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Sleep as an Underused Target for Rapid Response in the Treatment of Depression and Suicidal Ideation.

Social work has been instrumental in the development and implementation of psychotherapeutic treatments for depression and suicide. Much like their pharmacological counterparts, psychotherapeutic approaches tend to exercise a gradual and progressive influence on depression severity over a period of several weeks to months. The efficacy of such approaches may be boosted through greater research and clinical attention to the several interventions that exert a much more rapid (that is, less than one day or even instantaneous) effect on depressive symptoms and suicidal thoughts. Sleep deprivation is the most well-established of these three treatments, with a substantial body of evidence showing remission of depressive symptoms following total or partial sleep deprivation, despite limited knowledge of the explanatory mechanisms ( Giedke & Schwärzler, 2002). More recently, this connection between sleep and depression has been targeted biologically through deep brain stimulation (that is, the surgical implantation of an electrode that exerts a continuous electrical current to a particular brain region) of the subcallosal cingulate gyrus, which has demonstrated efficacy in reducing symptoms of treatment-resistant depression through direct stimulation of a sleep-related brain region ( Holtzheimer et al., 2012). Finally, infusion of ketamine, a pharmacological treatment that has been shown to increase total sleep and reduce nocturnal wakefulness, has recently been shown to alleviate symptoms of depression and reduce suicidal ideation within just hours of administration ( Ballard et al., 2014). Taken together, the common factor underlying these three interventions is a rapid and robust effect on depressive symptoms in the context of substantial effects on sleep or sleep-related brain areas. Although these interventions span a broad array of clinical approaches (that is, sleep therapy, brain surgery, and pharmacology) that are generally outside the scope of social work practice, their rapid efficacy may provide clues as to how to improve psychotherapeutic services for depression and suicidal ideation, particularly in the early stages of treatment. Several suggestions can be made as points for further research and potential clinical exploration. First, social workers treating depression or suicidal ideation should assess for sleep difficulties through psychosocial interviews and, potentially, through more direct screenings for sleep disorders, such as obstructive sleep apnea. Second, social workers can bring any identified sleep problems to the attention of clients for appropriate self-care and management, and when appropriate, treat sleep difficulties through collaborations with specialists. Finally, social work researchers examining psychosocial treatments can pay greater attention to whether sleep provides a mechanism of change. If not, these treatments can potentially be improved by adjunctive approaches to improving sleep, particularly early in the course of treatment. Although the precise role of sleep in depression and suicidal behavior is not yet well known, we may do well to acknowledge the impressive rapid treatment response associated with sleep-related interventions, and to incorporate that information into clinical practice when appropriate. Jordan DeVylder, PhD, MSW University of Maryland, Baltimore