlier. “They don’t need to learn to be helpless, they are already helpless,” Welsh says.
So if disrupted circadian rhythms are a likely cause of depression, what can be done to prevent rather than treat them? Is it possible to strengthen your circadian clock to increase psychological resilience, rather than remedy depressive symptoms by forgoing sleep?
Martiny thinks so. He is currently testing whether keeping a more regular daily schedule could prevent his depressed inpatients from relapsing once they’ve recovered and are released from the psychiatric ward. “That’s when the trouble usually comes,” he says. “Once they’re discharged their depression gets worse again.”
Peter is a 45-year-old care assistant from Copenhagen who has battled with depression since his early teens. Like Angelina and many others with depression, his first episode followed a period of intense stress and upheaval. His sister, who more or less brought him up, left home when he was 13, leaving him with an uninterested mother and a father who also suffered from severe depression. Soon after that, his father died of cancer – another shock, as he’d kept his prognosis hidden until the week before his death.
Peter’s depression has seen him hospitalised six times, including for a month last April. “In some ways being in hospital is a relief,” he says. However, he feels guilty about the effect it has on his sons, aged seven and nine. “My youngest boy said he cried every night I was in hospital, because I wasn’t there to hug him.”
So when Martiny told Peter about the study he had just started recruiting for, he readily agreed to participate. Dubbed ‘circadian-reinforcement therapy’, the idea is to strengthen people’s circadian rhythms by encouraging regularity in their sleep, wake, meal and exercise times, and pushing them to spend more time outdoors, exposed to daylight.
For four weeks after leaving the psychiatric ward in May, Peter wore a device that tracked his activity and sleep, and he completed regular mood questionnaires. If there was any deviation in his routine, he would receive a phone call to find out what had happened.
When I meet Peter, we joke about the tan lines around his eyes; obviously, he’s been taking the advice seriously. He laughs: “Yes, I’m getting outdoors to the park, and if it’s nice weather, I take my children to the beach, for walks, or to the playground, because then I will get some light, and that improves my mood.”
Those aren’t the only changes he’s made. He now gets up at 6 every morning to help his wife with the children. Even if he’s not hungry he eats breakfast: typically, yoghurt with muesli. He doesn’t take naps and tries to be in bed by 10pm. If Peter does wake up at night, he practises mindfulness – a technique he picked up in hospital.
Martiny pulls up Peter’s data on his computer. It confirms the shift towards earlier sleep and wake times, and shows an improvement in the quality of his sleep, which is mirrored by his mood scores. Immediately after his release from hospital, these averaged around 6 out of 10. But after two weeks they’d risen to consistent 8s or 9s, and one day, he even managed a 10. At the beginning of June, he returned to his job at the care home, where he works 35 hours a week. “Having a routine has really helped me,” he says.
So far, Martiny has recruited 20 patients to his trial, but his target is 120; it’s therefore too soon to know how many will respond the same way as Peter, or indeed, if his psychological health will be maintained. Even so, there’s mounting evidence that good sleep routine can help our mental wellbeing. According to a study published in Lancet Psychiatry in September 2017 – the largest randomised trial of a psychological intervention to date – insomniacs who underwent a ten-week course of cognitive behavioural therapy to address their sleep problems showed sustained reductions in paranoia and hallucinatory experiences as a result. They also experienced improvements in symptoms of depression and anxiety, fewer nightmares, better psychological wellbeing and day-to-day functioning, and they were less likely to experience a depressive episode or anxiety disorder during the course of the trial.
Sleep, routine and daylight. It’s a simple formula, and easy to take for granted. But imagine if it really could reduce the incidence of depression and help people to recover from it more quickly. Not only would it improve the quality of countless lives, it would save health systems money.
In the case of wake therapy, Benedetti cautions that it isn’t something people should try to administer to themselves at home. Particularly for anyone who has bipolar disorder, there’s a risk of it triggering a switch into mania – although in his experience, the risk is smaller than that posed by taking antidepressants. Keeping yourself awake overnight is also difficult, and some patients temporarily slip back into depression or enter a mixed mood state, which can be dangerous. “I want to be there to speak about it to them when it happens,” Benedetti says. Mixed states often precede suicide attempts.
A week after spending the night awake with Angelina, I call Benedetti to check her progress. He tells me that after the third sleep deprivation, she experienced a full remission in her symptoms and returned to Sicily with her husband. That week, they were due to be marking their 50th wedding anniversary. When I’d asked her if she thought her husband would notice any change in her symptoms, she’d said she hoped he’d notice the change in her physical appearance.
Hope. After she has spent more than half her life without it, I suspect its return is the most precious golden anniversary gift of all.
This article first appeared on Mosaic and is republished here under a Creative Commons licence.